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.
Emergency lectures - Management of the violent patient
Outline Epidemiology Verbal Management Physical Restraints Chemical Restraints
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
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
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
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
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
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.
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
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
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
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
Nobay et al, 2004SE: no sig differences in SBP, DBP, HR, RR, O2 sat
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
Richards et al, 1998• SE: sig HR, SBP, RR, temp @ 60min both groups• 40 add’t doses lorazepam vs 8 doses droperidol
Endotracheal Intubation• LOS 0.7d (not sig)• $ (107%)• RN care (4.5hrs QD)• ICU time (2d) Kuchinski, 1989
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.