Les Zun, MD, MBA, FAAEM Agitated Patients: Clinical Overview and Problem Definition Leslie Zun, MD, MBA, FAAEM Professor and Chair Rosalind Franklin University/Chicago

Les Zun, MD, MBA, FAAEM

Agitated Patients:Agitated Patients:Clinical Overview and Problem Clinical Overview and Problem

DefinitionDefinitionLeslie Zun, MD, MBA, FAAEM

Professor and ChairRosalind Franklin University/Chicago Medical School

Department of Emergency MedicineMount Sinai Hospital

FERNE/MEMC Session:FERNE/MEMC Session:


DisclosuresDisclosures

Alexza PharmaceuticalsAlexza PharmaceuticalsSanofi-Aventis Sanofi-Aventis

FERNE/MEMC Session:FERNE/MEMC Session:


AgitationAgitation Definition– Excessive verbal and/or motor behavior

Escalation– Verbal– Physical – Violence

Signs of agitation– Pacing– Irritable– Affective liability– Verbal outbursts– Clenching fists or jaws– Threatening or destructive behavior– Slamming or banging objects


PrevalencePrevalence

Psychiatric patients in US– 4.3 million ED US visits per year– 5.4% of ED patients

Prevalence of agitation in US – Up to 1.7 million ED visits

Incidence of violence in US – 50% of healthcare providers in their career– 51% of MDs and 67% of nurses in ED were physically

assaulted in the last 6 months– 2/3 containment and 1/3 random


EtiologyEtiology Drug and alcohol intoxication

or withdrawal Medical

– Hypoglycemia– Hyperthyroidism– Delirium– Dementia– Head Trauma– Temporal Lobe Epilepsy

Psychiatric– Schizophrenia– Mania– Agitated depression– Personality

disorder – Antisocial, borderline

– PT– Akathisia

Psychiatric

Medical

DeliriumDementia

Hyperthyroidism Head Trauma

Temporal Lobe Epilepsy

SchizophreniaMania

Agitated DepressionSubstance intoxication or Withdrawal

Akathisia Personality Disorder-Antisocial


EtiologyEtiology Drug and alcohol intoxication

or withdrawal Medical

– Hypoglycemia– Hyperthyroidism– Delirium– Dementia– Head Trauma– Temporal Lobe Epilepsy

Psychiatric– Schizophrenia– Mania– Agitated depression– Personality

disorder – Antisocial, borderline

– PTSD– Akathisia

Psychiatric

Medical

DeliriumDementia

Hyperthyroidism Head Trauma

Temporal Lobe Epilepsy

SchizophreniaMania

Agitated DepressionSubstance intoxication or Withdrawal

Akathisia Personality Disorder-Antisocial


EvaluationEvaluation

Differentiate medical from psychiatric etiology– Age– Prior history– Vital signs– Physical examination findings– Focal neurologic findings– Glucose– Oxygenation– Laboratories?– Radiography-CT Scan

Delirium vs. dementia


Delirium vs. dementiaDelirium vs. dementiaDelirium Dementia

Onset Acute Slow

Awareness Reduced Clear

Alertness Fluctuates Normal

Orientation Impaired Impaired

Memory Impaired Impaired

Perception Hallucinations Intact

Thinking Disorganized Vague

Language Slow Word finding difficulty


Patient IdentificationPatient IdentificationCitrone, L, Volavka: Violent patients in the emergency setting. Psych Clinic NA Citrone, L, Volavka: Violent patients in the emergency setting. Psych Clinic NA

1999;22:789-801.1999;22:789-801.

High risk– Schizophrenia + substance abuse + medication non-

compliance > Schizophrenia >Affective disorders Factors that precipitate violent behavior alone or

in combination– Comorbid substance abuse, dependence or intoxication– Hallucinations or delusions– Poor impulse control– Character pathology– Chaotic environment


Chaotic EnvironmentChaotic EnvironmentLevel of Agitation From ED Arrival Level of Agitation From ED Arrival

Zun, LS and Downey, LA: Level of agitation of patients presenting to an emergency department. Primary Care Companion Zun, LS and Downey, LA: Level of agitation of patients presenting to an emergency department. Primary Care Companion J Clin J Clin

PsychiatryPsychiatry 2008;10:108-113. 2008;10:108-113. R ichm ond Agitated-Sedation Scale

0

0 . 5

1

1 . 5

2

2 . 5

3

3 . 5

0 3 0 60 9 0 1 2 0 1 5 0 1 8 0

R e s tr a in e d

U n r e s t r i a n e d

Agitated Behavior Scale

0

5

1 0

1 5

2 0

2 5

3 0

0 3 0 6 0 9 0 1 2 0 1 5 0 1 8 0

R e s tr a in e d

U n r e s t ri a n e d


ProgressionProgression

Do all patients progress?

Which patients progress?

How to prevent progression?

Agitation Violence

Precipitating Events increasing agitation

Agitation reduction techniques


Reason to treat agitated patientsReason to treat agitated patientsPrevent violence

– Up to 75% ED staff victims of violence

Better able to assess the patient Binder, Rl, McNeil, DE: Contemporary practices in managing acutely violent patients in 20

psychiatric emergency rooms. Psych Services 1999;50:1553- 1554.

– 17 of 20 medical directors stated that the patients are so agitated that it is difficult to get vital signs.

– 14 of 20 said the protocol was to physically restrain patients and medicate them prior to a medical work-up

Begin therapeutic process Fishkind, AB: Agitation II: De-escalation of the aggressive patient and avoiding

coercion. Emergency Psychiatry, 2008.

– Collaborative interactions– Elicit information– Patients say all they want– Include patients in planning– Empathize


TreatmentTreatment

Treat medical condition Reduce stimulation Verbal de-escalation - “Talk em down” Alternatives to restraints Restrain

– Physical– Chemical – Combination

Seclusion


Prevent ViolencePrevent ViolenceBrasic, JR, Fogel, D:Clinical safety. Psych Clinic NA 1999;22:923-940.Brasic, JR, Fogel, D:Clinical safety. Psych Clinic NA 1999;22:923-940.

Identify violent patientsSearch patients for weaponsUse a comprehensive, collaborative

approach to the patientStrategies

– Administrative– Behavioral– Environmental


Prevent Violence-StrategiesPrevent Violence-StrategiesBrasic, JR, Fogel, D:Clinical safety. Psych Clinic NA 1999;22:923-940.Brasic, JR, Fogel, D:Clinical safety. Psych Clinic NA 1999;22:923-940.

– Administrative Gangs involvement Evacuation plan Staff training

– Behavioral Be direct, polite and respectful Keep close to open exit Listen to patient Use non-threatening speech and behavior Security alert

– Environmental Monitor rooms Well trained security presence – Clinical training programs eg CPI Panic alerts


Agitated Patients:Agitated Patients:Clinical Overview and Problem Definition Clinical Overview and Problem Definition

SummarySummary

Agitation and violence common in ED Evaluate for possible treatable conditions Apply techniques to reduce agitation

– Identify agitated patients– Be pre-emptive– Utilize appropriate resources

Employ strategies to prevent violence– Search all patients– Isolate and observe

Documents

Les Zun, MD, MBA, FAAEM Agitated Patients: Clinical Overview and Problem Definition Leslie Zun, MD, MBA, FAAEM Professor and Chair Rosalind Franklin University/Chicago