The Agitated Patient Wild and Crazy

1. The Agitated PatientWild and Crazy Randall Berlin, MD

2. Learning Objectives Review the toxic causes of agitated delirium. Recognize and treat life threatening complications. Sedation of the agitated patient. Recognize and treat rhabdomyolysis.

3. Case 1 - Form 10 • Police attended the house of patient X after complaints from the neighbors that he was screaming all night. Neighbors and his live in landlord stated that he had not slept at all and was not making any sense. Pt X followed one of his neighbors home and pushed him on his lawn.

4. Form 10 (cont’d) • Pt X is currently on medication, however has not been taking his medications. Pt X’s landlord said that he has been selling his valium and filled all his meds - no other meds available to pt X for 3 weeks. Pt X threatened to kill everyone/have them murdered/shot/poisoned. He is a danger to himself and others. • Your thoughts?

5. Schizophrenia • Drug withdrawal • Benzodiazepines • Personality Disorder • Illicit Drug Use

6. In the ED • Pt yelling and aggressive. • Security required to restrain. • BP 113/59; P 79; T 37 C; 94% RA • Pharmacologic sedation • Versed 5 mg IM • Olanzapine 10 mg IM

7. Old chart • Schizoaffective • Marijuana and cocaine abuse • Antisocial personality disorder • Dispostion • Admit to psychiatry

8. Patient 2 30 year old, 100 kg male bodybuilder is brought to the Emergency Department. He was arrested by the police after running naked down the middle of a major road. Two paramedics and four police are having trouble holding him down on the stretcher. Earlier that day the patient had a major motor seizure. • What are some causes of agitation?

9. Causes of agitation • Personality disorders • Borderline, antisocial • Ethanol enhanced personality disorders • Medical causes of delirium • Psychiatric causes of psychosis and agitation • Dementia • DRUG INTOXICATION • What drugs can cause agitated delirium?

10. Toxic causes of agitated delirium • Anticholinergics: antihistamines, antipyschotics etc • Sympathomimetics: cocaine, amphetamines • PCP • Hallucinogens: LSD, mushrooms • Salicylates • Withdrawal states: ethanol, benzodiazepines

11. P: 140; BP 150/95; RR 24; SaO2 98%; T 39.5 C Agitated Pupils 7 mm, reactive Diaphoretic Life threats? Back to the Case

12. Life threats • Sudden cardiac death • Hyperthermia

13. Sudden cardiac deathTypical scenario • 29 yo male pulled over by police for driving erratically. He was agitated and confused and resisted arrest. He was pepper sprayed and continued to resist. He was physically subdued and continued to struggle despite being placed in 4-point restraints on the ambulance stretcher and suddenly stopped moving.

14. Typical scenario (cont’d) • As he was being loaded into the ambulance, he was found to be pulseless and apneic. His passenger reported that he had been sniffing cocaine just prior to being stopped.

15. Sudden Cardiac Death Associated with Agitated Delirium • “Sudden In-Custody Death” • “Restraint Associated Cardiac Arrest”

16. Sudden Cardiac DeathSimilarities with most cases • Presence of excited delirium • Continued maximal struggle despite attempts at maximal restraint • Clear association exists between illicit drug use and the syndrome but not universal. • Non-drug related causes are almost always psychotic (schizophrenia, bipolar)

17. Sudden Cardiac DeathMechanism of Death • No definite etiology usually found at autopsy • Profound metabolic acidosis likely leading to cardiac arrest • Hyperthermia often contributory • Convulsions often contributory • Hyperkalemia often contributory • Restraint asphyxia unlikely explanation

18. Sudden Cardiac DeathSummary • Dr. Chris Linden: • “I constantly and emphatically remind our residents and fellows that the patient with agitated delirium, particularly one who is actively and persistently struggling against restraint, should be treated as a true emergency - a cardiac arrest waiting to happen.”

19. P: 140; BP 150/95; RR 24; SaO2 98%; T 39.5 C Agitated Pupils 7 mm, reactive Diaphoretic Life threats? Back to the Case

20. Life threats • Sudden cardiac death • Hyperthermia

21. Recognize the life threat!(not the drug) How important is hyperthermia?

22. Hyperthermia • 75% of drug overdose patients with a temperature greater than 40.5 C for greater than one hour die or have permanent neurologic sequelae

24. Back to the case • Wildly agitated Movie Trivia: “If you cut their tendons, even the largest elephant will fall.”

25. Movie Trivia • The Protector (2006) • Tony Jaa How can we control our wildly, agitated patient?

26. Control of the patient • Physical restraints • Chemical sedation • Intubation and paralysis

27. Code Black • Standardized approach • Standardized team

30. Physical restraints • Short term solution to gain IV access and treat with pharmaceutical agents • 5 or more people • Monitoring protocol • Documentation

31. Chemical sedation • Control psychomotor agitation while minimizing drug related complications • Identify and treat life threats What drugs can we use?

32. Benzodiazepines Lorazepam Diazepam Midazolam Antipsychotics Paralytics Succinylcholine Rocuronium

33. Benzodiazepines • Advantages • Treats hyperthermia • Prevents or treats seizures • Decreases mortality in animal studies of cocaine intoxication

34. Benzodiazepines • Disadvantages • Respiratory depression

35. Midazolam • Onset: IV - 1-5 minutes • Dose: 2.5-5.0 mg IV/IM q3-5min • Elderly: reduce dose

36. MidazolamBoxed Warning • May cause severe resp depression, resp. arrest or apnea • Initial doses in the elderly or debilitated should be conservative • Parental form contains benzyl alcohol; avoid rapid injection in neonates or prolonged infusions

37. Antipsychotics • Advantages • No respiratory depression

38. Antipsychotics • Disadvantages • Anticholinergic side effects • Impair heat dissipation • Lower the seizure threshold • Prolong the QT interval • Dystonic reactions • Increased mortality in animal studies of cocaine intoxication

39. Haloperidol • Peak: 10-20 minutes • Duration: days • Dose: 2-5 mg IV/IM q20min • Elderly: reduce dose

40. Haloperidol Boxed Warning • None • However, DROPERIDOL • Cases of QT prolongation and torsades de pointes, including some fatal cases, have been reported

41. Olanzapine • Peak: 15-45 minutes • Duration: days • Dose: 5-10 mg IM/SL q2-4h • Elderly: Reduced doses

42. Olanzapine Boxed Warning • Increased risk of death in pts with dementia related behavioral disorders • Increased risk of CVAs in elderly pts with dementia related psychosis

43. Intubation and Paralysis • Ultimate control • Consider in patients with • Risk of C-spine injury • Hyperthermia

44. Succinylcholine • In most cases it will be safe • Hyperkalemia is a risk in the patient with a protracted and fulminant course

45. Hyperthermia

46. Treatment of Hyperthermia • Mist and fan • Ice packs to groin and axilla

47. P: 140; BP 150/95; RR 24; SaO2 98%; T 39.5 C Agitated Pupils 7 mm, reactive Diaphoretic What toxidrome is this? Back to the Case

48. Sympathomimetic Toxidrome • Hyperdynamic vitals • Agitated mental status • Dilated pupils • Diaphoresis

49. What are the causes of death in cocaine intoxication?

50. Cocaine related deaths • Seizures • CVA • MI • Aortic dissection • Dysrhythmias • HYPERTHERMIA How does cocaine cause hyperthermia?