Agitation

Question 1

Which patients can the Agitation CPG be applied to?

Answer 1

All compulsory patients (351, Assessment/Treatment Orders)

Patients who present with agitated/aggressive behaviour

Question 2

If management commenced under Mild/Moderate Agitation, can management then be further escalated to Extreme Agitation?

Answer 2

Yes, with maximum doses of medications in that section then applying.

Question 3

What is the preferred drug under the Extreme Agitation guideline?

Answer 3

Ketamine.

Question 4

Define rousable drowsiness.

Answer 4

The patient is asleep but rouses if their name is called.

Question 5

Sedation should be initiated early in hyperthermic psychostimulant OD patients. Why?

Answer 5

Assist with cooling and avoid further increases in temperature associated with agitation.

Question 6

What CPG are patients affected by Ice/Methamphetamines treated under? What is the preferred drug and why?

Answer 6

Extreme agitation.
Preferred drug is Ketamine as doses of Midazolam that would normally be effective may not be effective in this circumstance.

Question 7

When can sedation be given in a traumatic head injury?

Answer 7

In pts GCS 10-14, sedation can only be given after consulting with the clinician.

Question 8

What is the most appropriate management for agitation in hypoxic/traumatic brain injuries?

Answer 8

Analgesia.

Question 9

What are the dosing considerations for Midazolam in elderly/frail patients?

Answer 9

Use the lowest dose possible, monitor carefully for side effects.

Question 10

Define delirium.

Answer 10

An acute and reversible change in cognitive function that is distinct from dementia.

Question 11

What is the Sedation consideration for paediatric patients?

Answer 11

For <12 y.o, consultation with RCH must occur before sedating these pts.

Question 12

When can restraints be applied without sedation?

Answer 12

When the patient will not sustain further harm by fighting against the restraints.

Question 13

If using restraints, what must be documented on the PCR?

Answer 13

Indication for the use of restraints, type of restraints and the times of application/removal.

Question 14

What supportive care needs to be provided when sedation is administered?

Answer 14

1. Airway Mx
2. O2 as indicated
3. Perfusion Mx as per a0705
4. Temp Mx

Question 15

The Mild/Moderate Agitation pathway is intended for patients who…?

Answer 15

Do not present a high risk of extreme violence, or for who, the risk is likely to be controlled with Midazolam.
Eg. combative dementia pt, hyperthermic psychostim etc.

Question 16

Hypersalivation is a known side effect of Ketamine. How is it managed?

Answer 16

Suctioning.

If airway compromised, Atropine may be required.

Question 17

What are the 6 points of paramedic safety to assess in the Agitation guideline?

Answer 17

1. Hazards
2. Violence
3. Clear egress
4. Body fluids
5. Sharps
6. Reduce stimuli

Question 18

What are the 3 communication points made for the Agitated patient?

Answer 18

1. Avoid confrontational behaviour
2. Gain patients co-operation for assessment
3. Utilise verbal de-escalation strategies

Question 19

What is the acronym used to assess clinical causes of agitation?

Answer 19

A - alchohol/drug intoxication
E - epilepsy
I - insulin or other metabolic cause
O - Overdose/oxygen
U - Underdose including withdrawal
T - Head trauma
I - Infection/sepsis
P - pain/psychiatric condition
S - stroke/TIA

Also consider grief/extreme stress

Question 20

If Able to Mx Without Sedation/Restraint in the agitated patient, what are the 4 management points?

Answer 20

1. Manage causes as per CPGs
2. Beware pt condition may change/increase
3. Transport with assistance to appropriate destination
4. Provide early notification where appropriate

Question 21

If the pt Requires Restraint/Sedation, how is this indicated?

Answer 21

1. Does not respond to verbal de-escalation
2. Clinical causes excluded
3. Pt risk to themselves or others

Question 22

What are the STOP notes as per the Pt Requires Restraint/Sedation guideline?

Answer 22

1. If pt severely agitated, treat as per Extreme Agitation
2. Ensure sufficient physical assistance
3. Mild to moderate head injury - manage pain + consult
4. All sedation is aiming for rousable drowsiness
5. Apply restraints as required, even to sedated pts

Question 23

Under the Mild to Moderate Agitation guideline, what are the doses for Midazolam?

Answer 23

Midazolam 5 - 10mg IM
Midazolam 2.5 - 5mg IM (reduced dose)
Repeat at 10 minute intervals if necessary, titrate to response.
Max. total dose = 20mg

Question 24

Under the Mild to Moderate Agitation guideline, which patients receive lower doses of Midazolam?

Answer 24

1. Elderly
2. Frail
3. Weight <60kg
4. SBP <100mmHg
5. Sedating drug/alcohol involvement

Question 25

Under the Extreme Agitation guideline, what are the doses for Ketamine?

Answer 25

<60kg = 200mg IM
60 - 90kg = 300mg IM
>90kg = 400mg IM

Question 26

Under the Extreme Agitation guideline, what are the doses for Midazolam if Ketamine not available?

Answer 26

Midazolam up to 20mg IM
Rpt @ 10 min intervals if necessary, titrate to response.
Max. total dose 40mg.

Question 27

Under the Extreme Agitation guideline, what drugs are able to be used?

Answer 27

IM Ketamine or IM Midazolam if Ketamine not available.

Question 28

Under the agitation guideline, what GCS is associated with a mild to moderate head injury?

Answer 28

10-14.