Sedation/Pain Control/Anesthesia 2: Management of Combative, Agitated, Delirious Patients
The manifestations of an acute psychiatric emergency may vary considerably ranging from a violently aggressive patient, possibly armed with a dangerous weapon, to a delirious patient displaying varying degrees of verbal or physical agitation. The initial approach to such a patient requires consideration of multiple factors including:
- The need to protect the physical safety of the health care providers and patients.
- The potential diagnosis and treatment of reversible causes for the altered behavior.
- Methods to control the potentially dangerous behavior.
Potential underlying etiology:
A
wide variety of medical conditions may contribute to the development of
delirium in a patient. Frequently many organic causes coexist
in
a susceptible patient.2 (See
Vol I—PATHWAY 1 Altered Level of Consciousness for a discussion of causes.) A thorough history, a
careful physical examination with special attention to abnormal vital
signs, and a psychiatric assessment are all necessary in identifying
the presence of an organic vs. functional psychiatric cause for the
abnormal behavior.4 The team must be diligent in their search for an
organic cause for the patient’s behavior, remembering that a new onset
of acute psychosis in patients older than 40 or under 12 years of age
suggests an organic etiology.
The following is a partial list of conditions that may be associated with violent, agitative, or delirious behavior1,2,3,4:
- Infections – UTI, respiratory, skin and soft tissue, sepsis, central nervous system.
- Fluid and electrolyte disturbances – dehydration, hyper/hyponatremia, hyper/hypocalcemia.
- Metabolic disorders – hypo/hyperglycemia, uremia, liver failure.
- Hypoxia
- Drug toxicity – alcohol, cocaine, hallucinogens, lithium, digoxin, phencyclidine, amphetamines, narcotics, barbiturates, anticholinergic meds, etc.
- Drug withdrawal – alcohol, barbiturates, etc.
- Encephalopathy – hypertensive, Wernicke’s.
- Intracranial trauma or hemorrhage.
- Poisoning
- Seizure or postictal state.
- Functional disorders – schizophrenia, personality disorders, etc.
- Dementia of any type.
- Use of a bladder catheter or the presence of a distended bladder.
- Low hematocrit (< 30%).
- The stay in an ICU, multiple room changes, lack of a clock or window or glasses or hearing aid.
Determination of the probability of medical vs. psychiatric cause for
the patient bring agitated/delirious:
Patients
with a medical cause for their abnormal behavior are more likely to
have an abrupt onset of their symptoms, be greater than 40 years old,
have impaired cognitive function, and have abnormal vital signs. If
they have hallucinations, they usually describe them as either visual
or tactile and are rather unorganized. Recent
hospitalizations or
surgery, history of multiple medications or substance abuse, seizures,
nystagmus, diaphoresis, or trauma also increase the likelihood that the
cause is organic rather than functional or psychiatric. On the other
hand, patients with a psychiatric or functional cause for their
abnormal behavior tend to have a more gradual onset of their symptoms,
are less than 40 years old, and have their cognition intact. Their
hallucinations tend to be auditory, more organized, bizarre, and
grandiose. Their vital signs are usually normal and they frequently
have a psychiatric history.4
General approach to the combative/ delirious patient:
There
seems to be an increasing number of patients that we encounter in our
hospitals, especially the Emergency Department, who are agitated or
potentially violent. There frequently are organic factors (see above)
that contribute to the patient’s disruptive or aggressive behavior. The
very nature of the unfamiliar environment and treating personnel is
often threatening to an ill or injured patient.
When approaching an agitated patient there are some historical and behavioral features that help to identify the potentially violent patient. Some of these features include3:
- Previous history of the patient demonstrating impulsive or violent behavior
- Patient’s behavior is aggressive, tense, macho, or associated with loud speech.
- Patient is a young male.
- Suicidal ideation
- Recent or threatened loss of job, home, or significant other
- Cognitive impairment
- Psychosis, especially paranoia
- The ingestion of psychoactive drugs or alcohol
The approach to a violent patient requires forethought and preparation. Remember: do not put yourself or others in danger. It is imperative that adequate numbers of staff and/or police and security personnel are present before approaching the patient. The number of helping personnel required depends on the patient’s size and strength. A patient with a gun or other weapon must not be seen for treatment until the weapon has been removed. Do not ask the patient to hand you the weapon but rather ask them to put it down and move away from it. The assessment of a potentially violent patient should be in an area where there is easy access to an open door for both the staff and the patient to escape. There are some patients who are so dangerously violent that the health care team members should not be involved in their initial restraint. In these circumstances, security personnel and/or police need to provide the initial patient restraint so that it is safe for the health care team to assess the patient’s needs.
Management of the combative/delirious patient:
The
management of the potentially violent or agitated patient may require
one or many techniques. General approaches to the control of these
patients include verbal management, physical restraints, or chemical
restraints.
Verbal management includes3:
- Speaking in a calm, simple, nonjudgmental manner
- Keep the door of the room open and allow equal access to the door for the patient and the health provider.
- Try not to keep the patient waiting.
- Allow the patient an opportunity to vent his or her feelings.
- Keep your distance from the patient.
- Try to form an alliance with the patient.
- Do not threaten the patient or appear dominant over the patient.
Physical Restraint3:
Sometimes
attempting to “talk a patient down” is unsuccessful or impractical. In
these cases, physical restraint (often followed by chemical restraint)
may be necessary. While restraints may raise some potential legal
issues, the ethical and legal duty of the health care team to provide
safe and adequate medical care to the patient may necessitate the use
of some form of restraints. Before engaging the patient, the team needs
to remove items that could be used as a weapon like scissors, ties,
nametags, etc. Be sure to have adequate numbers of personnel (ideally a
minimum of five staff members to control the four limbs and head) and
an organized plan for each member. The team needs to enter the room in
force and if possible initially maintain a distance of 15 to 20 feet
from the patient. Sometimes this “show of force” by the team along with
a firm explanation elicits greater cooperation from the patient without
the team going into action. If not, the team members need to move in
from several directions, as directed by the team leader. Each limb
needs to be restrained at a major joint (knee or elbow) along with
control of the head and trunk. In patients with a weapon or who are
extremely violent, the patient may be rushed with two converging
mattresses. Leather restraints need to be applied to each
extremity and secured to the boat cleats on the cart. Care should be
exercised to avoid neurovascular compromise of the extremities. A
cervical collar may be useful to alleviate biting and head banging. Be
sure that the patient maintains an adequate airway. Positioning the
patient on his or her side may reduce the risk of aspiration. Once the
patient is safely secured, search the patient for weapons or drugs. Be
sure to clearly document the reason use of restraints were necessary.
Chemical Restraints1,2,3:
Even
with the use of calming verbal management and physical restraints, some
patients remain unmanageable. The use of chemical means to control the
patient then needs to be considered. Many drugs have been used for
rapid tranquilization, including short-acting benzodiazepines, major
tranquilizers, or even neuromuscular blockade. Of the many drugs that
have been used, the greatest clinical experience exists with
haloperidol (Haldol). While IV administration of drugs results in a
more rapid and predictable response to the drug administered than the
IM approach, in the violent patient it may not be possible to initially
gain venous access. Thus, IM medications may need to be used initially.
Drugs useful by IM route include haloperidol, lorazepam, midazolam, and
droperidol. (See below for doses.)
Drug options and doses follow:
- Haloperidol (Haldol) is a high potency neuroleptic that can be used for
acute treatment of aggressive or agitated behavior. Side
effects
include extrapyramidal symptoms, neuroleptic malignant syndrome, and
tardive dyskinesia. Haloperidol is approved for PO and IM use. While
the IV administration is not approved, the drug is commonly used by the
IV route and appears to be safe. Prolongation of the QT interval has
been observed with its IV use. Dosage by PO or IM or IV routes include:
- For mild agitation and in the elderly – 0.5 to 2.0 mg.
- For moderate agitation – 2.0 to 5.0 mg.
- For severe agitation (especially in younger patients) – 5.0 to 10.0 mg.
- Dose may be repeated every 30 to 60 minutes until the target symptoms are controlled.
-
Lorazepam (Ativan) is a rapidly acting, well-absorbed
benzodiazepine that can produce respiratory depression and sedation and
worsen confusion. Lorazepam is especially useful to treat sedative drug
and alcohol withdrawal and as adjuncts to neuroleptics to promote
sedation and reduce extrapyramidal side effects. (Note:
diazepam
is not used IM due to its erratic absorption and possibility of causing
sterile abscesses.) Lorazepam dosage by PO or IM or IV routes include:
- 0.5 to 2.0 mg PO, IM or IV every 30 min.
- In younger patients – 2.0 to 4.0 mg IM.3
- Midazolam (Versed) is a rapid
acting
benzodiazepine. Dosage:
- IM 5.0 to 10.0 mg
- 1.0 mg IV slowly every 2 to 3 min up to 5 mg max.
- Droperidol* has been found to have a more rapid control of agitation than haloperidol. Dosage = 5.0 mg IM.3, 5
- Combination of haloperidol and lorazepam has been shown to be safe and tends to result in an increase in the degree of sedation with a lower dose of haloperidol.6, 1
Ongoing evaluation and supportive care:
After
the patient has been safely restrained, the patient’s ABCs need to be
carefully assessed and treated as necessary. A thorough diagnostic
work-up should also begin to exclude an organic medical cause for the
agitated behavior.
Evaluation includes:
- Position the patient to maximize airway management and allow general patient evaluation.
- Evaluate and treat the ABCs as needed, being aware that the patient may have received a large amount of sedative drugs.
- Consider the need for endotracheal intubation.
- DO the DONT.
- Measure Dextrose.
- Look for the need for Oxygen.
- Check for Narcotic overdose.
- Consider the need for Thiamine. (Thiamine deficiency increases the risk of delirium, especially in the elderly.7)
- Be sure that all vital signs are addressed if needed – BP, HR, RR, SaO2, temp, rhythm (ECG monitor).
- Review clinical history and medication use (SAMPLE History).
- Perform a thorough physical exam.
- Perform a mental status examination.
- Obtain routine lab studies including: CBC, glucose, electrolytes, creatinine, BUN, calcium, U/A, ECG, Tox screen.
- Consider the need for other studies: LP, CT of head, chest x-ray, liver function tests, thyroid function tests, EEG, MRI, therapeutic drug levels, B12 and folate levels.
- Treat specific organic
causes for the
delirium, for example:
- Offending drug – discontinue.
- Head trauma – CT brain scan, neurosurgical consultation.
- Infection – give appropriate antibiotics.
- FUO or stiff neck – LP
- Supportive Care:
- Maintain adequate ABCs.
- Maintain adequate hydration.
- Mobilize the patient.
- Orienting stimuli – clocks, windows, familiar people.
- Avoid restraints as much as possible – both physical and chemical.
- Calm reassurance.
- Bedside sitters to help with orientation.
- Relieve pain – opiates like MS rarely cause delirium, but meperidine is a common cause for confusion especially in the elderly.
* Before using droperidol, providers should be aware that, at the end of 2001, the FDA issued a black box warning pertaining to its use.
References
- Fife A, et al. Psychiatric Emergencies: Agitation or Aggression. In: UpToDate, Rose BD (Ed), UpToDate, Wellesley, MA, 2002.
- Francis J. Prevention and Treatment of Delirium. In: UpToDate, Rose BD (Ed), UpToDate, Wellesley, MA, 2002.
- Asmussen D. Management of the Combative Patient. Health One Emergency Review. Vol 3, No 4, 2002:9-11.
- Hillman M. Emergency Medical Psychiatric Evaluation. Health One Emergency Review. Vol 3, No 4, 2002:7-12.
- Thomas H, et al. Droperidol versus haloperidol for chemical restraint of agitated and combative patients. Ann Emerg Med. 1992, April; 21(4): 407-13.
- Wise MG, et al. Concise guide to consultation psychiatry. American Psychiatric Press. 1988.
- O’Keeffe ST, et al. Thiamine deficiency in hospitalized elderly patients. Gerontology. 1994; 40:18.