Date post: | 18-Jun-2015 |
Category: |
Education |
Upload: | hue-university-of-pharmacy-and-medicine |
View: | 1,908 times |
Download: | 2 times |
MANAGEMENT OF THE
VIOLENT PATIENT
Joshua Radke, MD
UC Davis Emergency Medicine
Disclosures
None
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 Emergency Department (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
Signs and Symptoms Provocative behavior
Angry demeanor
Pacing
Loud/pressured speech
Pounding walls
Throwing things
Gripping arm rails intensely
Clenched fists
Positive Predictors of Violence
Male gender
Prior history of violence
Psychiatric illness
Drug or ethanol abuse
Early Recognition Anger
Resist authority
Confrontational
Combative
Prevention
Isolate from other provocative patients/friends/family
Hospital gown
Anticipate combativeness while talking with patient
Management Options
Verbal de-escalation
Physical restraints
Chemical restraints
Verbal De-escalation
Calm, slow talking
Be firm and assertive
Avoid argumentative or condescending language
Physical Restraints
Prevention of harm to patient or others
Should not be applied for convenience or as a punitive measure
The Team Approach
5+ people
Team leader
1 person for each extremity
Physical Restraints
What Not To Do
What Not To Do
Hobble Restraint
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 amphetamine
Cause of Death: positional asphyxiawith excited delirium
Adverse Effects - Prone
Vomiting
Aspiration
Dysrhythmias
Commotio cordis
Skin breakdown
Limb ischemia
Neuropraxia
Fractures/ dislocations
Chemical Restraint
Benzodiazepines Typical antipsychotics Atypical antipsychotics Combination therapy Endotracheal Intubation
ACEP Policy
Level 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
Benzodiazepines
Diazepam
Lorazepam
Midazolam
Diazepam
PODose: 5-10 mgOnset: 1-2 hoursHalf-Life: 30-60 minutes
IVDose: 2-10 mgOnset: 20-30 minutes
Lorazepam PO
Dose: 1-2 mgOnset: 16 hoursHalf-Life: 14 hours
IMDose: 0.5 – 2 mgOnset: 20-30 min
IVDose: <2 mg/minOnset: 5-20 min
Midazolam
IMDose: 5-15 mg (q15 min)Onset: 15-20 minHalf-Life: 2-6 hr
IVDose: 1-2 mg q2-3 minOnset: 1-5 minHalf-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, 2004
SE: no sig differences in SBP, DBP, HR, RR, O2 sat
Typical Antipsychotics
Haloperidol
Droperidol
Haloperidol PO
Dose: 5-10 mgOnset: 2-6 hrHalf-Life: 12-18 hr
IMDose: 5-10 mgOnset: 30-60 min
IVDose: 1-2 mgOnset: 30-60 min
ACEP Clinical Policy
Level B recommendations• If rapid sedation is required,
consider droperidol instead of haloperidol.
Droperidol
IM/IVDose: 0.625-1.25 mgOnset: 30 minHalf-Life: 2-4 hr
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
Droperidol
Extrapyramidal Symptoms
Atypical antipsychotics
Risperidone
Olanzapine
Risperidone
PODose: 1-3 mgOnset: 30-60 minHalf-Life: 20 hr
Olanzapine
PODose: 10-20 mgOnset: 5-8 hrHalf-Life: 20 hr
IMDose: 5-10 mg q4 hrOnset: 15-45 min
Other
KetamineIM
○ 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
Beware• Excessive
secretions airway issues
• HTN and tachycardia
• Unknown interactions with PCP/special K
Combination Therapy
Benzo + antipsychotic
Lorazepam Haloperidol Combo
Decreased Agitation
+ ++ ++++
Cumulative Sleep
+++ ++ +++
Combination Therapy - Regimens Lorazepam + Haldol
2 mg Lorazepam5 mg HaldolIM/IV
Midazolam + Haldol5 mg Midazolam5 mg HaldolIM/IV
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." Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia: Mosby Elsevier, 2010.
Questions??