Emergency lectures - Management of the violent patient

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  • DDx: EtOH, drugs (meth, cocaine, PCP), psych, head trauma, post-ictal, hypoglycemia,
  • -242 midwest hospitals-6 month time perios
  • Angry and combative patient’s are usually easily identifiable
  • -Non-reliable identifiers: ethnicity, diagnosis, age, marital status, and education
  • Goal: Identify patient prior to escalation and prevent and/or de-escalate before they become combative
  • Prevent further escalation  quiet single room away from othersConsider expeditious evaluation to help prevent escalation (increasingly important with longer waiting times)Gown – way to search for weapons, and help prevent escapeAnticipate – stand between patient and door. Know basic defense maneuvers.
  • Physician should avoid being a holder to preserve physician-patient relationship
  • Avoid in liver disease, pregnancy
  • Avoid in renal dz, pregnancy
  • Avoid in pregnancy
  • DATA 1997-99Concern that H+L better than monotherapy but with prolonged sedationRCT, prospective, blinded. UCSF/HighlandSent survey to all academic EDs to see what single mostly commonly used agents were = H and LSEDATION = no agitation, no RN or security monitoring. AROUSAL = awakens to verbal command, can count backwards from 10 to 1, follow simple commandsL dropped part way b/c sig more time to sedation and time to awakening.
  • SEDATION = M 18.3 L 32.2 H 28.3AROUSAL = M 819. L 217.2 H 126.6GOAL: if your goal is for your patient to be sedated but not too sleepy for too long so that you can work with them then M is a good choice
  • Avoid in liver disease, movement disorder, breast feeding
  • Lower incidence of EPS
  • Prolonged QTc (torsades), caution in alcoholicsDiscontinued use in many US Eds (including UCDMC) 2/2 QTc concerns
  • RCT, prospective, NOT BLINDED because IRB concerned with pt consentDidn’t use combo L+D because didn’t want lengthy stays (Battaglia)tested IV to eliminate erratic absorption factor and also have most rapid tranq possible.can repeat dose @ 30min x1 for sedation score >= 4 or if sedation inadequate by attendingINCL: undiff'd pts who need sedationEXCL: visible/suspected head trauma, anti ACH toxidrome, prior NMS hxrated on 6pt sedation scale at 0,5,10,15,30,60 min. VS @ 0 and 60
  • SE = sig reduction in HR, SBP, RR, Temp in both groups, equallyRESULTS: SMALLER NUMBER BETTER.CONCL: IV D more rapid and better sedation than IV L.
  • Dystonic reaction – spasm of face, neck, and jaw muscles. Rhesussardonicus (lock jaw), dysphagia. Differing incubation periods
  • Caution in dementia
  • WE AREN’T ALLOWED TO DO IT!SE: if excessive secretions, then airway issues after K. HTN and tachy: BAD WITH INC ICP IN TBI/CHI AND AGITATED DELIRIUMHTN/tachy may worsen CV effects of +stim
  • be careful with RSI and intubationmay be considered assault and batterysimilar to issues with physical restraints.malpractice suit because of itneed good documentation listing why you chose to restrain pt in a particular way.

Transcript

  • 1. Joshua Radke, MDUC Davis Emergency Medicine
  • 2. Disclosures None
  • 3. Outline Epidemiology Verbal Management Physical Restraints Chemical Restraints
  • 4. Case 50’s yo male brought in by police Patient already handcuffed to the backboard, spit mask in place, otherwise naked Thrashing on gurney, screaming at staff and police Abrasions to face, smells of EtOH
  • 5. Violent Society Injury is the leading cause of death in those < 44 yo Homicide is the 2nd leading cause of death in 15-24 yo Rate of death from firearms is 8x in US than other countries
  • 6. Violence in the EmergencyDepartment (ED) Survey of emergency care workers Majority were verbally threatened 51% of physicians physically assaulted 67% of nurses physically assaulted Gates DM, J Emerg Med 2006
  • 7. Weapons in the ED ~4-8% of the ED population carries a weapon In one study, 26.7% of major trauma patients had a weapon
  • 8. Signs and Symptoms Provocative behavior  Pounding walls Angry demeanor  Throwing things Pacing  Gripping arm rails intensely Loud/pressured speech  Clenched fists
  • 9. Positive Predictors of Violence Male gender Prior history of violence Psychiatric illness Drug or ethanol abuse
  • 10. Early Recognition  Anger  Resist authority  Confrontational  Combative
  • 11. Prevention Isolate from other provocative patients/friends/family Hospital gown Anticipate combativeness while talking with patient
  • 12. Management Options Verbal de-escalation Physical restraints Chemical restraints
  • 13. Verbal De-escalation Calm, slow talking Be firm and assertive Avoid argumentative or condescending language
  • 14. Physical Restraints Prevention of harm to patient or others Should not be applied for convenience or as a punitive measure
  • 15. The Team Approach 5+ people Team leader 1 person for each extremity
  • 16. Physical Restraints
  • 17. What Not To Do
  • 18. What Not To Do Hobble Restraint
  • 19. Hobble Restraint• 30yo M, erratic bike riding in street• Handcuffed, hobble restraint, prone transport• Unresponsive, agonal  Asystolic• No ROSC with ACLS• +EtOH, nonlethal meth and amphetamineCause of Death: positional asphyxia with excited delirium
  • 20. Adverse Effects - Prone Vomiting  Neuropraxia Aspiration  Fractures/ dislocations Dysrhythmias Commotio cordis Skin breakdown Limb ischemia
  • 21. Chemical Restraint Benzodiazepines Typical antipsychotics Atypical antipsychotics Combination therapy Endotracheal Intubation
  • 22. ACEP PolicyLevel B recommendations• Use a benzodiazepine or a conventional antipsychotic as effective monotherapy for the initial drug treatment of the acutely agitated undifferentiated patient in the ED.Level C recommendations• The combination of a parenteral benzodiazepine and haloperidol may produce more rapid sedation than monotherapy in the acutely agitated psychiatric patient in the ED.
  • 23. Ideal Therapy• Works rapidly• Effective with multiple routes of administration• Does not interact with other sedating agents• Not addictive• Immune to tolerance• Minimal cardiorespiratory depression• Low side effect profile
  • 24. Benzodiazepines Diazepam Lorazepam Midazolam
  • 25. Diazepam PO  Dose: 5-10 mg  Onset: 1-2 hours  Half-Life: 30-60 minutes IV  Dose: 2-10 mg  Onset: 20-30 minutes
  • 26. Lorazepam PO  Dose: 1-2 mg  Onset: 16 hours  Half-Life: 14 hours IM  Dose: 0.5 – 2 mg  Onset: 20-30 min IV  Dose: <2 mg/min  Onset: 5-20 min
  • 27. Midazolam IM  Dose: 5-15 mg (q15 min)  Onset: 15-20 min  Half-Life: 2-6 hr IV  Dose: 1-2 mg q2-3 min  Onset: 1-5 min  Half-Life: 2-6 hr
  • 28. Nobay et al, 2004• Midazolam > lorazepam and haloperidol in time to sedation and arousal• 5mg IM midaz, 5mg IM haldol, 2mg IM loraz • Academic EDs use these• Measured time to sedation and arousal• Lorazepam dropped midway in study
  • 29. Nobay et al, 2004SE: no sig differences in SBP, DBP, HR, RR, O2 sat
  • 30. Typical Antipsychotics Haloperidol Droperidol
  • 31. Haloperidol PO  Dose: 5-10 mg  Onset: 2-6 hr  Half-Life: 12-18 hr IM  Dose: 5-10 mg  Onset: 30-60 min IV  Dose: 1-2 mg  Onset: 30-60 min
  • 32. ACEP Clinical PolicyLevel B recommendations • If rapid sedation is required, consider droperidol instead of haloperidol.
  • 33. Droperidol IM/IV  Dose: 0.625-1.25 mg  Onset: 30 min  Half-Life: 2-4 hr
  • 34. Richards et al, 1998• Compare lorazepam to droperidol• 5mg IV lorazepam or 5mg IV droperidol • If <50 kg, half dose • Can repeat @ 30” x1• Measured sedation scale • 0 = very sedated ; 5 = not sedated
  • 35. Richards et al, 1998• SE: sig  HR, SBP, RR, temp @ 60min both groups• 40 add’t doses lorazepam vs 8 doses droperidol
  • 36. Droperidol
  • 37. Extrapyramidal Symptoms
  • 38. Atypical antipsychotics Risperidone Olanzapine
  • 39. Risperidone PO  Dose: 1-3 mg  Onset: 30-60 min  Half-Life: 20 hr
  • 40. Olanzapine PO  Dose: 10-20 mg  Onset: 5-8 hr  Half-Life: 20 hr IM  Dose: 5-10 mg q4 hr  Onset: 15-45 min
  • 41. Other Ketamine  IM ○ Dose: 4-5 mg/kg ○ Onset: 4-5 min ○ Half-Life: 30-60 min  IV ○ Dose: 1 mg/kg ○ Onset: 1 min ○ Half-Life: 15 min
  • 42. Beware • Excessive secretions  airway issues • HTN and tachycardia • Unknown interactions with PCP/special K
  • 43. Combination Therapy Benzo + antipsychotic Lorazepam Haloperidol Combo Decreased + ++ ++++ Agitation Cumulative +++ ++ +++ Sleep
  • 44. Combination Therapy -Regimens Lorazepam + Haldol  2 mg Lorazepam  5 mg Haldol  IM/IV Midazolam + Haldol  5 mg Midazolam  5 mg Haldol  IM/IV
  • 45. Endotracheal Intubation•  LOS 0.7d (not sig)•  $ (107%)•  RN care (4.5hrs QD)•  ICU time (2d) Kuchinski, 1989
  • 46. References Ng, Vivienne. “My Chemical Romance with the Agitated and Combative Patient.” Grand Rounds Lecture 2011. Rosen, Peter, John A. Marx, Robert S. Hockberger, Ron M. Walls, James G. Adams, and Cynthia K. Aaron. “Chapter 188: The Combative Patient." Rosens Emergency Medicine: Concepts and Clinical Practice. Philadelphia: Mosby Elsevier, 2010.
  • 47.  Questions??