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    Approach To Aggressive Patients

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    docshahir
    The document provides guidelines for managing aggressive psychiatric patients in emergency settings. It emphasizes that the emergency physician's primary role is to rule out any potential organic causes of psychosis before assuming a psychiatric illness. Safety and stabilization of violent patients is critical by containing them in a safe environment while also addressing any medical issues. Physical restraints may be necessary in some cases and should be applied rapidly and humanely with a team approach. A full assessment of the patient, including appearance, physiological signs, behavioral observations, and conversation is important to evaluate risk of future aggression. Appropriate pharmacological treatment and disposition or referral depends on the clinical situation.

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    Download as PPT, PDF, TXT or read online from Scribd

    Approach To Aggressive Patients

    Uploaded by

    docshahir
    121 views25 pages
    The document provides guidelines for managing aggressive psychiatric patients in emergency settings. It emphasizes that the emergency physician's primary role is to rule out any potential organic causes of psychosis before assuming a psychiatric illness. Safety and stabilization of violent patients is critical by containing them in a safe environment while also addressing any medical issues. Physical restraints may be necessary in some cases and should be applied rapidly and humanely with a team approach. A full assessment of the patient, including appearance, physiological signs, behavioral observations, and conversation is important to evaluate risk of future aggression. Appropriate pharmacological treatment and disposition or referral depends on the clinical situation.

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    how to approach aggressive patient

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    Approach to Aggressive Patients

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    The document provides guidelines for managing aggressive psychiatric patients in emergency settings. It emphasizes that the emergency physician's primary role is to rule out any potential organic causes of psychosis before assuming a psychiatric illness. Safety and stabilization of violent patients is critical by containing them in a safe environment while also addressing any medical issues. Physical restraints may be necessary in some cases and should be applied rapidly and humanely with a team approach. A full assessment of the patient, including appearance, physiological signs, behavioral observations, and conversation is important to evaluate risk of future aggression. Appropriate pharmacological treatment and disposition or referral depends on the clinical situation.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    121 views25 pages

    Approach To Aggressive Patients

    Uploaded by

    docshahir
    The document provides guidelines for managing aggressive psychiatric patients in emergency settings. It emphasizes that the emergency physician's primary role is to rule out any potential organic causes of psychosis before assuming a psychiatric illness. Safety and stabilization of violent patients is critical by containing them in a safe environment while also addressing any medical issues. Physical restraints may be necessary in some cases and should be applied rapidly and humanely with a team approach. A full assessment of the patient, including appearance, physiological signs, behavioral observations, and conversation is important to evaluate risk of future aggression. Appropriate pharmacological treatment and disposition or referral depends on the clinical situation.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 25

    Approach to

    Aggressive
    Patients
    Psychiatry emergency
     Principal role of emergency physician is to
    differentiate organic and inorganic cause of
    psychosis

    Never assume patient that agrresive has psychiatric


    illness until all possible physical causes are ruled out

     Potentially life-threatening aetiology must be


    sought and addressed

     Never leave violent patient alone. If the patient


    is female, at least one female staff must be
    present
    DANGER
     Safety and stabilization:
     Contain violent and dangerously
    psychotic/ aggressive persons to
    Assessment provide safe environment for staff,
    patients, family, and visitors while
    simultaneously attending to
    airway, breathing and circulation
    Assessment
    Assessment
    Restraints
     In many cases, there is no substitute for the safe application of
    physical limb restraint
     When needed, restraints should be applied rapidly and
    humanely
     Patient should be reassured that this action is being taken for
    patient’s benefit
     Team of five members is recommended: one team leader, and
    one staff for each limb
     Sometimes, show of force and presence of many staff may be
    sufficient to subdue the patient without recourse to physical
    restraints
    Restraints
     If physical restraints needed:
    patient should be on the bed,
    with all four limbs restraint
    with leather/ linen restraint,
    positioned securely to
    restrain the patient
    effectively but minimally to
    reduce risk of injury
     Patient’s head should be
    elevated to reduce risk of
    aspiration
     Once restraint, patient
    should be offered
    medications, and if the
    patient refused, they must be
    administered involuntarily
    Assessment
    Examination rooms and seclusion
     Waiting rooms and examination rooms must be designed to
    ensure safety.
     Use of security staff, metal detectors, rooms that permit rapid
    and easy exit, panic button, and removal of any objects that
    could be used in violent attacks or suicide attempts e.g
    neckties, earrings, belts
     Staff should be aware of location of exits, and place themselves
    unobstructedly closer to an exit than the patient is placed.

     Patient who is violent/ aggressive must be kept advised of each


    action/ procedure and consequences if he remains to be
    aggressive
     If violent behavior persists, use of physical restraint is justified.
     All these steps must be documented
    ABC of assessing the potentially
    violent patient

    A = ASSESMENT
    1. GENERAL:
    Appearance
    Current medical status
    Psychiatric history
    Current medications
    Orientation

    2. Physiological indications for impending aggression


    Flushing of skin
    Dilated pupils
    Shallow rapid respirations
    ABC of assessing the potentially
    violent patient

    B = Behavioral indications
    General behavior (intoxicated, anxious, hyperactive)
    Irritability

    Hostility, anger
    Impulsivity

    Restless, pacing
    Agitation

    Suspiciousness
    ABC of assessing the potentially
    violent patient

    C = Conversation
    Admits to weapon
    Admits to history of violence
    Thoughts about harm to others
    Threats to harm
    Admit to substance use/abuse
    Command hallucination to harm others
    Admits extreme anger
    History
     Sudden onset of major changes in
     behaviour, mood, or thought in a
    previously normal patient, or definite
    deterioration in a patient with a chronic
    behavioural disorder, should stimulate
    evaluation for an underlying medical/
    neurological disorder
     Sudden change in behavior especially in
    patient of more than 40 years old, is an
    important indicator for a new and
    correctable disease process
    HISTORY  Past Medical History
     Detailed Medications and Drug
     Source of history : History
    patient, reliable family
    members, witness
     Substance abuse, alcohol History
     Recent Events :
     Baseline mental status,
    premorbid  Trauma
     Onset  Fever
     Duration till regain full
     Fitting episode
    conscious level  History of swimming/jungle
    trekking
     Response
     Limb weakness/numbness/facial
     Orientation and asymmetrical/slurred
    comprehension speech/choking episode
     Obeys command  Headache/blurry of
    vision/vomiting
    PHYSICAL EXAMINATION
    1. General examination
     Vital Signs, Glucometer
     Lethargy looking, septic looking
     Signs of trauma battle signs, raccoon eyes, ENT bleed

    2. Neurology exam :
     Higher mental status
     GCS
     Orientatation
     Command
     Speech
     Memory
     Cranial nerves
     Motor (tone, power, reflexes)
     Sensory (tactile localization, propioception, etc)
     Cerebellar signs
     Babinski sign, neck stiffness, clonus
    3. Cardiopulmonary exam :
     arrhythmias, murmurs, pneumonia, pulmonary edema

    4. Abdominal exam :
     ascites, caput medusa, liver enlargement or tenderness (hepatic
    encephalopathy)? tenderness?

    5. Genitourinary and rectal exam :


     urosepsis, melena, etc

    6. Skin, extremity, musculoskeletal exam :


     Look for injection marks, dialysis shunt, any signs of infection, mass.
    PSYCHIATRY HISTORY
     Recent life changes
     Losses (real or imagined)
     Informants and patient
     Chronic medical condition
     Chief complaints
     Level of adjustment
     Onset of present illness
     Family history
     Duration of present
    illness  Drugs and alcohol history
     Course of illness
     Predisposing factors
     Precipitating factors
     Perpetuating/relieving
    factors
    MENTAL STATE
    EXAMINATION
    General apperance and behaviour
     Attitude
     Comprehension
     Gait and posture
     Motor activity (catatonic/restless)
     Social manner (eye contact/non verbal language)
     Hallucinatory behaviour (smiling or crying without reason/talking to
    self/responding to auditory or visual hallucination)
     Rapport
    MENTAL STATE
    EXAMINATION
    Speech
     Rate or quantitiy (talkative/mutism)
     Volume (yelling/whispering)
     Flows of rhythm (stuttering/flight of ideas)
     Mood and Affect
     Mania (euphoria/elation/exaltation/ecstasy)
     Depressed (sad/irritable/angry)
     Thought
     Stream and form (not goal directed/non logical)
     Content (reality/fantasy)
    MENTAL STATE
    EXAMINATION
    Perception
     Hallucination (auditory/visual/olfactory/gustatory)
     Illusion
     Delusion
     Depersonalisation/derealisation (“As If Phenomena”)
     Cognition (Higher Mental State)
     Insight
     Judgement
     Social
     Test
    Toxidromes
    Investigations
    Lab testing depends on clinical suspicion + history + physical
    examination
     Urine toxicology screen / alcohol level are useful to
    determine the etiology of change in behaviour/ abnormal
    thought especially when the cause is unknown
     In elderly patients, they are more likely to have
    electrolyte imbalances, hyperglycemia, hypoglycemia,
    cardiovascular disease, renal disease, pulmonary disease,
    diabetes, thyroid abnormalities and drug interactions and
    intoxication, which may cause acute psychosis
     Serum levels of certain medications are useful especially
    in patients who is known to be on mood-stabilizing drugs,
    antiepileptic drugs, analgesics, digoxin and cyclosporine
    Investigations
    Diagnostic Imaging:
     CT brain and related brain imaging should be considered
    in patients with clear change of behaviour or suspected
    intracranial pathology
     Also indicated in cases of altered mental state
    accompanied by fever, new headache, focal neurological
    signs or traumatic brain injury
     Immunocompromised patients and those with altered
    mental status, accompanied by fever, meningeal signs
    and/or headache are usually need CT scan to rule out
    abscess or mass
    Pharmacological Therapy
    antipsychotic/ tranquilizing agent

    Choice of meds:
    Drug withdrawal/ intoxication:
     Lorazepam IM/ IV → begin with 1mg and
    titrate upwards
    Aggressively violent or rapid sedation needed:
     IM/ IV Midazolam → 2-5 mg
     Haloperidol → 2-5 mg
     IM/ IV Lorazepam → 1-2mg

    Agitation with undifferentiated etiology:


     IM/ IV Haloperidol → 2-5 mg
     IM/ IV Lorazepam → 1-2mg
     IM/ IV Midazolam → 2-5 mg
     Haloperidol + Lorazepam
    Elderly
     IM/ IV Haloperidol 1-2mg
     IM/ IV Midazolam 1-2mg
     IM/ IV Lorazepam 0.5mg
    Pharmacological Therapy
    Useful medication administration alternative in small number of psychotic
    patients is oral administration since they may feel less threatened than when
    confronted with a needle
     PO Haloperidol 20mg
     PO Diazepam 20mg
    Consultation/ Referral/ Disposition
    Judgement regarding referral depends on assessment of patient’s likelihood of becoming violent
    towards self or others.
    In patient who likely to be violent, potential victims who can be identified must be warned
    Clues that suggest potential violence include hostile behaviour, verbal aggressiveness, and statements
    about violent intent → this patient need immediate hospitalization
    Patient with marked disorientation/ confusion require inpatient medical evaluation for organic
    components
    In absence of medical indications, referral should be made to a psychiatrist/ psychiatry facility
    Patient who can safely leave the ED should receive clear discharge instruction, and specific follow up
    should be scheduled for any medical, mental health, and/ or surgical disorder that were identified

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