Management of the Agitated Patient Adam Watchorn July 28, 2011. Learning Goals. Causes of Agitation Verbal De-escalation Physical Restraints and Conducted Electrical Weapons Chemical Sedation. Causes of agitation What are the most common causes of agitation in the ED? .
July 28, 2011
CC: “I feel sick to my stomach”
PMHx: Smoker, ETOH
After waiting 45 min he left for a smoke
He returned and became angry, demanding to be seen and uttering threats
Staff tried to calm him but he left irate
Within minutes….this happened
Smashed store windows and lit car on fire
4 officers required to restrain him
He’s already TASERED twice
Meds: Lithium, Celexa
He continues to struggle against 4 RCMP officers without any sign of tiring
Security is called to help
He is diaphoretic and extremely agitated and violent
When would you consider physical restraints? sign of tiring
Patients are not responding to verbal techniques, are not cooperative and refusing oral treatment plus
What are some sign of tiring
Local trauma sign of tiring
AAEM Clinical Policy Statement 2010
The patient is now physically restrained but continues to struggle in the seclusion room
The nurses manage to get some vital signs
40.8, 156, 186/94
WHAT IS YOUR MANAGEMENT PLAN?
Medical Emergency: Resuscitation room
Agitation: Benzodiazepines +/- Intubation
Hyperthermia: COOL – fluids, ice
Acidosis: Bicarb 1-2 amps?
Described in literature as a combination of:
75M suddenly goes limp
Admitted 8 days ago for NSTEMI
36.5, 62, 136/74, 96%
Agitated and aggressive
LWMH, B-blocker, ACEI, Statin, ASA
CAD, DM, COPD, Depression
Why is he agitated?
How would you manage this patient?
Risperidone 2mg +
Haldol 5mg +
Haldol injection IM = 5% chance
Higher with repeat injections
Cogentin 1-2 mg IV (IM,PO)
Benadryl 25-50 mg IV (IM,PO)
Should long QT intervals worry us? suddenly goes limp
Another study with MIDAZOLAM showed:
20% required supplemental oxygen
50% required rescue medication
FAST but UNPREDICTABLE
55M suddenly goes limp
Fell down flight of stairs
Smells of Alcohol
GCS 12 (E3, V4, M5)
36.1, 76, 172/86
Large scalp hematoma
Becomes AGITATED and AGGRESSIVE to staff and pulls out his IV and and pulls off his collar
What are your management priorities?
Thanks for listening!
Thanks to Colleen Carey!