Agitated Patient Flashcards
What are the risks that need to be assessed on triage of the agitated pt in ED?
- Risk of suicide /self harm
- Risk of aggression to others
- Risk of absconding
- Risk of intoxication
Common diagnoses in presentation of acute agitation?
- Acute psychotic episode
- Acute manic episode
- Drug induced psychosis (esp amphetamines)
Aetiology of acute behavioural emergencies?
i) Drug affected pts: alcohol of sympathomimetic agents
ii) psychiatrically disturbed pts
iii) Extreme anti social / personality disordered pts
iv) medical conditions precipitating acute delirium
Why is physical/ chemical restraint a step requiring caution?
You are removing someone from their legal rights; all caution should be taken to consider available treatment options before chemical sedation.
Management of hostile, frightened pts?
Hostile, frightened, uncooperative pts often require rapid tranquilisation; pharmacological treatment must be tailored to the pt.
First line agents for rapid tranquilisation?
- try to develop rapport
- PO benzos: diazepam 10mg / clonazepam 2mg
Route of administration for rapid tranquilisers?
-Depends on pts condition
Mx of sedated pts?
- Monitoring: oximetry, haemodynamics, RR, BSL.
- Supportive care: hydration, IDC, pressure, DVT prophylaxis
Risks of rapid tranquillisation?
- Injury to staff and pt
- Physical injury from restraint
- Over sedation and resp depression,
- hypotension
- aspiration
- SCD (prolonging QT precipitating VT)
- Anticholinergic effects (e.g. delirium and AUR)
- Delirium
- Lowered seizure threshold
Tranquillisers ass/w prolonged QT?
- Thioridazine and clozapine
- Quetiapine and chlorpomazine
- Onlanzapine appears to be relatively safe
Features of midazolam?
- IM or IV
- Rapid effects (2-5mins)
- Fewer AEx than diazepam
- Elimination T1/2 prolonged in elderly (titrate dose)
- Can start with 2mg
Features of diazepam?
- PO or IV (nil IM)
- Prolonged terminal elimination (up to 20h)
Features of clonazepam?
- PO, IV or IM
- Elimination T1/2 = 20-50h
AEx haloperidol?
- Extrapyramidal effects
- Prolonged QT
Haloperidol delivery?
PO, IV or IM
Ix after sedation?
- FBE: Hb, WCC
- UEC: risk of QT changes
- LFTs: risk of EtOH/drug in population
- BSL
- ECG
- Paracetamol level
- EtOH level
- bHCG
- ?Blood culture
- CT Brain
Third line treatment of acute agitation in ED?
- Diaz 2.5-5mg IV
- Clonazepam 1-2mg Im or IV up to 8mg daily
- Haloperidol 2.5-5,g IM or IV
- Chlorpromazine
Ddx of acute psychosis?
- Primary psychotic disorder: e.g. schizophrenia
- 2” to medical condition: e.g.delirium
- Drugs / meds (e.g. anticholinergics, steroids)
- Infectious (CNS)
- Metabolic (hypoglycemia, hepatic, renal, thyroid)
- Structural (haemorrhage, neoplasm)
Strategies for violence prevention when managing an agitated patient?
- Remain calm, empathic and reassuring
- Ensure safety of staff and pts
- Call security/staff if req’d
- Restraint or chemical tranquillisation if required
Persons at high risk of suicide?
SADPERSONS Sex = male Age >45 Depression Previous attempts EtOH use Rational thinking loss Suicide in family Organised plan No spouse / support Serious illness
Prodromal signs indicating violence?
-Anxiety, restlessness, defensiveness, verbal attacks
