Treatment of Agitation: Restrain, Seclude or Medicate

Leslie S Zun, MD, MBA, FAAEMChairman and Professor

Department of Emergency MedicineRFUMS/Chicago Medical School

Mount Sinai HospitalChicago, Illinois

Objectives

To improve the treatment of agitation of psychiatric patients in the emergency setting

To review the evidence concerning physical restraints and chemical treatment

Reason to treat agitated patients

Prevent violence

Better able to assess the patient

Begin therapeutic process

Prevent ViolenceCitrone, L, Volavka: Violent patients in the emergency setting. Psych Clinic NA 1999;22:789-801.

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

Richmond Agitated Sedation Scale

0

0.5

1

1.5

2

2.5

3

3.5

0 30 60 90 120 150 180

RestrainedUnrestrianed

Zun LS, Downey LV; Level of agitation of psychiatric patients presenting to an emergency department.Prim Care Companion J Clin Psychiatry. 2008;10(2):108-13

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

Administrative Gangs

Evacuation plan

Search patients and visitors

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

Panic alerts

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

Treatment

Physical restraints

Seclusion

Chemical treatment

Combination

Physical RestraintsAlternatives to restraint useDowney LV, Zun LS, Gonzales SJ: Frequency of alternative to restraints and seclusion and uses of agitation reduction techniques in the emergency department. Gen Hosp Psychiatry. 2007 Nov-Dec;29(6):470-4.

Surveyed a random sample of ED and all Psychiatric EDs in the country.

Survey tool to determine agitation reduction techniques and reasons for differing level of usage

40% response rate

Almost all EDs (90%) and Psych EDs use alternatives (98%)

Physical RestraintsAlternatives to restraint useZun, LS, Downey, L, Gen Hosp Psych 2007.

Alternatives usedFrequency Effectiveness

Verbal 84% 36%

One to one 79% 48%

Decrease in

stimulation 74% 15%

Food or drink 69% 18%

Physical Restraints

Complications of Patient RestraintZun, LS: Complications of Patient Restraints, J Emerg Med 2003; 24:119-124.

The purpose of the study was to determine the type and rate of complications of patients restrained in the ED over 1 year.

221 patients were restrained in the ED

Mean of 4.78 hours

(range .2-24 hrs)

Position

supine position (87.1%)

sitting (8.1%)

prone (4.8%)

Chemical restraints were added (28.6%)

Results - Complications

Complication rate 5.4%

12 complications: Getting out of restraints (6)

Injured others (2)

Vomiting (1)

Injured self (1)

Other (1)

Hostile or increased agitation (1)

Aspiration (0)

Spitting (0)

Death (0)

No major complications such as death or disability

Seclusion Committee on Pediatric Emergency Medicine: The use of physical restraint intervention for children and adolescents in the acute care setting. Pediatrics 1997;99:497-498.Brown, RL, Genel, M, Riggs, J: Use of seclusion and restraint in children and adolescents. Arch Ped Adol Med 2000; 154: 653-655.

Involuntary confinement of a patient alone in a room, from which the patient is physically prevented from leaving for any period of time.

Variants

Did not differentiate locked versus unlocked

Free movement or no free movement

Separation from the group

Seclusion Use in Emergency MedicineZun, LS and Downey, L : The use of seclusion in emergency medicine. Gen Hosp Psych 2005; 27:365-

371.

Survey study of a random sample of 1067 US EDs medical directors

Response from 443 (41.6%)

27.8% use seclusion

Reasons not to use seclusion

Problems with physical plant 50.2%

Concern over safety 36.5%

Too many regulations 19.7%

Seclusion Use in Emergency MedicineZun, LS and Downey, L : The use of seclusion in emergency medicine. Gen Hosp Psych 2005; 27:365-371

Age placed in seclusion Adults 97.6% Adolescents 75.4% Children 32.5%

Complications noted 37.5% Formal training 81.1% Formal policies 83.6% Outstanding concerns:

Complication Use in children Addition of chemical sedation Training and seclusion policy

Use of Chemical Treatment Diagnosis

Undifferentiated

Psychiatric disturbance

General medical etiology

Substance intoxication or withdrawal

Route Oral, IM, IV, Inhalational

Dosage - Single dose or multiple doses

Onset and Offset - Sedation

Safety Hypotension Neuroleptic malignant syndrome

Respiratory depression Dystonic reaction

Increased violence Akathisia

Choice of Medications

Use of typical antipsychotics Haloperidol

Chlorpromazine

Droperidol

Loxapine

Thiothixene

Use of atypical antipsychotic Risperidone

Olanzapine

Ziprasidone

Aripiprazole

Quetiapine

Increased violent behaviorHerrera, JN, Sramek, JJ, Costa, JF et al: High potency neuroleptics and violence in schizophrenics. J Nervous Mental Dis 1988; 176:558-561.

16 male schizophrenic patients resistant to previous neuroleptic treatment

Comparison of Haloperidol to Clozapine or Chlorpromazine

Significantly more violent episodes occurred with haloperidol than other meds or placebo periods

Could this be from akathisia or drug-induced behavioral toxicity

ED Use of Droperidol Thomas, H, Schwartz, E, Petrilli, R: Droperidol versus haloperidol for chemical restraint of agitated and combative patients. Ann Emerg Med 1992; 21:407-413.

33 patients got haloperidol and 35 got droperidol IM

Droperidol decreased combativeness significantly more than IM haloperidol at 10 (p=.01) and 30 minutes (p=.04)

Sedation not studied

Hypotension found with equal doses of both drugs in 8 patients

FDA States - ECG monitoring should be performed prior to treatment and continued for 2-3 hours after completing treatment to monitor for arrhythmias

Combinations

Medication combinations Battaglia, J, Moss, S, Ruch, J, Et al: Haloperidol, lorazepam or both for psychotic agitation? A multicenter, prospective,

double-blind, emergency department study. Am J Emerg Med 1997; 15:335-340.

Prospective study of 98 agitated, aggressive undifferentiated patients over 18 months

Used rapid tranquilization method Given IM lorazepam (2 mg), haloperidol (5mg) or combination

Haloperidol had more EPS symptoms No difference in sedation amongst the groups Most rapid RT with combination

Medications/Restraint/Seclusion combinations No study of combination of medications and restrain or seclusion found

Problems with Current Medications

Sedation

Dystonic reactions

Hypotension

Akathisia

Increased agitation

QT prolongation

QT ProlongationGlassman, AH, Bigger: Antipsychotic drugs: prolonged QTc interval, torsade de pointes, and sudden death. Am J Psych 2001;158:1774-1782.

Prolongation of QT (msec) Ziprasidone 20.3

Risperidone 11.6

Olanzapine 6.8

Quetiapine 14.5

Thioridazine 35.6

Haloperidol 4.6

Findings Thioridazine is most marked assoc with Torsade

Haldoperidol can cause torsade and sudden death

Olanzapine, Risperidone and Quetiapine not associated with Torsade

QT Prolongation

Young patients who have family history of prolonged QT syndrome

Older patients with known heart disease or drugs that prolong QT need a pretreatment EKG

Electrolyte abnormalities may predispose to QT - hypokalemia

Advantages of the New Medications

Little hypotension

Less sedation

Few dystonic reactions

Replacement for Droperidol?

$8.84 USD

(dis)

$18.51 USD

for IM

$7.95 USD$3.85 USD

(for 40 mg)

$9.50 USD

Cost

Haloperidol IM est. $5 USD

Lorazepam IM est. $4 USD

10-15 mg IM9.75 mg IM20 mg oral

10-20 IM

Dose

Schizo, Bipolar Agitation

Schizo,

Bipolar Agitation

Schizo

Agitation

Indications

Oral, dis, IMOral, IMOral, IMForms

ZyprexaAripiprazoleGeodonBrand Name

OlanzepineRisperidoneZiperidone

Hypotension & postural hypotension 3%

Headache 12%

Boxed warning for QT interval

Other

6%7%8-20%Somnolence

2%2%Akathisia

4%8%3-10%Dizziness

ZyprexaAbilifyGeodonBrand Name

OlanzepineAripiprazoleZiperidone

Undifferentiated Agitated Patients in the EDMarten, M el al: Management of acute undifferentiated agitation in the emergency department Academic Emer Med 2005;12:1167-72.

144 patients randomized to either droperidol, ziprasidone and midazolam

Sedation in 10% of droperidol, 20% ziprasidone and 50% of midazolam At 15 min more agitation in the ziprasidone group At 30 min no difference in agitation At 45 min, more agitation in midazolam group

Respiratory depression noted in 8% droperidol, 15% ziprasidone and 21% midazolam.

No cardiac arrhythmias found in any group Adequate sedation is delayed with the use of ziprasidone relative to the other agents

Treatment Guidelines

Undifferentiated Conventional antipsychotics Atypical antipsychotics

Psychiatric Etiology Conventional antipsychotics Atypical antipsychotics

General Medical Etiology Allen, MH, Currier. GW, Hughes, DH, Reyes, Harde, M, Docherty, JP: Treatment of behavioral

emergencies. Post grad Med 2001; S1-88.

Conventional antipsychotics Benzodiazepine ? Atypical antipsychotics Dilemma in the elderly psychotic pts

Substance Intoxication or Withdrawal Allen, MH, Currier. GW, Hughes, DH, Reyes, Harde, M, Docherty, JP: Treatment of behavioral

emergencies. Post grad Med 2001; S1-88.

Benzodiazepine

ProblemsSpecial populations

Pregnant High-potency conventional antipsychotics lack known teratogenicity

Alshuler, LL, Cohen, L , Szuba, MP, et al: Pharmacologic management of psychiatric illness during pregnancy: dilemmas and guidelines. Am J Psych 1996;153:592-606.

Children Benzodiazepine or butyrophenones Dorfman, DH, Kastner, B: The use of restraints for pediatric psychiatric patients in emergency

departments. Ped Emerg Care 2004;20:151-156.

Antipsychotics - risperidone or olanzapine

Allen, MH, Currier. GW, Hughes, DH, Reyes, Harde, M, Docherty, JP: Treatment of behavioral emergencies. Post grad Med 2001; S1-88.

Take Home Point

Physical restraint is probably safe

Combination of haloperidol and lorazepam may cause oversedation

Consider atypical antipsychotic agents for the use in the emergency department