The Combative Patient

Question 1

Verbal de-escalation how-to:

Answer 1

One person
Security nearby
Open body language
Access to door
Not in reach of patient

’SAVE’

Support “let’s work together”
Acknowledge “I see this is hard for you”
Validate “I’d probably react the same”
Emotional naming “you seem frustrated”

Question 2

Physical restraint how-to:

Answer 2

EXPLAIN TO PATIENT- indication and process

Code black
6 people
- Head
- 1 for each limb
- Meds/ restraints
Apply O2 early (control spit, oxygen)
NEVER: cover mouth, press neck, pin chest or back

ONLY EVER A BRIDGE TO SEDATION. Never keep alert person physically restrained.

Physical restraints:
- 4 or 5 point
- Supine
- Head at 30deg
- 1 arm up, 1 arm down
- Attach to FRAME, not rail
- Must be quick to undo

Follow up care:
- IVC
- Pad or catheter
- Monitoring incl. Temp and ETCO2
- Ongoing PRN doses (eh. TDS 10mg loraz, TDS 5-10mg olanz)
-FREQUENT OBS
- ?Ix for organic causes
- MH act vs DOC
-DOCUMENT

Question 3

PO options for chemical deescalation:

Answer 3

BENZOS
Eg.
- Diazepam 5-20mg
- Lorazepam 1-3mg

ANTIPSYCHS
- Olanzapine 2.5-10mg
- Haloperidol 5-10mg
- Risperidone 0.25 - 0.5mg

Question 4

IM options for chemical deescalation:

Answer 4

BENZOS
- Midazolam 0.3/kg (max 30mg)
*never use diaz IM- unpredictable

ANTIPSYCH
- Droperidol 5-10mg. Repeat Q15.
- Olanzapine 2.5-10mg

OTHER
- Ketamine

Question 5

IV options for chemical deescalation:

Answer 5

BENZOS
- Midazolam 2.5-5mg. Max 30.
- Diazepam 5mg. Max 30.
- Clonazepam 1-2mg

ANTIPSYCH
- Droperidol 5-10mg. Repeat Q15. Max 30.
- Haloperidol 2.5-5mg. Max 20.

OTHER
- Ketamine

Question 6

Antipsychotic adverse effects:

Answer 6

Sedation
Hypotension
Anticholinergic (risperidone minimal)
QT prolongation
EPS

Best avoided in pregnant/lactating