Case 13 year-old autistic male here for surgical repair of pectus, now yelling, throwing things at nurses
Initial Approach To TheAgitated/Assaultive PatientCall securityAssess Environment, Physical demeanorTake verbal threats seriouslyRemain several feet awayKnow where the patient is at all timesClear the area of other patientsRemain calm, maintain confident andcompetent demeanorAvoid arguing with staff in front of patientRestraints
Non-Pharmacologic InterventionsJaacap, Agitation Treatment for Pediatrics
CHEMICAL RESTRAINT Involuntary use of psychoactive medication in a crisis situation to help a patient contain out-of-control aggressive behavior Necessary for safety of patient and staff when other methods of calming are inappropriate or not successful Parental consent not required due to emergent circumstances IM/IV/PO 8
Symptom Focused TreatmentWith Medication Treatment provided with the consent of the patient’s legal guardian and the age-appropriate assent of the child Usually PO 9
Characteristics of Ideal MedicationUsed for Acute Aggression Rapid onset Medium-long duration Multiple formulations Low interaction with other medications Low adverse reactions Broad anti-aggressive property
Potential Short-Term Side-Effects: Antipsychotics Leukopenia Avoid if ANC < 1000 Close monitoring in immunosuppressed patients 20
Neuroleptic Malignant Syndrome (NMS) Idiosyncratic response to anti- psychotics Have been reported with all types of antipsychotics, including atypicals Prevalence - 0.07-0.2% 5-30% mortality Can occur within hours of the first dose but usually 4-14 days Caused possibly by decreased dopamine
Treatment Stop antipsychotic Consider other medical causes Supportive care, IV hydration Benzodiazepines (Ativan) Dopamine agonists - Bromocriptine, Levodopa Muscular skeletal relaxant - Dantrolene
Case Example 16 year-old oncology patient recently discharged from OICU after 4 month stay now in clinic with psychosis, agitation after being home for less than a week. No personal or family history of psychotic disorder.
Alcohol/Benzo Withdrawal Can occur 12-24 hours after last drink Tremor (“shakes”) Tachycardia, diaphoresis, anorexia, insomnia Generalized seizures after 1-3 days Delirium tremens after 3-5 days Fever, disorientation, visual hallucinations, autonomic instability, agitation Need to be monitored in ICU setting
Treatment Thiamine to prevent Wernicke Encephalopathy (confusion, ataxia, ophthalmoplegia) IV hydration Electrolytes replacement Benzodiazepines Librium (25-50 mg PO PRN) Lorazepam (1-2 mg PO PRN)
Delirium Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) Reduced ability to focus, sustain, or shift attention. A change in cognition (such as memory deficit, disorientation, language disturbance) Development of a perceptual disturbance The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.
Treatment Treatment of the underlying cause Assessment of clinical status-harm to self or others Environmental manipulation (Calendar, Newspaper, Blinds opened/closed appropriately) Restraints Pharmacological Antipsychotics Haldol 0.5 – 5 mg po q6 prn (PO/IV/IM) Risperidone 0.5 – 2.0 mg po q6 prn (PO/SL) Benzodiazepines – not recommended
Treatment of Agitated Patient Treat any underlying medical pathology Non-Pharmacological Interventions Symptom Focused Treatment Chemical Restraint 33