Transcript On the Road Again - Calgary Emergency Medicine

The Agitated Patient
Wild and Crazy
Randall Berlin, MD
Learning Objectives
Review the toxic causes of agitated delirium.
Recognize and treat life threatening complications.
Sedation of the agitated patient.
Recognize and treat rhabdomyolysis.
Case 1 - Form 10
• Police attended the house of patient X after
complaints from the neighbors that he was
screaming all night. Neighbors and his live
in landlord stated that he had not slept at all
and was not making any sense. Pt X
followed one of his neighbors home and
pushed him on his lawn.
Form 10 (cont’d)
• Pt X is currently on medication, however has not
been taking his medications. Pt X’s landlord said
that he has been selling his valium and filled all
his meds - no other meds available to pt X for 3
weeks. Pt X threatened to kill everyone/have them
murdered/shot/poisoned. He is a danger to himself
and others.
• Your thoughts?
• Schizophrenia
• Drug withdrawal
– Benzodiazepines
• Personality Disorder
• Illicit Drug Use
In the ED
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Pt yelling and aggressive.
Security required to restrain.
BP 113/59; P 79; T 37 C; 94% RA
Pharmacologic sedation
– Versed 5 mg IM
– Olanzapine 10 mg IM
Old chart
• Schizoaffective
• Marijuana and cocaine abuse
• Antisocial personality disorder
• Dispostion
– Admit to psychiatry
Patient 2
30 year old, 100 kg male bodybuilder is brought
to the Emergency Department. He was arrested
by the police after running naked down the
middle of a major road. Two paramedics and
four police are having trouble holding him down
on the stretcher. Earlier that day the patient had a
major motor seizure.
What are some causes of agitation?
Causes of agitation
• Personality disorders
– Borderline, antisocial
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Ethanol enhanced personality disorders
Medical causes of delirium
Psychiatric causes of psychosis and agitation
Dementia
DRUG INTOXICATION
• What drugs can cause agitated delirium?
Toxic causes of agitated delirium
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Anticholinergics: antihistamines, antipyschotics etc
Sympathomimetics: cocaine, amphetamines
PCP
Hallucinogens: LSD, mushrooms
Salicylates
Withdrawal states: ethanol, benzodiazepines
Back to the Case
• P: 140; BP 150/95;
RR 24; SaO2 98%;
T 39.5 C
• Agitated
• Pupils 7 mm,
reactive
• Diaphoretic
• Life threats?
Life threats
• Sudden cardiac death
• Hyperthermia
Sudden cardiac death
Typical scenario
• 29 yo male pulled over by police for driving
erratically. He was agitated and confused
and resisted arrest. He was pepper sprayed
and continued to resist. He was physically
subdued and continued to struggle despite
being placed in 4-point restraints on the
ambulance stretcher and suddenly stopped
moving.
Typical scenario (cont’d)
• As he was being loaded into the ambulance,
he was found to be pulseless and apneic.
His passenger reported that he had been
sniffing cocaine just prior to being stopped.
Sudden Cardiac Death
Associated with Agitated Delirium
• “Sudden In-Custody Death”
• “Restraint Associated Cardiac Arrest”
Sudden Cardiac Death
Similarities with most cases
• Presence of excited delirium
• Continued maximal struggle despite
attempts at maximal restraint
• Clear association exists between illicit drug
use and the syndrome but not universal.
• Non-drug related causes are almost always
psychotic (schizophrenia, bipolar)
Sudden Cardiac Death
Mechanism of Death
• No definite etiology usually found at autopsy
• Profound metabolic acidosis likely leading to
cardiac arrest
• Hyperthermia often contributory
• Convulsions often contributory
• Hyperkalemia often contributory
• Restraint asphyxia unlikely explanation
Sudden Cardiac Death
Summary
• Dr. Chris Linden:
– “I constantly and emphatically remind our
residents and fellows that the patient with
agitated delirium, particularly one who is
actively and persistently struggling against
restraint, should be treated as a true emergency
- a cardiac arrest waiting to happen.”
Back to the Case
• P: 140; BP 150/95;
RR 24; SaO2 98%;
T 39.5 C
• Agitated
• Pupils 7 mm,
reactive
• Diaphoretic
• Life threats?
Life threats
• Sudden cardiac death
• Hyperthermia
Recognize the life threat!
(not the drug)
How important is hyperthermia?
Hyperthermia
• 75% of drug overdose patients with a
temperature greater than 40.5 C for greater
than one hour die or have permanent
neurologic sequelae
Back to the case
• Wildly agitated
Movie Trivia: “If you cut
their tendons, even the
largest elephant will
fall.”
Movie Trivia
• The Protector (2006)
• Tony Jaa
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
How can we control our
wildly, agitated patient?
Control of the patient
• Physical restraints
• Chemical sedation
• Intubation and paralysis
Code Black
• Standardized approach
• Standardized team
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Physical restraints
• Short term solution to gain IV access and
treat with pharmaceutical agents
• 5 or more people
• Monitoring protocol
• Documentation
Chemical sedation
• Control psychomotor agitation while
minimizing drug related complications
• Identify and treat life threats
What drugs can we use?
• Benzodiazepines
– Lorazepam
– Diazepam
– Midazolam
• Antipsychotics
• Paralytics
– Succinylcholine
– Rocuronium
Benzodiazepines
• Advantages
– Treats hyperthermia
– Prevents or treats seizures
– Decreases mortality in animal studies of
cocaine intoxication
Benzodiazepines
• Disadvantages
– Respiratory depression
Midazolam
• Onset: IV - 1-5 minutes
• Dose: 2.5-5.0 mg IV/IM q3-5min
• Elderly: reduce dose
Midazolam
Boxed Warning
• May cause severe resp depression, resp.
arrest or apnea
• Initial doses in the elderly or debilitated
should be conservative
• Parental form contains benzyl alcohol;
avoid rapid injection in neonates or
prolonged infusions
Antipsychotics
• Advantages
– No respiratory depression
Antipsychotics
• Disadvantages
– Anticholinergic side effects
• Impair heat dissipation
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Lower the seizure threshold
Prolong the QT interval
Dystonic reactions
Increased mortality in animal studies of cocaine
intoxication
Haloperidol
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Peak: 10-20 minutes
Duration: days
Dose: 2-5 mg IV/IM q20min
Elderly: reduce dose
Haloperidol
Boxed Warning
• None
• However, DROPERIDOL
– Cases of QT prolongation and torsades de
pointes, including some fatal cases, have been
reported
Olanzapine
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Peak: 15-45 minutes
Duration: days
Dose: 5-10 mg IM/SL q2-4h
Elderly: Reduced doses
Olanzapine
Boxed Warning
• Increased risk of death in pts with dementia
related behavioral disorders
• Increased risk of CVAs in elderly pts with
dementia related psychosis
Intubation and Paralysis
• Ultimate control
• Consider in patients with
– Risk of C-spine injury
– Hyperthermia
Succinylcholine
• In most cases it will be safe
• Hyperkalemia is a risk in the patient with a
protracted and fulminant course
Hyperthermia
Treatment of Hyperthermia
• Mist and fan
• Ice packs to groin and axilla
Back to the Case
• P: 140; BP 150/95;
RR 24; SaO2 98%;
T 39.5 C
• Agitated
• Pupils 7 mm,
reactive
• Diaphoretic
• What toxidrome
is this?
Sympathomimetic Toxidrome
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Hyperdynamic vitals
Agitated mental status
Dilated pupils
Diaphoresis
What are the causes of death in
cocaine intoxication?
Cocaine related deaths
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Seizures
CVA
MI
Aortic dissection
Dysrhythmias
HYPERTHERMIA
How does cocaine cause hyperthermia?
How does cocaine cause
hyperthermia?
• Psychomotor agitation --> increased heat
production
• Vasoconstriction-->decreased heat
dissipation
• A direct central effect
• A metabolic effect
Back to the Case
• The patient is physically restrained, an IV is
started and midazolam is titrated.
• Thirty minutes later, 30 mg of midazolam
has been given, the patient is still agitated
and his temp is 40 C
• A RSI is done and the patient is paralyzed.
My approach
• Midazolam 2.5 - 5.0 mg IV q3-5min
• Endpoints
– Control of patient
– Control of hyperthermia
• Ativan 2 mg IV
That should be the worst of it
• Review differential diagnosis
• Look for complications
History
• Collateral history from police, paramedics,
friends or family
– Medical and psych history, alcohol and drug
usage, medications
• Previous medical records
Physical
• Toxidromes
• Signs of infection
– Meningismus, cellulitis, pneumonia, etc
• Trauma
• Thyroid disease
Labs
• CBC, electrolytes, renal function, CK,
EKG, urine dip
• When indicated
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LFTs, Ca, Mg, Phos, TSH, T4,
CXR,
LP,
head CT
Back to the case
• A Foley catheter is inserted and tea colored
urine comes out.
• How do we explain this finding.
Rhabdomyolysis
How can we
confirm the
diagnosis?
Rhabdomyolysis
• Urine
– Urine dipstick
– Urine for myoglobin
Treatment?
• Blood
– Myoglobin
– Creatine Kinase
Rhabdomyolysis
• Treatment
– Hydration and electrolyte management
– ? Alkalinization
– ? Mannitol
Rhabdomyolysis
• Hydration
– Goal: urine output: 1-2 cc/kg/hr
• Alkalinization
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Implement when CK greater than 5000
1 amp bicarb IV push
1 L of D5W (remove 150 cc) and add 3 amps of bicarb
Run at 100-150 cc/hr
Goal: urine pH > 6
• Monitor serial CK
– If still rising look for a compartment syndrome
Re-assessments
• Drain the bladder
• Look and treat for causes of pain
• Re-assess need for restraints and document
progress
Summary of Approach
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Control
Life threats
Differential Diagnosis
Complications
Summary of Drug Therapy
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Drug induced: benzodiazepines
Drug withdrawal: benzodiazepines
Psychiatric: antipsychotic
Dementia: antipsychotic
Unknown: benzodiazepines
Tox Trivia
Name the Movie
• Tagline for this 1994 movie
– Girls like me don't make invitations like this to just anyone!
• Directed by Quentin Tarratino
• Starred John Travolta, Uma Thurman, Samuel L. Jackson
• The stories of two mob hit men, a boxer and a pair of diner
bandits intertwine in four tales of violence and redemption.
Uma Thurman overdoses on
what drug and how do they
revive her?
Heroin
Adrenaline