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FERNE/MEMC Session:. Agitated Patients: Clinical Overview and Problem Definition. Leslie Zun, MD, MBA, FAAEM Professor and Chair Rosalind Franklin University/Chicago Medical School Department of Emergency Medicine Mount Sinai Hospital. FERNE/MEMC Session:.

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Agitated patients clinical overview and problem definition l.jpg

FERNE/MEMC Session:

Agitated Patients:Clinical Overview and Problem Definition

Leslie Zun, MD, MBA, FAAEM

Professor and Chair

Rosalind Franklin University/Chicago Medical School

Department of Emergency Medicine

Mount Sinai Hospital

Les Zun, MD, MBA, FAAEM


Disclosures alexza pharmaceuticals sanofi aventis l.jpg

FERNE/MEMC Session:

DisclosuresAlexza PharmaceuticalsSanofi-Aventis

Les Zun, MD, MBA, FAAEM


Agitation l.jpg
Agitation

  • Definition

    • Excessive verbal and/or motor behavior

  • Escalation

    • Verbal

    • Physical

    • Violence

  • Signs of agitation

    • Pacing

    • Irritable

    • Affective liability

    • Verbal outbursts

    • Clenching fists or jaws

    • Threatening or destructive behavior

    • Slamming or banging objects

Les Zun, MD, MBA, FAAEM


Prevalence l.jpg
Prevalence

  • Psychiatric patients in US

    • 4.3 million ED US visits per year

    • 5.4% of ED patients

  • Prevalence of agitation in US

    • Up to 1.7 million ED visits

  • Incidence of violence in US

    • 50% of healthcare providers in their career

    • 51% of MDs and 67% of nurses in ED were physically assaulted in the last 6 months

    • 2/3 containment and 1/3 random

Les Zun, MD, MBA, FAAEM


Etiology l.jpg
Etiology

  • Drug and alcohol intoxication or withdrawal

  • Medical

    • Hypoglycemia

    • Hyperthyroidism

    • Delirium

    • Dementia

    • Head Trauma

    • Temporal Lobe Epilepsy

  • Psychiatric

    • Schizophrenia

    • Mania

    • Agitated depression

    • Personality disorder – Antisocial, borderline

    • PT

    • Akathisia

Les Zun, MD, MBA, FAAEM


Etiology6 l.jpg
Etiology

  • Drug and alcohol intoxication or withdrawal

  • Medical

    • Hypoglycemia

    • Hyperthyroidism

    • Delirium

    • Dementia

    • Head Trauma

    • Temporal Lobe Epilepsy

  • Psychiatric

    • Schizophrenia

    • Mania

    • Agitated depression

    • Personality disorder – Antisocial, borderline

    • PTSD

    • Akathisia

Les Zun, MD, MBA, FAAEM


Evaluation l.jpg
Evaluation

  • Differentiate medical from psychiatric etiology

    • Age

    • Prior history

    • Vital signs

    • Physical examination findings

    • Focal neurologic findings

    • Glucose

    • Oxygenation

    • Laboratories?

    • Radiography-CT Scan

  • Delirium vs. dementia

Les Zun, MD, MBA, FAAEM


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Delirium vs. dementia

Les Zun, MD, MBA, FAAEM


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Patient IdentificationCitrone, L, Volavka: Violent patients in the emergency setting. Psych Clinic NA 1999;22:789-801.

  • High risk

    • Schizophrenia + substance abuse + medication non-compliance > Schizophrenia >Affective disorders

  • Factors that precipitate violent behavior alone or in combination

    • Comorbid substance abuse, dependence or intoxication

    • Hallucinations or delusions

    • Poor impulse control

    • Character pathology

    • Chaotic environment

Les Zun, MD, MBA, FAAEM


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Chaotic EnvironmentLevel of Agitation From ED Arrival Zun, LS and Downey, LA: Level of agitation of patients presenting to an emergency department. Primary Care Companion J Clin Psychiatry 2008;10:108-113.

Les Zun, MD, MBA, FAAEM


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Progression

  • Do all patients progress?

  • Which patients progress?

  • How to prevent progression?

Les Zun, MD, MBA, FAAEM


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Reason to treat agitated patients

  • Prevent violence

    • Up to 75% ED staff victims of violence

  • Better able to assess the patient

    Binder, Rl, McNeil, DE: Contemporary practices in managing acutely violent patients in 20 psychiatric emergency rooms. Psych Services 1999;50:1553- 1554.

    • 17 of 20 medical directors stated that the patients are so agitated that it is difficult to get vital signs.

    • 14 of 20 said the protocol was to physically restrain patients and medicate them prior to a medical work-up

  • Begin therapeutic process

    Fishkind, AB: Agitation II: De-escalation of the aggressive patient and avoiding coercion. Emergency Psychiatry, 2008.

    • Collaborative interactions

    • Elicit information

    • Patients say all they want

    • Include patients in planning

    • Empathize

Les Zun, MD, MBA, FAAEM


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Treatment

  • Treat medical condition

  • Reduce stimulation

  • Verbal de-escalation - “Talk em down”

  • Alternatives to restraints

  • Restrain

    • Physical

    • Chemical

    • Combination

  • Seclusion

Les Zun, MD, MBA, FAAEM


Prevent violence brasic jr fogel d clinical safety psych clinic na 1999 22 923 940 l.jpg
Prevent ViolenceBrasic, JR, Fogel, D:Clinical safety. Psych Clinic NA 1999;22:923-940.

  • Identify violent patients

  • Search patients for weapons

  • Use a comprehensive, collaborative approach to the patient

  • Strategies

    • Administrative

    • Behavioral

    • Environmental

Les Zun, MD, MBA, FAAEM


Prevent violence strategies brasic jr fogel d clinical safety psych clinic na 1999 22 923 940 l.jpg
Prevent Violence-StrategiesBrasic, JR, Fogel, D:Clinical safety. Psych Clinic NA 1999;22:923-940.

  • Administrative

    • Gangs involvement

    • Evacuation plan

    • Staff training

  • Behavioral

    • Be direct, polite and respectful

    • Keep close to open exit

    • Listen to patient

    • Use non-threatening speech and behavior

    • Security alert

  • Environmental

    • Monitor rooms

    • Well trained security presence – Clinical training programs eg CPI

    • Panic alerts

Les Zun, MD, MBA, FAAEM


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Agitated Patients:Clinical Overview and Problem Definition Summary

  • Agitation and violence common in ED

  • Evaluate for possible treatable conditions

  • Apply techniques to reduce agitation

    • Identify agitated patients

    • Be pre-emptive

    • Utilize appropriate resources

  • Employ strategies to prevent violence

    • Search all patients

    • Isolate and observe

Les Zun, MD, MBA, FAAEM


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