Approach to a patients with Acute Behavioural Disturbance in Emergency Departments

1. Approach to a
patients with Acute
Behavioural
Disturbance in
Emergency
Departments
Rashid A. M. Abuelhassan
R4 KFMC Emergency Medicine Training Program

2. You’ve been called by the
nurse saying that the new
patient is acting
Aggressively !
• What should you do?
• What are your
priorities?
• What is the DD?
• How to calm him down?
• Next step ?

4. Causes
Either
• Medical
• Psychiatric ( mood – thought / 1st ,compliance or
acute stressor)
Substance Abuse ( Use /withdrawal ) exacerbation –
precipitate )

5. DD of agitated pt.
• Infectious (encephalitis, meningitis, UTI, pneumonia)
• Withdrawal (alcohol, barbiturates, benzodiazepines)
• Acute metabolic disorder (electrolyte, hepatic or renal failure)
• Trauma (head injury, postoperative)
• CNS pathology (stroke, hemorrhage, tumour, seizure disorder,
Parkinson’s)
• Hypoxia (anemia, cardiac failure, pulmonary embolus)
• Deficiencies (vitamin B 12 , folic acid, thiamine)
• Endocrinopathies (thyroid, glucose, parathyroid, adrenal)
• Acute vascular (shock, vasculitis, hypertensive encephalopathy)
• Toxins, substance use, medication (alcohol, anesthetics,
anticholinergics, narcotics)
• Heavy metals (arsenic, lead, mercury)
• Environmental ( hypo/Hyperthermia )
• Acute pshycosis

6. Triaging
EARLY SIGNS AND
SYMPTOMS OF
AGITATION,
INCLUDING:
• restlessness (pacing,
fidgeting, hand
wringing, fist
clenching, posturing)
• irritability
• decreased attention
• inappropriate or
hostile behaviors.
+

7. Mental Status Exam

8. ABC of assessing the potentially
violent patient:
A= Assessment:
Primary Survey
Appearance
Current medical status
Psychiatric History
(history of violence)
Current medication
Oriented (time, place,
person)
Physiological indications
for impending aggression
Flushing of skin
Dilated pupils
Shallow rapid respirations
Excessive perspiration
B= Behavioural indications:
Observation of behaviour
General behaviour
(intoxicated, anxious,
hyperactive)
Irritability
Hostility, anger
Impulsivity
Restlessness, pacing
Agitation
Suspiciousness
Property damage
Rage (especially children)
Intimidating physical
behaviour (clenched fist,
shaping up)
C= Conversation
Patient self-report
Admits to weapon
Admits to history of violence
Thoughts about harm to
others
Threats to harm
Admits to substance
use/abuse
Command hallucinations to
harm other
Admits extreme anger

9. Management ( General Rules)
• Early recognition and use of de-escalation strategies
• Consider personal safety at all times
• Consider the safety of other patients and their visitors at all times
• Place the person in a quiet and secure area and let staff know
what is happening and why
• Never turn your back on the individual
• Don’t walk ahead of the individual and ensure adequate space
• Provide continuous observation and record behaviour changes in
patient notes
• Let the person talk (everyone has a story to tell, let them tell it)
• Never block off exits and ensure you have a safe escape route

10. • Non-pharmacologic
• Verbal de-escalation
• Offer comforting items: blanket, meal, pillow, etc
• Quiet room
• Physical restraints
• Pharmacologic: Goal is to calm patient without oversedation
• No history of psychosis
• Haloperidol 0.5mg-5mg +/- lorazepam 0.25-2mg (PO/IM/IV)
• Consider risperidone 0.5-2mg PO or olanzapine 2.5-20mg
(PO/IM/SL) or ziprasidone 10-20mg IM
• Known or suspected underlying psychotic illness
• Continue treatment with previous antipsychotic or
• PO: olanzapine 5-10mg or risperidone 0.5-2mg +/- lorazepam: 0.5-2mg
• IM: olanzapine 2.5-20mg or ziprasidone 10-20mg or
• (PO/IM/IV) Haloperidol 0.5-5mg +/- lorazepam 0.5-2mg
• Consider adding benztropine 0.5-2mg or diphenhydramine 25-50mg (PO/IV/IM) (reduces
dystonia or extrapyramidal reaction)
Management

12. Medical restrain

13. Indications for Restraining and sedating a violent and
aggressive patient:
• Preventing harm to the patient
• Preventing harm to other patients
• Preventing harm to caregivers and other staff
• Preventing serious disruption or damage to the
environment
• To assist in assessing and management off the patient
• Restraints should never be use for ease of convenience
Management ( restrains, When?)

14. • Applied by 5 persons .
• should always be followed up with chemical restraints.
• need to be secure enough to restrain the patient, but
able to be easily removed if the patient begins to
vomit, seizure.
• must be applied in the least restrictive maner and for
the shortest period of time.
• Padding should be applied between restraints and
regular neurovascular observations every 15-30mins .
• should document the reason for restraints, what limbs
are restrained, how frequent neurovascular
observations are needed, and when the restraints need
reviewed, Idealy every 2 hours by treating clinician.
Management ( restrains, Rules!)

15. Complications of sedation and
restraining patients
• Respiratory depression and pulmonary aspiration
• Sudden cardiac death/Excited delirium
• Hypotension
• Deep venous thrombosis & pulmonary embolus
• Rhabdomyolysis
• Dystonic reactions
• Neuroleptic malignant syndrome
• Anticholinergic effects
• Delirium
• Lactic acidosis
• Lowered seizure threshold
• Special problems in the elderly

17. History & physical
• History ( collateral – from pt) PMH, ? Inf, ? Med,
substance use/withdraw
• Examination ( toxidrome)
• Vitals ( T = infection/tox)
• Neuro ( Focalaty/ infection)

19. SAD PERSON SCORE
• S: Male sex
• A: Age
• D: Depression
• P: Previous attempt
• E: Excess alcohol or substance use
• R: Rational thinking loss
• S: Social supports lacking
• O: Organized plan
• N: No spouse
• S: Sickness
This score is then mapped onto a risk assessment scale as follows:
0–4: Low 5–6: Medium 7–10: High

20. Investigations
• Point-of-care glucose
• CBC
• Chemistry, LFTs
• CXR
• ECG
• Urine Analysis +/- pregnancy
• Consider:
• Ammonia
• TSH
• Head CT ? LP ?
• Levels ? ( ASA, Tylenol, toxicology screen, EtOH)

21. Thank you …