Behavioral and
Psych
Emergencies
Mark Winther, MD
April 18, 2007
Outline
Epidemiology
Case #2
The Agitated Pt
Chemical Restraints
Risk Assessment
– IM
Tarasoff Decision
– Case #3
Case #1
– IM vs. PO
Drugs
Case #4
– Psychotropics
Clinical Relevance
– Benzodiazepines
Case #5
Physical Restraints
Epidemiology
0.8%-5% of all incidents to which EMS respond involve
violence or the threat of violence. Brice JH et al.
Injuries not well reported
– Fernandes et al. surveyed staff in urban ED,
68% reported physical assault in past year
– 54% never officially reported it
– 27% lost work days
Up to 10% of psychiatric pts are homicidal
5% being both homicidal and suicidal
Bars are open ‘till 4 am in Albany…
The Agitated Patient
Why are they agitated?
–
–
–
–
Acute psychosis
Drugs/ETOH
Infectious
Hypoglycemia
– Hypoxia
– Head injury
– Acute Delirium
– Pain
Along a continuum
The Acutely Agitated Patient
How important is the diagnosis?
– Expert consensus surveys (American Association of Emergency
Psychiatry) diagnosis is unknown 85% of the time.
– ~85% stated restraints were used prior to instituting a medical
work-up.
Diagnosis helps in long term management.
– Exceptions: Hypoxia, Head Injury, Infectious, Seizure
– Selection needs to minimize exacerbation of potential comorbid
conditions (cardiovascular disease or CNS depression)
Rapid Tranquilization
Method of pharmacologic management of acute
agitation or psychosis using high –potency
psychotropic.
Often combined with a benzodiazepine
– Synergistic
– Reduces EPS
Rapid Tranquilization
Extra Pyramidal Side-effects
The Agitated Patient
Personal Safety is Primary
– Impossible to predict what is going to happen
– Make your safety a priority
• Pt’s must be searched/disarmed
• Clear route of rapid escape
• Additional security personnel
The Agitated Patient
“When it comes to syphilis suspect your
grandmother?” Sir William Osler
– Exposure (e.g. HIV & Hep B/C)
Job Threatening
Outline
Epidemiology
Case #2
The Agitated Pt
Chemical Restraints
Risk Assessment
– IM
Tarasoff Decision
– Case #3
Case #1
– IM vs. PO
Drugs
Case #4
– Psychotropics
Clinical Relevance
– Benzodiazepines
Case #5
Physical Restraints
Risk Assessment
Assessment of the pt’s
situational context (i.e. put
yourself in their shoes)
– Many homicidal pt’s have the
perception there is no
alternative to violence
– Losing a grip on reality (e.g.
delusional)
Convey empathy & authenticity
Risk Assessment
Major risk factor – PRIOR
VIOLENCE
Assess psycho-pathology
(e.g. presence of a
delusional belief or
command hallucination)
Maximize deterrents
– E.g. Religion, Legal
Consequences, Family
Risk Assessment
One yr cross-sectional
study of paramedic
restraint use and assault
on EMS personnel.
Cheney, et al.
Pertinent Demographic
Variables
– Time of Day
– Gender
– Hx/Presence of violence
– Pt injured under
supervision
– Pt arrested
– Perceived need for
chemical restraint
Risk Assessment
Call volume – 65,000 patients per year
271 Restrained pts in urban area
Primary outcome was whether paramedic
assault occurred during pt management &
whether chemical restraint has a role
71% of pts were suspected of drug/ETOH
intoxication
Assaults on EMS personnel occurred in 27% of
cases, with injury occurring in 4%
Risk Assessment
Other Risk Factors
–
–
–
–
Father’s drug use
Hx of LOC
Abused as child
Drug abuse (use or
withdrawal from)
– Unemployed
– Violent fantasies
– Hx of suicide attempts
– Homeless
Tarasoff Decision (1976)
A student named Prosenjit Poddar at University of California was
seeing a psychologist at the Student Health Center because a
young women named Tatiana Tarasoff rejected his affections.
The psychologist, reasoning that Poddar was dangerous because of
his pathological attachment to Tarasoff & b/c he intended to
purchase a gun, notified the police both verbally and in writing. The
police questioned Poddar and found him to be rational; they made
Poddar promise to stay away from Tarasoff. Two months later,
however, Poddar killed Tarasoff. When Tarasoff's parents attempted
to sue the University of California, health center staff members, and
the police, the courts dismissed the case.
Tarasoff Decision (1976)
Family appealed to the California Supreme
Court – concluded the therapist had a Duty to
Warn. Thereby formulating the duty of
therapists, imposing a duty to use reasonable
care to protect third parties against dangers
posed by patients.
States vary in application of decision, applies
more to psychiatrists, however “threats” of pt
may only have been voiced to EMS.
Case #1
Call comes in:
48 yo caucasian male threatening to “cut my
throat” after police were called to his residence
for domestic disturbance. Suspected to be
intoxicated.
Case #1
On arrival:
Pt is arguing with police & noted to be very
anxious. He is angry that police are not
arresting his ex-wife. Reports a hx of “pain
medication” addiction, & recently released from
prison for parole violation.
What else would you like to know?
Psychotropics
“Typical/Conventional” -Believed to be due to blockade of dopamine (D2)
receptors in the limbic system
High Potency vs. Low Potency
Side Effects
– Extrapyramidal (EPS) > Rigidity, Bradykinesia, Tremor, Akathisia
– QT prolongation
Psychotropics
Haldol
– Typical dosing 2-5 mg.
– Max dose 40 mg/day.
– IM route of onset ~15-20 min. (Actually faster)
– EPS not dose related
Psychotropics
“Atypicals”
– Mechanism of action is believed to be due to
antagonism of dopamine (D2) and serotonin
(5-HT2) receptors
– Associated with less side effects (EPS)
– Various agents & forms available
– $$$
Benzodiazepines
Bind to gamma aminobutyric
acid (GABA) receptors, the
major inhibitory
neurotransmitter in the CNS
Effects – Anxiolytic, raises sz
threshhold
Side Effects
– High therapeutic index
– Drowsiness, AMS, &
Sedation
Outline
Epidemiology
Case #2
The Agitated Pt
Chemical Restraints
Risk Assessment
– IM
Tarasoff Decision
– Case #3
Case #1
– IM vs. PO
Drugs
Case #4
– Psychotropics
Clinical Relevance
– Benzodiazepines
Case #5
Physical Restraints
Case #2
Call comes in:
28 yo male in custody of Albany Police after altercation
in bar. Large scalp laceration & belligerant. Pt had to be
physically restrained by police and sustained injuries in
the process.
Case #2
On arrival:
Young male with copious amount of blood on scalp and
face who is yelling at police and other patrons. He is
obviously intoxicated and noted to have a large posterior
scalp lacerations believed to be the result of being hit in
the head with pool stick. Pt is belligerent, spitting, and
threatening to “Kill everyone of you f@#%kers!”. You
learn pt is well know to police w/ a hx of aggravated
assault.
What else would you like to know?
IM Chemical Restraint
Traditionally short acting IM
formulations of conventional
antipsychotic drugs have been
preferred in the “emergency” setting
– Options were limited (e.g. Haldol,
Droperidol)
– No access needed
Downside to IM use
– Risk of injury to staff and/or pt
– Pt preference (may affect long
term compliance)
– Aggressive Tx
– Increased EPS???
Current Guidelines
Second Generation (Atypical) antipsychotics
– Superior tolerability & Safety
– As or more effective than traditional agents
– More formulations available
• Liquid concentrate
• Rapidly dissolving tablets
– Less sedating (ideal situation is tx results in an
awake and lucid pt that is cooperative)
Patient Preference
Weiden et al. asked 339 pts w/ acute schizophrenia or
psychosis to choose b/w receiving acute Tx w/ an oral
2nd gen antipsychotic plus an oral benzo or std IM care
(conventional antipsychotic w/ or w/o a benzo).
– 25% had no preference
– 45% preferred oral route
– 29% preferred IM std care
FDA Warning
IM Zyprexa (olanzapine) has
been associated with
excessive sedation &
cardiorespiratory depression
when combined with IM Ativan
(lorazepam)
Problematic if IM Zyprexa is
used & pt is insufficiently
sedated
In addition, recent concern with
atypicals used in elderly and
increased risk of mortality.
Oral Medications
Wide range of peak
plasma levels
Safety profiles essentially
the same in all
formulations (atypicals)
Case #3
Call comes in:
47 yo caucasian female in Albany County holding cell
with possible MI. Pt complaining of chest pain.
Case #3
On arrival:
Upon arrival you see a disheveled female with profuse
diaphoresis, tremulousness, and pacing. She is yelling
at the police, accusing them of putting poison in her
food. Police state she has a long hx of ETOH abuse.
You are able to obtain a set of vitals – HR 130, BP
178/110, RR 22, pulse ox 98%, Temp 102.4.
What else would you like to know?
IM Medications
Monotherapy may w/ IM
benzodiazepines may be
indicated in certain
clinical situations
(substance withdrawal,
delirium)
Meta-analysis: IM 2nd
generation with similar
efficacy to Haldol w/ less
side effects
IM vs. PO
Very small studies
Demonstrate similar
desired effects, IM Haldol
likely slightly faster onset
& more side effects.
Case #4
Call comes in:
Young female who was “going crazy!!”. Call
placed by BF who states they were doing heroin
and cocaine.
Case #4
On arrival:
Upon arrival, pt is throwing objects around the
house, screaming, has multiple
abrasions/lacerations on her face and arms.
She becomes belligerent and combative,
throwing herself onto the ground and slamming
her face into the floor. PMH unknown – BF met
her 3 days earlier.
What else would you like to know?
Outline
Epidemiology
Case #2
The Agitated Pt
Chemical Restraints
Risk Assessment
– IM
Tarasoff Decision
– Case #3
Case #1
– IM vs. PO
Drugs
Case #4
– Psychotropics
Clinical Relevance
– Benzodiazepines
Case #5
Physical Restraints
Clinical Relevance
All or nothing – Pt’s are either cooperative
enough to transport or need to be “wrestled”???
Options and availability on rigs…(IM, IV, intranasal)
Case #5
Call comes in:
45 yo AAM w/ hx of schizophrenia is in front of a hotel shaking his
head around violently, and yelling..
Case #5
On arrival:
45 yo AAM who is acutely psychotic with hallucinations & resisting
aid. Police attempt to restrain patient. After initial struggle, pt
escapes and runs around briefly and is taken down with force by
police and strapped to gurney in a supine position.
Due to pt’s combative state, EMS are unable to obtain vitals but see
no signs of overt trauma. Pt is placed in back of ambulance, skin is
noted to be warm & dry, pupils are equal, midrange & reactive.
Awake and alert on the beginning of transport but becomes
markedly less responsive during transport.
Case #5
W/in 15 minutes & as they arrive the pt is in full arrest. As they are
backing up pt is intubated w/ a Combitube and ACLS is started –
receiving epi, atropine, dextrose and remains in asystolic arrest w/
fixed pupils, midrange and non-reactive.
Pt is rushed into trauma bay and Combitube is d/c’d, endotracheal
tube is placed, central venous access is obtained and standard
resuscitation is cont’d. Twenty-two min after arrival, pt remains in
asystole and is now pronounced.
Physical Restraints – Key
Points
Indications:
– Behavior or threats that create
or imply a danger to the
patient or others (including
delay of treatment)
– Safe and controlled access for
medical procedures
– Involuntary evaluation or
treatment of incompetent
combative patients
Appropriate personnel
Sufficient Restraint (Case #4)
Position of patient
Physical Restraints – Key
Points
Documentation
– An emergency existed
– The need for tx was explained to the pt (regardless
of competence)
– Evidence of the patient’s incompetence to refuse
treatment
– The patient refused treatment or was unable to
consent to treatment
– The restraints were used for the safety of the patient
or others
– Failures of less restrictive methods of control (such
as verbal counsel)
– The type/method of restraint used and which limbs
were restrained
– Injuries that occur during the restraint procedure
– Continuously assess pt
References
1) McNiel, Dale and Binder, Renee. Psychiatric Emergency Service Use and Homelessness,
Mental Disorder, and Violence. Psychiatric Services. 2005;56:699-704.
2) Cheney P, Gossett L. Relationship of Restraint Use, Patient Injury, and Assaults on EMS
Personnel. Prehospital Emergency Care. 2006;10/2:207-12.
3) Thienhaus O and Piasecki M. Assessment of Psychiatric Patients’ Risk of Violence Toward
Others. Psychiatric Services. 1998;49/9:1129-1131.
4) Mintzer Jacobo. The Clinical Impact of Agitation in Various Psychiatric Disorders: Management
Consensus and Controversies. J Clin Psychiatry. 2006;67 (suppl 10):3-15.
5) Currier G and Medori R. Orally Versus Intramuscularly Administered Antipsychotic Drugs in
Psychiatric Emergencies. Journal of Psychiatric Practice. 2006;12:1 30-39.
6) Jibson M. Overview of Antipsychotic Medications. Up to Date 2006;1-12
7) Tintinalli J, et al. Emergency Medicine; A Comprehensive Study Guide. “Psychotropic
Medications” 1816-1820.