ED management of the Acutely Agitated patient

We all know what it is like to have an acutely agitated patient present to your ED. It is challenging, intimidating, dangerous and disruptive for your staff and and your other patients.

It can be difficult to take a step back from the evolving situation and assess . You may be consumed by the desire to regain control of the situation. It may be difficult to think about (let alone treat) whatever pathology is underlying.

What is ABD?

ABD = acute behavioural disturbance. There are several similar definitions and terminology used can be confusing (excited delirium, acute agitation or drug intoxicated or drug affected behaviour). My favourite is from the Royal College of Emergency Medicine in UK

  • Sudden onset of aggressive and violent behaviour and autonomic dysfunction
  • Often occurs in the setting of acute drug ingestion or serious mental illness

ABD is a presents as a spectrum of features that includes acute delirium, agitation as well as as adrenergic dysfunction

It is associated with sudden death in 10% cases and there have been several high profile deaths in recent years in several countries

It is important to recognise and to treat it quickly

How many patients are affected in Victoria?

If we look at 2013/ 14 Victorian ambulance data and assume that crystal methamphetamine-related presentations are resposible for most of our ABD patients then we have

  • 3.4 ambulance attendances per day (0 to 10 patients) in metropolitan Melbourne
  • 0.8 ambulance attendances per day (0 to 6 patients) in regional Victoria
  • Most patients present between midday and 6pm in metropolitan Melbourne, between the hours of 6pm and midnight in regional Victoria
  • The peak day was Sunday in metropolitan Melbourne, the peak day was Saturday in regional Victoria

What are the typical symptoms?

A person can display mildly erratic behaviour ranging to extreme agitation and physical exertion

Things to look out for

  • extreme aggression, violent behaviour
  • excessive strength/ continued struggling with police restraint
  • reduced reaction to pain
  • acute psychotic state
  • hyperthermia, tachypnoea, tachycardia

ABD patients may have symptoms that are similar to other conditions. Other things to think about are

  • hypoxia
  • substance intoxication or withdrawal
  • hypoglycaemia
  • head trauma
  • CNS infection, haemorrhage
  • seizure, stroke or post ictal state

Describe general management principles for this patient group?

The general approach to these patients is very important

Remember you are dealing with one of 3 different types of patients

  • cooperative
  • disruptive not dangerous
  • excited delirium

Listen to Reuben Strayer give a fascinating talk about this at #SMACCDUB in June 2016

General principles that I try to implement

  • Evaluate your patient in safe area – evacuate other patients if this is in the ambulance entrance area
  • Make sure your staff is safe, are there any concealed weapons, can you move the patient to a secluded area, involve your security staff early. Call a Code Grey!

De-escalation techniques are important

  • talk to your patient in a calm and confident voice
  • do not confront your patient
  • do not maintain prolonged eye contact
  • never stand over them
  • offer them food or a cigarette if this is appropriate
  • try reduce the amount of ‘testosterone’ in the room if it is safe to do so

Different patients will respond differently and there is no one approach that fits

Some patients are unsuitable for de-escalation and physical restraint may be required. This is defined as the ‘intentional restriction of a person’s voluntary movement or behaviour by the use of a device, removal of mobility aids or physical force’

In most cases, in ED we will use category 1 restraint (emergency single episode restraint) and documentation must include – reason for restraint, condition prior to restraint (see SAT score), form of restraint applied, details of event, length of time restraint was applied for and condition post restraint. Restraint devices should be removed as soon as the patient is adequately sedated

SAT tool for sedation assessment

The Sedation Assessment Tool is a 7 point scoring system, based on level of arousal and speech patterns

  • It was described in Emergency Medicine Australasia in 2011
  • It ranges from plus 3 which is highly agitated to minus 3 which is heavily sedated
  • Endpoint for sedation is -1 (patient is drowsy but rousable)

 

SEDATION ASSESSMENT TOOL (SAT)
Score Responsiveness Speech Scale
+3 Combative, violent, out of control Continual loud outbursts +1 to +3

Agitation

+2 Very anxious and agitated Loud outbursts
+1 Anxious/restless Normal/talkative
0 Awake, calm Speaks normally 0 = normal
-1 Asleep but rouses if name called Slurring or slowing -1 to -3

Sedation

-2 Responds to physical stimulation Few recognizable words
-3 No response to stimulation Nil

 

What drugs can you use?

Chemical sedation or rapid tranquilisation may also be required for an ABD patient.

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Australia is fortunate to have access to droperidol, this is thought to be the first line agent to treat most cases of  ABD. However it is not available in Ireland, UK or in the USA

The main drug categories I use are benzodiazepines, antipsychotics and sometimes ketamine

Benzodiazepeines are familiar to most emergency doctors, they are safe you can give them via the oral and parenteral route. The main side effect to watch out for is respiratory depression. Lorazepam is not readily available in Bendigo Health and this acts as a useful bridge between (short acting) diazepam and other longer acting agents

Antipsychotic medications include droperidol or olanzepine. They are dopamine receptor antagonists and this is why they may work well in ABD – theory is that is caused by dopamine excess. Be careful with acute dystonic reactions

My treatment approach is based on the patient’s SAT score

  • SAT +1 – patient is cooperative 

Offer them something orally – use diazepam or olanzapine – any sedative will suffice

  •  SAT +2 – patient is agitated, vocal loud and probably hard to reason with

Now they are disruptive (but not yet dangerous) this is a difficult group to treat and requires tactical negotiation and experience

If possible try something oral but you may need IM meds early

Start with droperidol 5 – 10 mg IM and wait 15 minutes to see how this works

Repeat this dose if needed and now add in midazolam 5mg IM as a 2nd line agent

  • SAT+3 – your patient is aggressive and dangerous this is a full blown excited delirium!

Draw up 2 syringes – 10mg IM droperidol and 10mg IM midazolam

Use an IM injection and get your patient to resus to monitor them

What about ketamine – can I use it?

Things to consider

  • In recent years, there has been a splurge in the number of articles written by authors espousing the use of ketamine for the “Chemical takedown”
  • We use IM ketamine sucessfully for paediatric sedation – it is reasonable to consider it’s use in this situation
  • Many of the studies that describe droperidol use are done in Australia – maybe this is why ketamine has not been adopted (yet)
  • Ketamine has been incorporated into Victoria prehospital guidelines as a first line agent in excited delirium – see CPG A0709
  • A suggested single dose agent  is ketamine 5 mg/kg IMI, see Reuben Strayer again
  • My feeling is that ketamine will be introduced on a gradual basis once practitioners become more used to using it

Post sedation care for ABD patients

  • Be careful with a patient that may have taken a combination of drugs – benzos could cause respiratory depression or hypotension in this group
  • If you get IV access once the patient is settled then you could use this for further doses – no need to make this a priority at the start
  • Monitor them as if the have had procedural sedation – this means regular pulse ox, ECG and BP monitoring as well as SAT score
  • If a patient develops a dystonic reaction as a result of antipsychotic use then reach for benztropine 1-2mg IV
  • When the patient is sedated, the care is mainly supportive – check electrolytes, rehydration will often be useful, do a full examination and get imaging if this is indicated

What does the literature say about drugs for ABD?

The science here is pretty scarce

There have been a few papers published in recent years – led by Australian authors

  • The 1st DORM study was published in the Annals of Emergency Medicine in 2010 by Isbister et al. It used 3 arms to compare droperidol, midazolam and the droperidol/ midaz combo for 91 agitated ED patients.It showed that there was no difference in time to sedation when using droperidol, midaz or the combination. There was less top up sedation needed when the combination was used and the incidence of prolonged QT interval was the same in all groups
  • DORM 2 was published in the Annals of Emergency Medicine in August 2015 by Calver et al. It had over 1000 patients in a prospective observational study across 6 Australian EDs. Their main finding was that droperidol was safe to use for sedation – 13 of 1009 patients had abnormal QT intervals and 7 of these were using another medication that could explain this. DORM 2 had it’s limitations but seems to support safety of droperidol
  • The SOOTH study was been published in 2016. This was a RCT in 2 Melbourne metropolitan EDs and included at 349 acutely agitated patients requiring intravenous sedation. The authors found that midazolam and droperidol used IV for sedation is better than monotherapy using either droperidol or olanzapine alone

What about children?

If you are faced with an agitated child the general management principles remain the same as in adults

  • deescalate the situation
  • offer oral sedation first, parenteral sedation if needed

The Royal Children’s Hospital Melbourne guidelines suggest a treatment algorithm

What does #FOAMed say?

There are many fantastic resources listed on this topic – here are my favourite

Listen to some of the experts talk about how you could manage the agitated patient

Also listen to the podcast that I recorded this month for RCEM FOAMed network with Andy Neill

Take home points to consider

  • There are many drug regimens that are available and safe
  • If you are a trainee, there is no need to be too gung-ho to use new drugs that are outside your EDs normal practice, talk to your bosses and choose wisely!
  • If you are a consultant developing a new policy then talk to your colleagues and see what others are using and what you could use in your setting
  • A combination of droperidol and midazolam seem to be the standard in Australia at the moment