View stunning SlideShares in full-screen with the new iOS app!Introducing SlideShare for AndroidExplore all your favorite topics in the SlideShare appGet the SlideShare app to Save for Later — even offline
View stunning SlideShares in full-screen with the new Android app!View stunning SlideShares in full-screen with the new iOS app!
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.