Which method is the most restrictive for dealing with an aggressive patient who is out of control?
SummaryAgitation is a common, nonspecific symptom of many medical, psychiatric, psychosocial, and substance-related conditions. Initial management should aim to ensure the safety of the patient and staff and identify and treat critical causes of agitation. Once safety measures are initiated, deescalation techniques should be prioritized to help the patient calm down, avoid progression to aggressive and/or violent behavior, and allow a full medical and psychiatric evaluation. Stabilization, treatment of critical illnesses, alleviation of distressing symptoms, prevention of complications, and maintenance of patient dignity are major priorities for care. Calming medications (e.g., sedatives, tranquilizers) and physical restraints should be restricted to the goal of preventing harm to the patient or others if deescalation techniques are ineffective. Diagnostic studies may be required to evaluate for suspected underlying causes or complications. Optimal management requires familiarity with local institutional protocols and, in some cases, the involvement of a behavioral emergency response team. Show
DefinitionEpidemiologyEpidemiological data refers to the US, unless otherwise specified. EtiologyIf there is no known history of psychiatric illness or current symptoms differ from previous presentations of a known psychiatric disease, suspect a medical or substance-related cause. [4][5] Clinical featuresManagementManagement recommendations in this article are primarily consistent with the 2012 and 2020 American Academy of Emergency Psychiatrists (AAEP) Best Practices in the Evaluation and Treatment of Agitation (BETA) consensus statements. [2][4][6][7][8] Be aware of the following when considering whether to treat agitation as a medical issue: Gather as much information as possible before reaching conclusions about the etiology of agitation and be aware of provider biases, prejudices, and clinical uncertainty. Patients with agitation may threaten their own safety or those of others. Call for help whenever possible. Patients with agitation are often vulnerable and/or subject to neglect and abuse. Maintaining patient and provider safety while respecting patient dignity and autonomy can be very challenging and often distressing to all involved. Avoid making rushed decisions. Patient and staff safety when managing agitated patients [1][3][6]Follow local security protocols and call for help if patient or staff safety is under threat. Do not approach patients alone if they have signs of potential for violence and/or multiple risk factors for violent behavior. [3] Consider the following in patients with suspected medical causes of agitation and/or patients in need of sedation because they are endangering themselves or others. IV access in agitated patientsAttempt IM sedation prior to IV placement in uncooperative patients. Call for help if agitation is refractory and urgent IV access is still required. Do not attempt IV placement alone. Airway management in agitated patientsRisk assessment and mitigationManaging critical causes of agitationThese include etiologies that are rapidly reversible and/or pose an imminent threat to life. Immediate assessment [2][4][5]
If an immediately life-threatening cause is strongly suspected in an uncooperative patient not responding to deescalation techniques, consider calming medication and, if necessary, physical restraint to enable further evaluation and treatment. [4]
Diagnostic approachObtain the following as soon as safely possible: Patients with a known psychiatric disorder, with no concerning history or physical exam findings, and whose symptoms are consistent with those of their preexisting psychiatric disease are unlikely to require further diagnostic workup. [2][4][5] Basic studiesRoutine laboratory studies are not recommended. Diagnostic testing should be tailored to each patient based on clinical features, history, and physical examination findings. [21] Additional studiesConsider a more extensive diagnostic workup in patients with: atypical presentations of known psychiatric illnesses, age > 45 years without prior psychiatric illness, or immune deficiency. [2] DeescalationNoncoercive verbal and nonverbal techniques are used to help the patient calm down and cooperate with medical evaluation and treatment. This approach can relieve the symptoms of agitation, decreasing the need for coercive measures and potential for violence and associated harm to patients and staff. [1][6] Involuntary medications or physical restraint should only be used if a serious attempt at deescalation has failed to ensure the safety of the patient and staff. [6] PharmacotherapyConsider calming medication if there is an insufficient response to nonpharmacological measures, with the overarching goal of relieving distress, treating underlying conditions, and permitting a safe medical and psychiatric evaluation. Do not administer medication involuntarily unless it is to prevent imminent self-harm or harm to others, or it is mandated by a valid court order. [4][23] Calming medications of all classes can potentially cause oversedation, hemodynamic instability, and respiratory compromise, especially if used in combination. Repeated dosing of intramuscular medication can lead to overdose due to less predictable absorption and drug accumulation. Obtain IV access in the agitated patient as soon as safely possible. For severe agitation consider combining IM typical antipsychotics (e.g., haloperidol) with short-acting IV benzodiazepines (e.g., midazolam) under careful observation. [2] BenzodiazepinesThe following suggested agents and dosages are consistent with the 2012 and 2020 AAEP best practices and expert reviews in the literature. Follow local hospital policy whenever available as dosage recommendations vary widely. [1][2][7][31] General principles [2][7][31][32][33]
Beware of drug accumulation with frequent dosing; respiratory suppression can occur if benzodiazepines are prescribed at high doses or when used in patients exposed to other CNS depressants (e.g., alcohol). [7][31] Lorazepam dosage [2][7][31][32][33]
Midazolam dosage [2][7][31][32][33]
AntipsychoticsThe following suggested agents and dosages are consistent with the 2012 and 2020 AAEP best practices and expert reviews in the literature. Follow local hospital policy whenever available as dosage recommendations vary widely. [1][2][7][31] General principles
Anticipate common adverse effects of all antipsychotics such as extrapyramidal symptoms (e.g., akathisia, acute dystonia), QTc prolongation, and orthostatic hypotension. Beware of drug accumulation with frequent dosing; Avoid repeat dosing before the expected time to effect of each drug. Second-generation antipsychotics [1][2][7][32]Preferred over first-generation antipsychotics as first-line treatment of agitation due to delirium and psychosis. Olanzapine dosage
Risperidone dosage
Ziprasidone dosage [35][36]
First-generation antipsychotics [1][2][7][32]
Haloperidol dosage
Haloperidol administered intravenously (IV) may be associated with high rates of adverse effects (e.g., extrapyramidal symptoms, QTc prolongation, torsades de pointes) and is likely best reserved for extreme situations. Alternate routes (PO or IM) are generally considered safer. [7][37][38][39] Droperidol dosage [40][41]
Dissociative anestheticsThe following suggested agents and dosages are consistent with the 2012 and 2020 AAEP best practices and expert reviews in the literature. Follow local hospital policy whenever available as dosage recommendations vary widely. [1][2][7][31] Ketamine [1][2][21][28][30]Consider dose reduction for at-risk patients: e.g., older age, impaired drug metabolism, cardiac disease, high risk of hypotension. Consult a clinical pharmacist if the optimal agents and dosages are uncertain.
Physical restraintsThe following recommendations are consistent with the 2008 Joint Commission standards on restraints and seclusion (and their 2020 revision), the 2008 Centers for Medicare & Medicaid Services (CMS) restraint and seclusion guidelines, the 2012 AAEP BETA consensus statement, and the 2020 American College of Emergency Physicians (ACEP) policy statement on the use of restraints. [8][23][46][47][48] Physical restraints can cause significant harm, including long-term psychological trauma and death. They should only be considered to enable crucial diagnostics and treatment and/or prevent harm to the patient and others. They should never be used for punishment, discipline, retaliation, or provider convenience! [23][50] Use calming medications before or immediately after applying restraints to reduce the risk of injury, complications from the patient's efforts to resist restraints, and the negative psychological consequences of restraint and coercion. [2][51] PreparationIf possible, the treating clinician should avoid actively applying the restraints in order to preserve the clinician-patient relationship. [1] Approaching the patientProcedureDo not restrain patients in the prone position, as this can result in asphyxiation and death. If chest restraints are used, ensure that they do not impede chest expansion and adequate ventilation. [1] The level of monitoring should be decided based on an individual risk assessment in accordance with local hospital protocols and regional laws. Always follow regional laws and local hospital protocol. Hospitals are obligated to have specific policies on restraint and seclusion that must be in accordance with regional law, including regulating authority to order restraints, patient monitoring, and circumstances that allow the discontinuation of restraints. Excited delirium controversy
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When working with an angry patient it is best to do which of the following?One of the best tactics for disarming an angry patient is to show empathy. Unlike sympathy, which is an understanding of someone else's suffering, empathy involves experiencing someone else's emotions. Take the time to hear out your patient's upsets and concerns.
How do you control aggressive behavior?Managing aggression. Control your body language and tone of voice.. Stay calm.. Offer a way out.. Discourage bystanders.. Don't make threats.. Don't make predictions.. Wait for the right moment.. Maintain safety.. Which approach is the best to use with an individual who is displaying aggressive behaviors?No physical contact: Do not initiate physical contact if the resident's behavior is escalating. Touching can trigger violence in some residents. Approach: Always approach the resident from the front and not the back. Respond calmly and provide support with positive and friendly facial expressions.
Which factor is a predictor of violent behavior?Physical factors increase the risk of violence as well. These include lack of sleep, physical exhaustion, use of drugs or alcohol, brain trauma, heat, hunger, cold, physical disability, or chronic pain. Situational Factors. Situational factors are also predictive of violence.
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