Transcript Agitation - Ferne Homepage

FERNE/MEMC Session:
Agitated Patients:
Clinical Overview and Problem
Definition
Leslie Zun, MD, MBA, FAAEM
Professor and Chair
Rosalind Franklin University/Chicago Medical School
Department of Emergency Medicine
Mount Sinai Hospital
Les Zun, MD, MBA, FAAEM
FERNE/MEMC Session:
Disclosures
Alexza Pharmaceuticals
Sanofi-Aventis
Les Zun, MD, MBA, FAAEM
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Definition
Agitation
– Excessive verbal and/or motor behavior
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Escalation
– Verbal
– Physical
– Violence
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Signs of agitation
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Pacing
Irritable
Affective liability
Verbal outbursts
Clenching fists or jaws
Threatening or destructive behavior
Slamming or banging objects
Les Zun, MD, MBA, FAAEM
Prevalence
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Psychiatric patients in US
– 4.3 million ED US visits per year
– 5.4% of ED patients
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Prevalence of agitation in US
– Up to 1.7 million ED visits
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Incidence of violence in US
– 50% of healthcare providers in their career
– 51% of MDs and 67% of nurses in ED were physically
assaulted in the last 6 months
– 2/3 containment and 1/3 random
Les Zun, MD, MBA, FAAEM
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Etiology
Drug and alcohol intoxication
or withdrawal
Medical
– Hypoglycemia
– Hyperthyroidism
– Delirium
– Dementia
– Head Trauma
– Temporal Lobe Epilepsy
Psychiatric
– Schizophrenia
– Mania
– Agitated depression
– Personality
disorder – Antisocial,
borderline
– PT
– Akathisia
Schizophrenia
Mania
Agitated Depression
Substance intoxication or Withdrawal
Akathisia
Personality Disorder-Antisocial
Psychiatric
Medical
Delirium
Dementia
Hyperthyroidism
Head Trauma
Temporal Lobe Epilepsy
Les Zun, MD, MBA, FAAEM
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Drug and alcohol intoxication
or withdrawal
Medical
– Hypoglycemia
– Hyperthyroidism
– Delirium
– Dementia
– Head Trauma
– Temporal Lobe Epilepsy
Psychiatric
– Schizophrenia
– Mania
– Agitated depression
– Personality
disorder – Antisocial,
borderline
– PTSD
– Akathisia
Etiology
Schizophrenia
Mania
Agitated Depression
Substance intoxication or Withdrawal
Akathisia
Personality Disorder-Antisocial
Psychiatric
Medical
Delirium
Dementia
Hyperthyroidism
Head Trauma
Temporal Lobe Epilepsy
Les Zun, MD, MBA, FAAEM
Evaluation
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Differentiate medical from psychiatric etiology
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Age
Prior history
Vital signs
Physical examination findings
Focal neurologic findings
Glucose
Oxygenation
Laboratories?
Radiography-CT Scan
Delirium vs. dementia
Les Zun, MD, MBA, FAAEM
Delirium vs. dementia
Delirium
Dementia
Onset
Acute
Slow
Awareness
Reduced
Clear
Alertness
Fluctuates
Normal
Orientation
Impaired
Impaired
Memory
Impaired
Impaired
Perception
Hallucinations
Intact
Thinking
Disorganized
Vague
Language
Slow
Word finding
difficulty
Les Zun, MD, MBA, FAAEM
Patient Identification
Citrone, L, Volavka: Violent patients in the emergency setting. Psych Clinic NA
1999;22:789-801.
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High risk
– Schizophrenia + substance abuse + medication non-
compliance > Schizophrenia >Affective disorders
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Factors that precipitate violent behavior alone or
in combination
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Comorbid substance abuse, dependence or intoxication
Hallucinations or delusions
Poor impulse control
Character pathology
Chaotic environment
Les Zun, MD, MBA, FAAEM
Chaotic Environment
Level of Agitation From ED Arrival
Zun, LS and Downey, LA: Level of agitation of patients presenting to an emergency department. Primary Care Companion J Clin
Psychiatry 2008;10:108-113.
Les Zun, MD, MBA, FAAEM
Progression
Agitation reduction
techniques
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Do all patients
progress?
 Which patients
progress?
 How to prevent
progression?
Violence
Agitation
Precipitating Events
increasing agitation
Les Zun, MD, MBA, FAAEM
Reason to treat agitated patients
 Prevent
violence
– Up to 75% ED staff victims of violence
 Better
able to assess the patient
Binder, Rl, McNeil, DE: Contemporary practices in managing acutely violent patients in 20
psychiatric emergency
rooms. Psych Services 1999;50:1553- 1554.
– 17 of 20 medical directors stated that the patients are so
agitated that it is difficult to get vital signs.
– 14 of 20 said the protocol was to physically restrain
patients and medicate them prior to a medical work-up
 Begin
therapeutic process
Fishkind, AB: Agitation II: De-escalation of the aggressive patient and avoiding
coercion. Emergency Psychiatry, 2008.
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Collaborative interactions
Elicit information
Patients say all they want
Include patients in planning
Empathize
Les Zun, MD, MBA, FAAEM
Treatment
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Treat medical condition
Reduce stimulation
Verbal de-escalation - “Talk em down”
Alternatives to restraints
Restrain
– Physical
– Chemical
– Combination
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Seclusion
Les Zun, MD, MBA, FAAEM
Prevent Violence
Brasic, JR, Fogel, D:Clinical safety. Psych Clinic NA 1999;22:923-940.
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Identify violent patients
 Search patients for weapons
 Use a comprehensive, collaborative
approach to the patient
 Strategies
– Administrative
– Behavioral
– Environmental
Les Zun, MD, MBA, FAAEM
Prevent Violence-Strategies
Brasic, JR, Fogel, D:Clinical safety. Psych Clinic NA 1999;22:923-940.
– Administrative
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Gangs involvement
Evacuation plan
Staff training
– Behavioral
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Be direct, polite and respectful
Keep close to open exit
Listen to patient
Use non-threatening speech and behavior
Security alert
– Environmental
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Monitor rooms
Well trained security presence – Clinical training programs eg CPI
Panic alerts
Les Zun, MD, MBA, FAAEM
Agitated Patients:
Clinical Overview and Problem Definition
Summary
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Agitation and violence common in ED
 Evaluate for possible treatable conditions
 Apply techniques to reduce agitation
– Identify agitated patients
– Be pre-emptive
– Utilize appropriate resources
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Employ strategies to prevent violence
– Search all patients
– Isolate and observe
Les Zun, MD, MBA, FAAEM