management of the agitated patient adam watchorn july 28, 2011
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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? . - PowerPoint PPT PresentationTRANSCRIPT
Management of the Agitated PatientAdam 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?
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?
Reversible or Potentially Treatment Conditions
GOT IVS • Glucose – hypoglycemia• Oxygen – hypoxia• Trauma – brain, pain• Infectious – meningitis, encephalitis• Vascular – stroke, SAH• Seizure
45MCC: “I feel sick to my stomach”
PMHx: Smoker, ETOHPsychHx: 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
COULD THIS HAVE BEEN PREVENTED?
28M BIBPSmashed store windows and lit car on fire
4 officers required to restrain him
He’s already TASERED twice
PMHx: BipolarMeds: Lithium, Celexa
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
When would you consider physical restraints?
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!!!
What are some complications?
Complications of physical restraints
Local trauma
Aspiration
Rhabdomyolysis
Positional Asphyxia
I’ve been TASERED!
A) None
B) ECG
C) ECG, Troponins
D) ECG, Troponins, ECHO
I’ve been TASERED!
A) None
B) ECG
C) ECG, Troponins
D) ECG, Troponins, ECHO
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.”
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
Medical Emergency: Resuscitation room
Agitation: Benzodiazepines +/- Intubation
Hyperthermia: COOL – fluids, ice
Acidosis: Bicarb 1-2 amps?
DESPITE YOUR MANAGEMENT PLAN HE CONTINUES TO STRUGGLE THEN SUDDENLY GOES LIMP
MONITOR SHOWS ASYSTOLE
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
Why do these patients die?
Multifactorial• Positional asphyxia• Hyperthermia and acidosis• Catecholamine-induced fatal arrhythmias• Stress cardiomyopathy
WHAT’S YOUR FAVOURITE CHEMICAL SEDATION?
75MAdmitted 8 days ago for NSTEMI
36.5, 62, 136/74, 96%Bizarre behaviourAgitated 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!
Risperidone 2mg + Ativan 2mg
Haldol 5mg + Ativan 2mg
5 – 10 mg IM q30min
Acute Extrapyramidal Syndromes
Haldol injection IM = 5% chanceHigher with repeat injections
Cogentin 1-2 mg IV (IM,PO)Benadryl 25-50 mg IV (IM,PO)
Should long QT intervals worry us?
Proportion (%) of abnormal QT intervalsDORM STUDY
Drop 10 mg Midaz 10 mg Drop 5 mg + Midaz 5 mg
0
2
4
6
8
10
12
14
16
67
14
IS THERE A BENEFIT OF COMBINING HALDOL AND ATIVAN?
SEDATION MORE RAPID WITH COMBINATION
% PATIENTS WITH EPS SYMPTOMS
Haldol 5 mg Ativan 2 mg Haldol 5 mg + Ativan 2 mg
0
5
10
15
20
25
20
3
6
WHAT MEDICATION WORKS THE FASTEST?
Mean time to sedation, min
Midaz 5 mg Haldol 5 mg Ativan 2 mg0
5
10
15
20
25
30
35
18.3
28.3
32.2
However, no mention of side effects…..
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?
SUMMARY OF CHEMICAL SEDATION
ORAL FIRSTRISPERIDONE 2.5 MG + ATIVAN 2 MG
UNDIFFERENTIATED AGITATION1) HALDOL 2 – 10 MG + ATIVAN 2-4 MG2) MIDAZOLAM 5-10 MG
AGITATION RELATED TO PSYCHOSIS1) HALDOL 2-10 MG + ATIVAN 2-4 MG2) OLANZEPINE 10 MG
55MBIBA collared/boardedFell down flight of stairs
Smells of AlcoholGCS 12 (E3, V4, M5)36.1, 76, 172/86Large scalp hematoma
Becomes AGITATED and AGGRESSIVE to staff and pulls out his IV and and pulls off his collar
What are your management priorities?
Management
• Agitation: Sedation Intubation– Protect C-spine– Facilitate CT scan
• Prevent Hypoxia and Hypotension
Take away points
1) Your voice + Oral Meds when possible2) Perform an early assessment because:– Agitation + Abnormal VS = emergency– Agitation + Head trauma = emergency
3) Be aware of the complications with restraints and chemical sedation
4) Choose your weapon wisely (Haldol, Ativan, Midazolam, Olanzepine, etc)
Questions
Thanks for listening!Thanks to Colleen Carey!