Management of the Aggressive Patient

The aggressive patient in

the Emergency Department

Dr Ioana Vlad

Emergency Department Consultant

Objectives

Why are patients aggressive

Recognize the aggressive patient

Management of the aggressive patient

When

How

Behaviour + cause

Psychiatric emergency

• Disturbance in behaviour, feeling or thinking

• Final outcome of many pathologies or external stress overwhelming the person’s ability to cope

• If not attended to, can result in harm to the patient or someone else

Why?

ED is the place where acutely unwell patients

are brought from the community

- intoxicated or withdrawing

- psychiatric illnesses

- organic illnesses

atmosphere of the ED is often one of confusion, injuries, bad news, crowding

- proximity of rival groups

o gangs

o intoxicated driver and family of victim

Recognize

Stress behaviours indicating increasing agitation

use of profanity and verbal outbursts

pacing or frequent alteration of body position or posture

Recognize

Aggression

towards an individual

aiming to create fear

• Eye contact – direct / non-hostile

• Personal space

• Door position

• Body language

• Move chairs, hide scissors, remove lanyards etc.

Prevent

Patient history – alerts / medical or psychiatric records

Compulsory search / change into hospital gowns

Hospital protocol / “code blacks”

Separate rival gang members or victim-perpetrator groups

Use chemical and / or physical restraints early

When is chemical restraint NOT appropriate?

- aggressive behaviour (verbal or physical) and no evidence of an acute medical or psychiatric illness that is impairing their cognition

- should be escorted out by security rather than be restrained - police assistance can be sought

Chemical restraint

• Rapid tranquilization

– Safe

– Titratable

• Benzodiazepines

• Neuroleptics

• (Ketamine)

• (Clonidine, dexmedetomidine)

• (Propofol)

Benzodiazepines

Midazolam

- IM or IV

- max effect 10 min, lasts 2 hrs

Diazepam

- PO or IV; erratic absorption IM

- painful when administered IV

- longer acting than midazolam

Lorazepam

- only available as PO

Complications Oversedation Hypotension Airway or ventilatory compromise Paradoxical reactions Delirium Tolerance

Neuroleptics

Droperidol / (haloperidol)

- IM or IV

- 2.5 – 10 mg

Olanzapine

- IM or SL or PO

- max 30 mg / 24 hrs

Risperidone

- 0.25-2mg PO/SL

- works well in elderly

- orthostatic hypotension common

Complications Oversedation Hypotension Acute dystonia Anticholinergic delirium (Seizures) (QT prolongation)

Knott JC & al. Ann Emerg Med. 2006

• RCT iv midazolam or droperidol

• Primary endpoint = time to sedation (from the initial dose until a score of 2 or less 5 highly aroused and

violent

4 highly aroused

3 moderately aroused

2 mildly aroused and pacing

1 settled

0 asleep

Knott JC & al. Randomized Clinical Trial Comparing Intravenous Midazolam and Droperidol for Sedation of the Acutely Agitated Patient in the Emergency Department. Ann Emerg Med. 2006;47:61-67

Knott JC & al. Ann Emerg Med. 2006

Knott JC & al. Randomized Clinical Trial Comparing Intravenous Midazolam and Droperidol for Sedation of the Acutely Agitated Patient in the Emergency Department. Ann Emerg Med. 2006;47:61-67

DORM study (Isbister GK& al. Ann Emerg Med. 2010)

• RCT

• im droperidol 10 mg, midazolam 10 mg, or droperidol 5 mg/midazolam 5 mg

Isbister GK & al. Randomized Controlled Trial of Intramuscular Droperidol Versus Midazolam for Violence and Acute Behavioral Disturbance: The DORM Study. Ann Emerg Med. 2010;56:392-401

DORM study (Isbister GK& al. Ann Emerg Med. 2010)

Isbister GK & al. Randomized Controlled Trial of Intramuscular Droperidol Versus Midazolam for Violence and Acute Behavioral Disturbance: The DORM Study. Ann Emerg Med. 2010;56:392-401

When do you stop?

When do you stop?

RESPONSIVENESS SPEECH

SCORE

+3 Combative, violent, out of control Continual loud outbursts

+1 to +3 Agitation

+2 Very anxious and agitated Loud outbursts

+1 Anxious / restless Normal / Talkative

0 Awake / calm Speaks Normally

ZERO

-1 Asleep but rouses if name is called Slurring or slowing

-1 to -3 Sedation

-2 Responds to physical stimulation Few recognisable words

-3 No response to stimulation Nil

When do you stop?

SEDATION ASSESSMENT TOOL (S.A.T.)

Post sedation care

– Document

• Why?

• How?

• What next?

– One-to-one nurse special

– O2 applied via Hudson mask

– Continuous O2 sats monitoring and end-tidal CO2 monitoring

– Continuous cardiac monitoring

Post sedation care

– BP checked 5 minutely for 20 minutes post

each sedation dose, then half hourly

– Bladder care

• bladder scans every 3-4 hrs if they do not void OR postvoid

• IDC should be inserted when bladder volume is > 400 mls

– BSL checked 2 hourly if ≥ 4 mmol/L, or hourly if it is < 4 mmol/L (Rx if < 3.5 mmol/L)

– Pressure care – turn every 2 hours to prevent pressure areas

– Temperature control

When do you decide to physically restrain a patient?

• risk of harm

• failed negotiations

• usually combined with chemical restrain

• secure large joints

• documentation

– regular review of need to continue restraints

– neurovascular obs

What do you do after physically restraining a patient?

American Joint Commission on Accreditation

of Hospital Organizations

1. Protection and preservation of patient rights,

dignity, and well-being

1. Use based on patient’s assessed needs

2. Use of least restrictive method

3. Safe application and removal by competent staff

4. Monitoring and reassessment of the patient during use

5. Meeting of patient needs during use

6. Time limitation of orders that are provided by licensed practitioners

7. Documentation in the medical record

4:30 pm Sunday afternoon Code black R3 33 M transferred from Fresh start

clinic after having a naltrexone implant 3 hours previously

He is extremely agitated, confused,

sweaty, pulling monitoring leads off.

4:30 am Code black at triage 43 M brought in by police after being

noticed to behave eratically in a petrol station

Being held by 4 police officers; sweaty,

swearing…..

- Retrospective study

- 298 patients evaluated for psychiatric complaints in the ED

- 4% of patients had acute medical conditions

Tintinalli JE, Peacock FW, Wright MA. Emergency medical evaluation of psychiatric patients. Ann Emerg Med 1994;23:859-862

Tintinalli JE & al. Ann Emerg Med 1994

6:30 pm

Code black C23

56 M manic / on forms 1 & 3 awaiting transfer to Graylands hospital

He needs to go at the casino to meet his mates, so he’s out of here!

• Cycles of extreme mood swings and behaviours that

can result in loss of job, relationships

• Impulsiveness with little regard for personal safety or consequences of actions - high risk for “accidentally” or intentionally killing self

• Racing thoughts, tangential thinking make it difficult to follow directions or complete tasks e.g. giving UA

• Confusion as to why others are concerned about them

The bipolar / manic

• Keep directions/statements short and simple (may have to repeat them)

• Don’t argue with the patient

• Medicate early for agitation

• Assume patient will be unpredictable and plan for it

• New onset mania needs medical workup

The bipolar / manic

• Traumatic childhood abuse or neglect

• Rigid or fixed perception of the world

• Poor self-image, chaotic personal relationships, “emotional dysregulation” with intense reactions to situations, extreme fear of abandonment and ineffective coping skills in crisis

• Often associated eating disorders, substance abuse

The borderline personality disordered

• Manipulative , passive-agressive communication

• Tend to want you to know what they want, without

telling you directly

• Unpredictable, provocative; high risk for self-harming behaviours / can be chronically suicidal with many “attempts”

• Anxiety around being poorly treated, ignored is common trigger for acting out

The borderline personality disordered

• Avoid power struggles / give choices

• No punitive treatments, threats, ultimatums or

excessive restrictions - they will give the patient a reason to escalate

• Find out what they need and want; try to accommodate them if you are able / explain why if you can’t

• Be aware of non-verbal communication

• Expedite process of evaluation

The borderline personality disordered

• Disorganised thinking, delusions/ hallucinations

• Drug induced or related to other disorders

• Typically don’t realize that their thinking is delusional or irrational / may not understand what is happening to them

• Paranoid, hyper-vigilant; may extend their paranoia to include staff / believe that others are reading their thoughts, secretly plotting against them

• Could be self-harming or suicidal, if having command hallucinations

The psychotic

• Can be very frightened, anxious

• Approach slowly, using non-threatening body language

• Don’t feed into delusions, but don’t directly contradict them either e.g. “That sounds very frightening.”

• If the patient is there due to safety issues, ask what would be helpful to them to feel safe in the ER

• Medicate early (neuroleptics)

• Consider organic cause if new symptoms

The psychotic

1:30 am

Code black cubicle 15

89 F from nursing home

Triage: increasingly aggressive behaviour

Reason for code black: shouting, trying to get out of bed and to kick nursing staff who are trying to assess her

Dementia demographics • 2011 estimated

– 298,000 Australians had dementia

• in 2007 projected number for 2011 was 222,000

– 163,849 permanent residents care facilities

• 85,159 (52%) had a diagnosis of dementia

Australian Institute of Health and Welfare 2012. Dementia in Australia. Cat. no. AGE 70. Canberra: AIHW

www.cihi.ca

Dementia demographics

Dementia demographics

www.cihi.ca

Behavioural problems in dementia

• Agitation and aggression

= inappropriate verbal or motor behaviour

- occurs in 60% of people who have dementia

- spectrum

- usual reasons: pain, physical illness, medications (anticholinergics / hypnosedatives), disorientation, separation from family or other unmet needs

Types of behavioural problems

Types of behavioural problems

Behavioural problems in dementia

• 25% of people with dementia will experience psychosis

– delusions tend to reflect underlying memory loss or perceptual changes (people stealing money or personal items, that their spouse or caregiver is an imposter, or about infidelity in their spouse)

Behavioural problems in dementia

• Visual hallucinations

– may be very vivid in dementia with Lewy Bodies (DLB) – eg seeing people in fancy dress having a party in the room

• Auditory hallucinations

– uncommon in dementia

– may be observed with the person misinterpreting noises and voices

Behavioural problems in dementia

• Misidentifications due to perceptual disturbances

– believing someone else is in the house

– perceiving familiar people as imposters

– thinking that events on television are happening to them

– being unable to recognise own reflection in the mirror

What makes a behaviour a problem?

• Dysfunction

• Aggression so severe that it puts their placement in jeopardy by harming others or themselves

• Disruptive vocalizations so intense that their safety is at risk from the aggressive peers

• Generalized restlessness so profound it leads to falls / injuries

What makes a behaviour a problem?

• The context

– In a small nursing home a person who walks constantly may be pacing whereas at a larger facility they are “walking the halls”

– Frail resident means little threat of injury to others if aggressive

– Non-compliance with multivitamin vs. insulin

– Continued soft spoken talking vs. yelling

– Antipsychotics / mood stabilizers / antidepressants in

dementia provide modest benefit (especially for

behavioural problems)

– Treating the cause and minimizing the environmental

change are essential

Frightened patients with no insight into their situation are trying to defend themselves.

Take home points

• Violence rarely erupts without warning

• Not all patients need to be sedated

• Personalized regimen

• Post-sedation care

• Not all violence is psych or alcohol related

• Drunk people get hit by cars

“Anger is an emotion that makes your mouth work

faster than your brain”