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Agitated Patients: Clinical Overview and Problem Definition

FERNE/MEMC Session:. Agitated Patients: Clinical Overview and Problem Definition. Leslie Zun, MD, MBA, FAAEM Professor and Chair Rosalind Franklin University/Chicago Medical School Department of Emergency Medicine Mount Sinai Hospital. FERNE/MEMC Session:.

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Agitated Patients: Clinical Overview and Problem Definition

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  1. FERNE/MEMC Session: Agitated Patients:Clinical Overview and Problem Definition Leslie Zun, MD, MBA, FAAEM Professor and Chair Rosalind Franklin University/Chicago Medical School Department of Emergency Medicine Mount Sinai Hospital Les Zun, MD, MBA, FAAEM

  2. FERNE/MEMC Session: DisclosuresAlexza PharmaceuticalsSanofi-Aventis Les Zun, MD, MBA, FAAEM

  3. Agitation • 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 Les Zun, MD, MBA, FAAEM

  4. Prevalence • 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 Les Zun, MD, MBA, FAAEM

  5. Etiology • 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 Les Zun, MD, MBA, FAAEM

  6. Etiology • 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 Les Zun, MD, MBA, FAAEM

  7. Evaluation • 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 Les Zun, MD, MBA, FAAEM

  8. Delirium vs. dementia Les Zun, MD, MBA, FAAEM

  9. Patient IdentificationCitrone, L, Volavka: Violent patients in the emergency setting. Psych Clinic NA 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 Les Zun, MD, MBA, FAAEM

  10. Chaotic EnvironmentLevel of Agitation From ED Arrival Zun, LS and Downey, LA: Level of agitation of patients presenting to an emergency department. Primary Care Companion J Clin Psychiatry 2008;10:108-113. Les Zun, MD, MBA, FAAEM

  11. Progression • Do all patients progress? • Which patients progress? • How to prevent progression? Les Zun, MD, MBA, FAAEM

  12. Reason to treat agitated patients • Prevent 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 Les Zun, MD, MBA, FAAEM

  13. Treatment • Treat medical condition • Reduce stimulation • Verbal de-escalation - “Talk em down” • Alternatives to restraints • Restrain • Physical • Chemical • Combination • Seclusion Les Zun, MD, MBA, FAAEM

  14. Prevent ViolenceBrasic, JR, Fogel, D:Clinical safety. Psych Clinic NA 1999;22:923-940. • Identify violent patients • Search patients for weapons • Use a comprehensive, collaborative approach to the patient • Strategies • Administrative • Behavioral • Environmental Les Zun, MD, MBA, FAAEM

  15. Prevent Violence-StrategiesBrasic, 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 Les Zun, MD, MBA, FAAEM

  16. Agitated Patients:Clinical Overview and Problem Definition Summary • 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 Les Zun, MD, MBA, FAAEM

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