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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

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

agitation
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
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
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
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
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

delirium vs dementia
Delirium vs. dementia

Les Zun, MD, MBA, FAAEM

slide9
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

slide10

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

progression
Progression
  • Do all patients progress?
  • Which patients progress?
  • How to prevent progression?

Les Zun, MD, MBA, FAAEM

reason to treat agitated patients
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

treatment
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
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
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

agitated patients clinical overview and problem definition summary
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