Management of the Agitated Patient Adam Watchorn July 28, 2011

1. Management of the Agitated Patient Adam Watchorn July 28, 2011

2. Learning Goals • Causes of Agitation • Verbal De-escalation • Physical Restraints and Conducted Electrical Weapons • Chemical Sedation

3. Causes of agitationWhat are the most common causes of agitation in the ED?

4. 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

5. Causes of agitationWhat causes of agitation can we reverse in the ED?

6. Reversible or Potentially Treatment Conditions GOT IVS • Glucose – hypoglycemia • Oxygen – hypoxia • Trauma – brain, pain • Infectious – meningitis, encephalitis • Vascular – stroke, SAH • Seizure

7. 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

9. Could this have been prevented?

10. 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

11. 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

12. When would you consider physical restraints?

13. Indications for Physical Restraints 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!!!

14. What are some complications?

15. Local trauma Aspiration Rhabdomyolysis Positional Asphyxia Complications of physical restraints

17. I’ve been TASERED! A) None B) ECG C) ECG, Troponins D) ECG, Troponins, ECHO

18. I’ve been TASERED! A) None B) ECG C) ECG, Troponins D) ECG, Troponins, ECHO

19. 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.”

20. 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?

21. Management Medical Emergency: Resuscitation room Agitation: Benzodiazepines +/- Intubation Hyperthermia: COOL – fluids, ice Acidosis: Bicarb 1-2 amps?

22. despite your management plan he continues to struggle then suddenly goes limp

23. Monitor shows asystole

24. EXCITED DELIRIUM SYNDROME Described in literature as a combination of: • Acute drug intoxication • Mental illness • Struggle with law enforcement • Physical, chemical or TASER restraint • Sudden unexpected death

25. Why do these patients die? Multifactorial • Positional asphyxia • Hyperthermia and acidosis • Catecholamine-induced fatal arrhythmias • Stress cardiomyopathy

27. What’s your favourite chemical sedation?

28. 75M 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?

29. Oral is the best! Risperidone 2mg + Ativan 2mg Haldol 5mg + Ativan 2mg

30. 5 – 10 mg IM q30min

33. Acute Extrapyramidal Syndromes Haldol injection IM = 5% chance Higher with repeat injections Cogentin 1-2 mg IV (IM,PO) Benadryl 25-50 mg IV (IM,PO)

34. Should long QT intervals worry us?

35. Proportion (%) of abnormal QT intervalsDORM STUDY

36. Is there a benefit of combining Haldol and Ativan?

37. Sedation more rapid with combination

38. % PATIENTS WITH EPS SYMPTOMS

39. What medication works the fastest?

40. Mean time to sedation, min

41. However, no mention of side effects….. Another study with MIDAZOLAM showed: 20% required supplemental oxygen 50% required rescue medication BOTTOM LINE: FAST but UNPREDICTABLE

42. Why would you choose Olanzepine over haldol?

44. Summary of Chemical Sedation

45. Oral firstRisperidone 2.5 mg + Ativan 2 mg

46. Undifferentiated Agitation1) Haldol 2 – 10 mg + Ativan 2-4 mg2) Midazolam 5-10 mg

47. Agitation related to psychosis1) Haldol 2-10 mg + Ativan 2-4 mg2) Olanzepine 10 mg

48. 55M 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?

49. Management • Agitation: Sedation  Intubation • Protect C-spine • Facilitate CT scan • Prevent Hypoxia and Hypotension

50. Take away points • 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)