Agitated Patient

Question 1

What are the risks that need to be assessed on triage of the agitated pt in ED?

Answer 1

• Risk of suicide /self harm
• Risk of aggression to others
• Risk of absconding
• Risk of intoxication

Question 2

Common diagnoses in presentation of acute agitation?

Answer 2

• Acute psychotic episode
• Acute manic episode
• Drug induced psychosis (esp amphetamines)

Question 3

Aetiology of acute behavioural emergencies?

Answer 3

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

Question 4

Why is physical/ chemical restraint a step requiring caution?

Answer 4

You are removing someone from their legal rights; all caution should be taken to consider available treatment options before chemical sedation.

Question 5

Management of hostile, frightened pts?

Answer 5

Hostile, frightened, uncooperative pts often require rapid tranquilisation; pharmacological treatment must be tailored to the pt.

Question 6

First line agents for rapid tranquilisation?

Answer 6

• try to develop rapport

- PO benzos: diazepam 10mg / clonazepam 2mg

Question 7

Route of administration for rapid tranquilisers?

Answer 7

-Depends on pts condition

Question 8

Mx of sedated pts?

Answer 8

• Monitoring: oximetry, haemodynamics, RR, BSL.

- Supportive care: hydration, IDC, pressure, DVT prophylaxis

Question 9

Risks of rapid tranquillisation?

Answer 9

• 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

Question 10

Tranquillisers ass/w prolonged QT?

Answer 10

• Thioridazine and clozapine
• Quetiapine and chlorpomazine
• Onlanzapine appears to be relatively safe

Question 11

Features of midazolam?

Answer 11

• IM or IV
• Rapid effects (2-5mins)
• Fewer AEx than diazepam
• Elimination T1/2 prolonged in elderly (titrate dose)
• Can start with 2mg

Question 12

Features of diazepam?

Answer 12

• PO or IV (nil IM)

- Prolonged terminal elimination (up to 20h)

Question 13

Features of clonazepam?

Answer 13

• PO, IV or IM

- Elimination T1/2 = 20-50h

Question 14

AEx haloperidol?

Answer 14

• Extrapyramidal effects

- Prolonged QT

Question 15

Haloperidol delivery?

Answer 15

PO, IV or IM

Question 16

Ix after sedation?

Answer 16

• 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

Question 17

Third line treatment of acute agitation in ED?

Answer 17

• Diaz 2.5-5mg IV
• Clonazepam 1-2mg Im or IV up to 8mg daily
• Haloperidol 2.5-5,g IM or IV
• Chlorpromazine

Question 18

Ddx of acute psychosis?

Answer 18

• 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)

Question 19

Strategies for violence prevention when managing an agitated patient?

Answer 19

• Remain calm, empathic and reassuring
• Ensure safety of staff and pts
• Call security/staff if req’d
• Restraint or chemical tranquillisation if required

Question 20

Persons at high risk of suicide?

Answer 20

SADPERSONS
Sex = male
Age >45
Depression
Previous attempts
EtOH use
Rational thinking loss
Suicide in family
Organised plan
No spouse / support
Serious illness

Question 21

Prodromal signs indicating violence?

Answer 21

-Anxiety, restlessness, defensiveness, verbal attacks