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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? .

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Management of the agitated patient adam watchorn july 28 2011

Management of the Agitated Patient

Adam Watchorn

July 28, 2011


Learning goals
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
Causes of agitationWhat are the most common causes of agitation in the ED?


Causes of agitation
Causes of agitation

  • Organic

    • Substance related

      • Cocaine, Amphetamines, Alcohol

    • Medical conditions

      • Hypoxia, hypoglycemia, brain injury, pain stimulus, CNS infection

        • Rare: brain tumors, thyroid disorders, hyperparathyroidism, Wilson’s disease, Huntington disease

  • Psychiatric

    • Psychosis

      • Manic episode

      • Schizophrenia

  • Non-organic and Non-psychiatric

    • Personality disorders


Causes of agitation what causes of agitation can we reverse in the ed
Causes of agitationWhat causes of agitation can we reverse in the ED?


Reversible or potentially treatment conditions
Reversible or Potentially Treatment Conditions

GOT IVS

  • Glucose – hypoglycemia

  • Oxygen – hypoxia

  • Trauma – brain, pain

  • Infectious – meningitis, encephalitis

  • Vascular – stroke, SAH

  • Seizure


Management of the agitated patient adam watchorn july 28 2011

45M

CC: “I feel sick to my stomach”

PMHx: Smoker, ETOH

PsychHx: none

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



Management of the agitated patient adam watchorn july 28 2011

28M BIBP

Smashed store windows and lit car on fire

4 officers required to restrain him

He’s already TASERED twice

PMHx: Bipolar

Meds: Lithium, Celexa


Management of the agitated patient adam watchorn july 28 2011

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



Indications for physical restraints
Indications for Physical Restraints sign of tiring

Patients are not responding to verbal techniques, are not cooperative and refusing oral treatment plus

  • At risk to harming themselves or staff

  • Delaying diagnosis and treatment

DOCUMENT THIS!!!


Management of the agitated patient adam watchorn july 28 2011

What are some sign of tiring

complications?


Management of the agitated patient adam watchorn july 28 2011

Local trauma sign of tiring

Aspiration

Rhabdomyolysis

Positional Asphyxia

Complications of

physical restraints


I ve been tasered
I’ve been TASERED! sign of tiring

A) None

B) ECG

C) ECG, Troponins

D) ECG, Troponins, ECHO


I ve been tasered1
I’ve been TASERED! sign of tiring

A) None

B) ECG

C) ECG, Troponins

D) ECG, Troponins, ECHO


What evaluations are needed in the ed after a taser device activation
What evaluations are needed in the ED after a TASER device activation?

AAEM Clinical Policy Statement 2010

  • No support for routine laboratory studies, ECGs, or prolonged ED observation for ongoing cardiac monitoring in an asymptomatic awake and alert patient (Level of Recommendation: Class A)

  • “….no evidence of dangerous lab abnormalities, physiological changes, or immediate or delayed cardiac ischemia or dysrhythmias after exposure to TASER electical discharges of up to 15 seconds.”


Management of the agitated patient adam watchorn july 28 2011

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?


Management
Management struggle in the seclusion room

Medical Emergency: Resuscitation room

Agitation: Benzodiazepines +/- Intubation

Hyperthermia: COOL – fluids, ice

Acidosis: Bicarb 1-2 amps?



Monitor shows asystole
Monitor shows suddenly goes limpasystole


Excited delirium syndrome
EXCITED DELIRIUM SYNDROME suddenly goes limp

Described in literature as a combination of:

  • Acute drug intoxication

  • Mental illness

  • Struggle with law enforcement

  • Physical, chemical or TASER restraint

  • Sudden unexpected death


Why do these patients die
Why do these patients die? suddenly goes limp

Multifactorial

  • Positional asphyxia

  • Hyperthermia and acidosis

  • Catecholamine-induced fatal arrhythmias

  • Stress cardiomyopathy


What s your favourite chemical sedation
What’s your suddenly goes limpfavourite chemical sedation?


Management of the agitated patient adam watchorn july 28 2011

75M suddenly goes limp

Admitted 8 days ago for NSTEMI

36.5, 62, 136/74, 96%

Bizarre behaviour

Agitated and aggressive

Meds:

LWMH, B-blocker, ACEI, Statin, ASA

PMHx:

CAD, DM, COPD, Depression

Why is he agitated?

How would you manage this patient?


Oral is the best
Oral is the best! suddenly goes limp

Risperidone 2mg +

Ativan 2mg

Haldol 5mg +

Ativan 2mg


5 10 mg im q30min
5 – 10 mg IM q30min suddenly goes limp


Acute extrapyramidal syndromes
Acute suddenly goes limpExtrapyramidal Syndromes

Haldol injection IM = 5% chance

Higher with repeat injections

Cogentin 1-2 mg IV (IM,PO)

Benadryl 25-50 mg IV (IM,PO)



Proportion of abnormal qt intervals dorm study
Proportion (%) of abnormal QT intervals suddenly goes limpDORM STUDY


Is there a benefit of combining haldol and ativan
Is there a benefit of combining suddenly goes limpHaldol and Ativan?


Sedation more rapid with combination
Sedation suddenly goes limpmore rapid with combination


Patients with eps symptoms
% PATIENTS WITH suddenly goes limpEPS SYMPTOMS



Mean time to sedation min
Mean time to sedation, min suddenly goes limp


However no mention of side effects
However, no mention of side effects….. suddenly goes limp

Another study with MIDAZOLAM showed:

20% required supplemental oxygen

50% required rescue medication

BOTTOM LINE:

FAST but UNPREDICTABLE


Why would you choose olanzepine over haldol
Why would you choose suddenly goes limpOlanzepine over haldol?


Summary of chemical sedation
Summary of Chemical Sedation suddenly goes limp


Oral first risperidone 2 5 mg ativan 2 mg
Oral first suddenly goes limpRisperidone 2.5 mg + Ativan 2 mg


Undifferentiated agitation 1 haldol 2 10 mg ativan 2 4 mg 2 midazolam 5 10 mg
Undifferentiated Agitation suddenly goes limp1) Haldol 2 – 10 mg + Ativan 2-4 mg2) Midazolam 5-10 mg


Agitation related to psychosis 1 haldol 2 10 mg ativan 2 4 mg 2 olanzepine 10 mg
Agitation related to psychosis suddenly goes limp1) Haldol 2-10 mg + Ativan 2-4 mg2) Olanzepine 10 mg


Management of the agitated patient adam watchorn july 28 2011

55M suddenly goes limp

BIBA collared/boarded

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?


Management1
Management suddenly goes limp

  • Agitation: Sedation  Intubation

    • Protect C-spine

    • Facilitate CT scan

  • Prevent Hypoxia and Hypotension


Take away points
Take away points suddenly goes limp

  • Your voice + Oral Meds when possible

  • Perform an early assessment because:

    • Agitation + Abnormal VS = emergency

    • Agitation + Head trauma = emergency

  • Be aware of the complications with restraints and chemical sedation

  • Choose your weapon wisely (Haldol, Ativan, Midazolam, Olanzepine, etc)


Questions
Questions suddenly goes limp

Thanks for listening!

Thanks to Colleen Carey!