Managing the Agitated, Intoxicated Patient

1. Managing the Agitated, Intoxicated Patient Terrence Mulligan DO, MPH FACEP, FAAEM, FACOEP, FIFEM, FNVSHA, HPF Clinical Associate Professor, Department of Emergency Medicine University of Maryland School of Medicine, Baltimore, Maryland USA Extraordinary Senior Lecturer, Stellenbosch University, South Africa Board Member, International Federation for Emergency Medicine Board Member, African Federation for Emergency Medicine Immediate Past Chair, ACEP Section for International Emergency Medicine Co-Chair, AAEM International Emergency Medicine Committee

2. LECTURE OUTLINE • Case Presentation • Definitions • Agitation • Aggression • Violence • Medical causes of altered mental status • Management of the violent patient • Social, verbal and design / operational • Chemical and physical restraints • Questions

3. Case Presentation • On day 1 a 22 yr male is brought to ED for strange and unruly behavior at home. • His mother had brought him in because he had not slept for the past 4 nights, was not eating, was pacing the apartment “damning people to hell” and stating “Now I’m a fish that Jesus is pulling out of the water!” • Both mom and the patient denied any drug use. The patient had no past medical history, was not on any medications, and had no allergies. He agreed to speak to a psychiatrist but did not understand why

4. Case Presentation • On physical exam • vital signs were: BP 130/75, pulse 90, respirations 14, temp. 98.5 • He was well kept and mildly agitated • HEENT: EOMI, PERRL • neck supple • Heart: S1S2 RRR no MRG • Lungs: clear to bases • Abdomen: soft, nontender, no masses • Extremities: atraumatic, no C/C/E • Neuro: strength 5/5, sensory intact, normal gait • Laboratory workup included: CBC normal, Chem normal, urine toxicology screen negative, serum toxicology screen and alcohol negative. • The psychiatric assessment was mania. The patient was not felt to be a harm to himself or others, and he agreed to take lorazepam. He was given a follow up appointment in 2 days.

5. Case Presentation • On day 2 his mother brought the patient to the front door of the ED. • He believed he was there because his mother was sick and needed to be seen • He refused to come into the front door because "the people here are going to kill me“ • Mom stated he refused to take the medication he was prescribed and when he got home yesterday began throwing plates, glasses and furniture around the apartment, yelling, "Jesus is coming, here I am“ • Once in the ED, the patient refused to enter a room or be examined instead pacing up and down the main hall yelling, "Jesus is coming, here I am“ • When security approached him he attempted to punch one of the officers.

6. QUESTIONS to consider • Causes for this behavior • Methods of approaching the patient for • Evaluation • Medical treatment • Prevention of injury to patient & staff • Medico-ethical & medico-legal aspects

7. DEFINTIONS:Agitation / Aggression / Violence • AGITATION • a mental state of extreme emotional disturbance • AGGRESSION • verbal aggression • physical aggression against objects or against people or towards oneself • VIOLENCE • physical aggression by one person against another • Crime is defined as the intentional violation of criminal law • Hostility is a loosely defined term and can refer to aggression, irritability, suspicion, uncooperativeness, or jealousy.

8. Definitions and Descriptions of Altered Mental Status Coma : A state of profound unconsciousness from which one can not be roused Obtundation : A level of consciousness responsive only to deep pain Stupor : Marked decrease in reaction to environmental stimuli Lethargy : Resembling profound slumber, can be aroused but immediately relapses Delirium : A clouded state of consciousness and confusion, difficulty concentrating, disordered thinking/perception Dementia : General mental deterioration with disorientation, impaired memory, judgment and intellect Brain death

9. Pathophysiology of Altered Mental Status

10. Other Common Causes of Altered Mental Status • Infection • Toxic • Metabolic • Hypoxemia • Hypercarbia • Cerebrovascular • CNS • Psychiatric

11. DELERIUM Global impairment of cognitive function Acute in onset 65 and older most commonly affected Reversible Difficulty with attention and recent memory Hallucinations Sleep-wake cycle affected Underlying causes PSYCHIATRIC Global and progressive impairment of cognitive function Gradual Illness can make acutely worse Many underlying causes Irreversible? DELERIUM vs. FUNCTIONAL / PSYCHIATRIC

12. EMERGENCY MEDICINE REPORTSEMRonline.com

13. DON’T MISDIAGNOSE YOUR PATIENT!

14. IS THIS ORGANIC, PSYCHIATRIC, TOXICOLOGIC, etc?

15. Pitfalls in the Management of Patients with Altered Mental Status • Assuming ETOH / drugs / dementia are responsible • Not considering hypoglycemia • Failure to consider C-spine injury • Non-aggressive airway management • Failure to obtain ECG • Inadequate exam • Not recognizing toxidromes • Delays in imaging the brain

16. Approach to the Patient With Altered Mental Status • Primary survey • Immediate interventions • Diagnostic studies • Supportive care • Secondary survey

17. Neurologic Examination • Pupillary exam • Respiratory patterns • Posture and spontaneous movements • Cranial nerve exam • Extraocular movements • Glasgow Coma scale

18. Emergency Approach to Psychiatric Evaluation • Recognition • Chief complaint • Be wary of “medical clearance” • Triage • VITAL SIGNS • Physical exam • Determine potential life threats • Psychiatric interview • Mental Status Exam

19. Psychiatric interview • Open-ended, undirected questions about chief complaint • Past medical/psychiatric history, onset of illness • Mental status exam: • Appearance, consciousness, speech, orientation, memory, calculation, judgment • Summary

20. Who needs emergent psychiatric consultation? • Acutely psychotic • Suicidal • Homicidal • Patient is a danger to self or others • New psychiatric symptoms or acute worsening

21. Emergency Situations Requiring Emergent Intervention • Life threatening illness • Is patient a threat to self or staff? • Behaviors indicative of serious psychiatric illness • Violence • Abrupt changes in behavior during interview • Listen to your staff! • Fear of losing control

22. MANAGEMENT OF THE VIOLENT PATIENT • Common problem in the emergency department • It is important once a patient becomes violent to protect the patient and the staff from harm • With proper management, injury to staff and patient may be prevented

23. THE VIOLENT PATIENT: Typical Profile • Male • 15 to 30 years old • Alcohol or Drugs history on board • Low education • Residential Instability • Unemployed • Known Violent History • Expresses Intent To Harm

24. The Violent Patient:Psychiatric history • Schizophrenic disorders • Mania, depression • Antisocial personality • Lying, stealing, defiant behavior • Adjustment Disorder • Medical Disorders

25. The Violent Patient:Tactics/Measures to Decrease Violence • Verbal • Social • Design / operational

26. The Violent Patient:VERBAL INTERVENTIONS • Try to understand patient’s situation • Provider must voice expectations firmly • Don’t lie or be dishonest • Don’t be patronizing / accusatory / insulting • “Show of force” team-- 4 to 5 people

27. The Violent Patient:VERBAL INTERVENTIONS • Avoid eye contact with patient. • Do not block exits and leave door to room open. • Maintain distance from potentially violent patient; do not invade the patient's "space“ • Adopt passive, non-confrontational posture and attitude, and allow patient to ventilate his feelings. Develop a therapeutic alliance with the patient. • Treat patient as you expect him to behave.

28. The Violent Patient:VERBAL INTERVENTIONS • Offer food or drink or blankets, etc. • Do not make challenging, provocative, or belligerent remarks. • If patient acts out, tell patient directly “your behavior is frightening others and we cannot allow such behavior” • Do not turn your back on potentially violent patient. • Never underestimate the potential for violence.

29. The Violent Patient:SOCIAL INTERVENTIONS • Seclusion • The placing of a patient alone in a locked room from which he/she cannot leave • A specific room in which a patient is secluded must be • Observable • devoid of any potentially harmful objects • meet the local health code for such rooms • If the patient does not respond to seclusion then physical restraints may be necessary.

30. The Violent Patient:Design & Operations • Security Personnel • Highly visible • Always available • Respond to incidents in force • Alert systems / “Panic Buttons” • to alert staff & security of a problem • Access-limited entry points • Closed-circuit video surveillance • Search patients / visitors - remove weapons

31. The Violent Patient:Indicators of escalation to violence • Patient exhibits or threatens violence. • Patient makes ED staff anxious or fearful. • Behavior alternates between shouting and dozing, and between cooperation and belligerence. • Patient expresses fear of losing control.

32. The Violent Patient:Indicators of escalation to violence • Patient is uncooperative, hostile, agitated and unable to sit still. • Patient is intoxicated with alcohol or other chemicals or withdrawing from drugs. • Patient has a past history of violence. He is a "Frequent flyer" known to police or ED staff for violence or impulsive behavior. • Patient has tense, rigid posture, is easily startled and suspicious. All of these warning signs should be taken seriously and when recognized should be discussed among the staff in order to protect the patient and the staff from harm

33. The Violent Patient: Use of physical restraints • When it becomes clear that the patient will not cooperate and is not responding to intervention, then restraints are indicated to prevent injury to patient and staff

34. PHYSICAL RESTRAINT INDICATIONS • When verbal and social intervention fails • Prevent harm to patient or staff • Intentional / unintentional / accidental • Prevent disruption of treatment • To honor a patient’s request for them

35. Restraint Application • Must have organized approach for calling security and applying restraints • Application of restraints requires a team approach with one member of the team controlling the patients head and a member of the team controlling each of the patients extremities • Restraints are a reasonable choice with few side effects if used in appropriate situations

36. Restraint Application • Personnel to be included: • Security / police • Use of force / restraining techniques • search for weapons • Physicians • Nurses • ?? Family • ?? Psychiatry

37. How to restrain a patient: • Verbal restraint should be attempted first • Quiet, empty room • Keep safe distance • Physical restraint • Team leader plus 5 helpers: security, head nurse, attending • Explain to the patient what you are doing and why

38. How to restrain a patient: • Team of 4 or more people with assigned roles • At least one person per limb • Inform the patient of your intent to apply restraints • Position to avoid aspiration • Check circulation at all extremities • Remove restraints gradually • Proper documentation of the procedure to remain in compliance, including indications

39. Physical restraints: Clinical Pearls • Always use leather / sturdy restraints • The patient should be restrained in the supine position or on the side to allow for a patent airway • Be certain to search the patient for weapons • Do a complete physical exam • Document and explain the need for restraint application

40. Physical restraints: Clinical Pearls • YOU MUST USE CHEMICAL RESTRAINTS WITH PHYSICAL RESTRAINTS • Ensures control • Decreases medical / physical complications • Agaitation / Injury / rhabdomyolysis • Failure can constitute assault & battery / abuse

41. Physical Restraint Adjunctive Therapy Chemical restraint is a key and necessary component of physical restraint • Benzodiazepines • Lorazepam 1-2 mg IV / IM • Diazepam 2.5-5 mg IV / IM • ?? midazolam • Neuroleptics • Haloperidol 5mg IV / IM

42. THREATS OF VIOLENCE:The Tarasoff Obligation • The physician has a duty to warn a potential victim of a patients plan to harm them • This does not violate physician / patient obligation of confidentiality • The physician may be held negligent for failure to warn a potential victim of a patients expressed plan of violence against them

43. Question #1 A patient presents to your ED. He psychotic and combative. You have already tried to verbally calm this patient. Your next step is: • Give him 2mg lorazepam IM • Put him in a closed, empty room and close the door • Call a psychiatry consult • Call for assistance and demonstrate a “show of force”

44. Question #1 • A patient presents to your ED. He psychotic and combative. You have already tried to verbally calm this patient. Your next step is: • Give him 2mg lorazepam IM • Put him in a closed, empty room and close the door • Call a psychiatry consult • Call for assistance and demonstrate a “show of force”

45. Question #2 To safely restrain a violent patient all are needed except: • A calm and non-judgmental approach • A written restraining order • At least 3 people to assist • A clear explanation to the patient

46. Question #2 • To safely restrain a violent patient all are needed except: • A calm and non-judgmental approach • A written restraining order • At least 3 people to assist • A clear explanation to the patient

47. Question #3 One of the safest drugs for sedation of agitated patients in the ED is: • midazolam • haloperidol • risperidone • chlorpromazine [thorazine]

48. Question #3 One of the safest drugs for sedation of agitated patients in the ED is: midazolam haloperidol risperidone chlorpromazine [thorazine]

49. Question #4 • A key feature that distinguishes delirium from dementia / psychiatric causes is: • Memory loss • Acute onset • Psychotic elements • Disorientation

50. Question #4 • A key feature that distinguishes delirium from dementia / psychiatric causes is: • Memory loss • Acute onset • Psychotic elements • Disorientation