Dealing with Agitated Patients - Agitated Delirium Emergency Care

1. Dealing with Agitated
Patients
By Rob Keating

2. To Discuss
Causes of Agitation
Excited Delirium
Safety
Restraint – Physical
Hypoxia
Restraint – Chemical

3. Video

4. Causes
Brain Injury
Medical Condition – Neurological / Infection
Drug Related
Consider reversible causes – Hypoglycaemia
Hypoxia
Hypotension
Pain
Regardless of the Cause – Follow the same steps

5. Excited Delirium - ExD
Autopsies reveal elevated levels of dopamine.
Drugs ( Cocaine or Bath Salts) blocks re-uptake of
dopamine resulting in elevated levels.
Many ED patients have psych history as well.
The combination basically leads to a runaway train
effect where the body's metabolism increases to the
point acidosis and other imbalances cause
respiratory and cardiac arrest.

6. The Presentation
Psychotic behavior
Aggressive behavior
Hyperthermia
Sweating
Screaming or Roaring
Remember mnemonic :
NOT A CRIME

7. “N-O-T- A- C-R-I-M-E”
• Naked = stripping off clothing and sweating profusely
• Objects = recall violence against objects, especially glass, shiny objects
• Tough = the person is very strong, unstoppable, seemingly endless
endurance, and a diminished pain or insensitivity to pain
• Acute onset = You are told the person “just snapped”
• Confused = The person is unsure who (s)he is, where (s)he is located, why
(s)he is there, and lacks perception
• Resistant = The person cannot or refuses to follow commands to stop
his or her behavior.
• Incoherent speech = The person is shouting; bizarre content
• Mental health issues or Makes you feel uncomfortable
• Early EMS request, back-up request, and supervisor request.

8. Safety
Am I going to get hurt?
Are they going to hurt themselves?
What can I do to prevent this?

9. Safety
Assess the Scene
Confirm the scene is under control
Maintain Situational Awareness
Have a safe exit planned
Try Verbal de-escalation – and non confrontation FIRST
If not working – Be ready to Restrain patient

10. Hypoxia :
Lethal Combinations
Accelerated Metabolism – Drug induced

11. Hypoxia :
Lethal Combinations
Accelerated Metabolism – Drug induced
Catecholamine ( Adrenaline ) Release – Injury / Fear

12. Hypoxia :
Lethal Combinations
Accelerated Metabolism – Drug induced
Catecholamine ( Adrenaline ) Release – Injury / Fear
Police - Choke Holds

13. Hypoxia :
Lethal Combinations
Accelerated Metabolism – Drug induced
Catecholamine ( Adrenaline ) Release – Injury / Fear
Police - Choke Holds
Police - Tear Gas

14. Hypoxia :
Lethal Combinations
Accelerated Metabolism – Drug induced
Catecholamine ( Adrenaline ) Release – Injury / Fear
Police - Choke Holds
Police - Tear Gas
Police - Hog Tied Position

15. Hypoxia :
Lethal Combinations
Accelerated Metabolism – Drug induced
Catecholamine ( Adrenaline ) Release – Injury
Police - Choke Holds
Police - Tear Gas
Police - Hog Tied Position
Police – Kneeling / Pressure on back

16. Hypoxia :
Lethal Combinations
Accelerated Metabolism – Drug induced
Catecholamine ( Adrenaline ) Release – Injury / Fear
Police - Choke Holds
Police - Tear Gas
Police - Hog Tied Position
Police – Kneeling / Pressure on back
Police – Spit Mask / Pillow case / T-shirt

17. Hypoxia :
Lethal Combinations
Accelerated Metabolism – Drug induced
Catecholamine ( Adrenaline ) Release – Injury / Fear
Police - Choke Holds
Police - Tear Gas
Police - Hog Tied Position
Police – Kneeling / Pressure on back
Police – Spit Mask / Pillow case / T-shirt
Police – Tazer

18. Video

19. Hypoxia - New Zealand

20. Verbal restraint—Any verbal communication from a prehospital provider to a patient utilized for
the sole purpose of limiting or inhibiting the patient’s behavior.
• Physical restraint—Any method in which a technique or piece of equipment is applied to the
patient’s body in a manner that reduces the subject’s ability to move his arms, legs, head or
body.
• Chemical restraint—Any pharmaceutical administered by healthcare providers specifically
for the purpose of limiting or controlling a person’s behavior or movement.
•

21. Physical Restraint
Ideally 5 People
One person for each
extremity
Restrain SUPINE on
Scoop Stretcher
Tie arms opposite corners
Secure knees and hold
head down
Eliminate dangers of
Hypoxia

22. Reversing Hypoxia
Position
Oxygenate
Check Temp + Cool
Monitor ETCO2

23. Chemical Restraint
Administer chemical sedation as soon as possible
Chemical sedation : Ketamine or Paralytic Agent is best
Caution : Ketamine with Cocaine OD

24. Affordable Realistic Tactical Training 24
Best Approach
Access
Capture
Control Restrain Sedate
Transport
Chart
Plan

25. ExD Cards

26. compiled by Jenni Brackenreg
The art of anticipating:
A skilled practitioner anticipates the
potential for a catastrophic reaction to
occur and takes steps to avoid it
developing.

27. Summary
Safety First
Teamwork – Police and EMS
Sedation is best – so call for it – call early
=