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Leslie S Zun, MD, MBA, FAAEM
Chairman and Professor
Department of Emergency Medicine
RFUMS/Chicago Medical School
Mount Sinai Hospital
Chicago, Illinois
Objectives
To improve the treatment of
agitation of psychiatric patients
in the emergency setting
To review the evidence
concerning physical restraints
and chemical treatment
Prevent Violence
Citrone, L, Volavka: Violent patients
in the emergency setting.
Psych Clinic NA 1999;22:789-801.
Comorbid substance
abuse, dependence or
intoxication
Hallucinations or delusions
Poor impulse control
Character pathology
Chaotic environment
Richmond Agitated
Sedation Scale
3.5
3
2.5
2
Restrained
Unrestrianed
1.5
1
0.5
0
0
30
60
90
120
150
180
Prevent Violence
Strategies
Brasic, JR, Fogel, D:Clinical safety. Psych Clinic NA 1999;22:923-940.
Administrative
Behavioral
Gangs
Evacuation plan
Search patients and visitors
Staff training
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
Panic alerts
Treatment
Physical restraints
Seclusion
Chemical treatment
Combination
Physical Restraints
Alternatives to restraint use
Downey LV, Zun LS, Gonzales SJ: Frequency of alternative to restraints and seclusion and uses of agitation
reduction techniques in the emergency department. Gen Hosp Psychiatry. 2007 Nov-Dec;29(6):470-4.
Physical Restraints
Alternatives to restraint use
Zun, LS, Downey, L, Gen Hosp Psych 2007.
Alternatives used
Frequency Effectiveness
Verbal
One to one
Decrease in
stimulation
Food or drink
84%
79%
36%
48%
74%
69%
15%
18%
Physical Restraints
Complications of Patient Restraint
Zun, LS: Complications of Patient Restraints, J Emerg Med 2003; 24:119-124.
Results - Complications
Death (0)
Seclusion
Committee on Pediatric Emergency Medicine: The use of physical restraint intervention for children and adolescents in
the acute care setting. Pediatrics 1997;99:497-498.
Brown, RL, Genel, M, Riggs, J: Use of seclusion and restraint in children and adolescents. Arch Ped Adol Med 2000;
154: 653-655.
Adults
Adolescents
Children
Complications noted
Formal training
Formal policies
Outstanding concerns:
Complication
Use in children
Addition of chemical sedation
Training and seclusion policy
97.6%
75.4%
32.5%
37.5%
81.1%
83.6%
Diagnosis
Undifferentiated
Psychiatric disturbance
General medical etiology
Substance intoxication or withdrawal
Hypotension
Respiratory depression
Increased violence
Choice of Medications
Haloperidol
Chlorpromazine
Droperidol
Loxapine
Thiothixene
Risperidone
Olanzapine
Ziprasidone
Aripiprazole
Quetiapine
ED Use of Droperidol
Thomas, H, Schwartz, E, Petrilli, R: Droperidol versus haloperidol for chemical restraint of agitated
and combative patients. Ann Emerg Med 1992; 21:407-413.
Combinations
Medication combinations
Battaglia, J, Moss, S, Ruch, J, Et al: Haloperidol, lorazepam or both for psychotic agitation? A multicenter, prospective,
double-blind, emergency department study. Am J Emerg Med 1997; 15:335-340.
Medications/Restraint/Seclusion combinations
No study of combination of medications
and restrain or seclusion found
Sedation
Dystonic reactions
Hypotension
Akathisia
Increased agitation
QT prolongation
QT Prolongation
Glassman, AH, Bigger: Antipsychotic drugs: prolonged QTc interval, torsade de pointes, and sudden
death. Am J Psych 2001;158:1774-1782.
Prolongation of QT (msec)
Ziprasidone
Risperidone
Olanzapine
Quetiapine
Thioridazine
Haloperidol
20.3
11.6
6.8
14.5
35.6
4.6
Findings
QT Prolongation
Ziperidone
Brand Name Geodon
Forms
Oral, IM
Risperidone
Aripiprazole
Oral, IM
Olanzepine
Zyprexa
Oral, dis, IM
Indications
Schizo,
Bipolar
Agitation
9.75 mg IM
Schizo,
Bipolar
Agitation
$7.95 USD
$8.84 USD
(dis)
$18.51 USD
for IM
Dose
Schizo
Agitation
20 mg oral
10-20 IM
Cost
$3.85 USD
Haloperidol IM (for 40 mg)
est. $5 USD
$9.50 USD
Lorazepam IM
est. $4 USD
10-15 mg IM
Ziperidone
Aripiprazole
Olanzepine
Brand Name
Geodon
Abilify
Zyprexa
Dizziness
3-10%
8%
4%
Akathisia
2%
2%
Somnolence
8-20%
7%
Other
Boxed
Headache
warning for 12%
QT interval
6%
Hypotension
& postural
hypotension
3%
Treatment Guidelines
Undifferentiated
Conventional antipsychotics
Atypical antipsychotics
Psychiatric Etiology
Conventional antipsychotics
Atypical antipsychotics
General Medical Etiology
Allen, MH, Currier. GW, Hughes, DH, Reyes, Harde, M, Docherty, JP: Treatment of behavioral
emergencies. Post grad Med 2001; S1-88.
Conventional antipsychotics
Benzodiazepine
? Atypical antipsychotics
Dilemma in the elderly psychotic pts
Substance Intoxication or Withdrawal
Allen, MH, Currier. GW, Hughes, DH, Reyes, Harde, M, Docherty, JP: Treatment of behavioral
emergencies. Post grad Med 2001; S1-88.
Benzodiazepine
Problems
Special populations
Pregnant
High-potency conventional
antipsychotics lack known teratogenicity
Alshuler, LL, Cohen, L , Szuba, MP, et al: Pharmacologic management of psychiatric illness during
pregnancy: dilemmas and guidelines. Am J Psych 1996;153:592-606.
Children
Benzodiazepine or butyrophenones
Dorfman, DH, Kastner, B: The use of restraints for pediatric psychiatric patients in emergency
departments. Ped Emerg Care 2004;20:151-156.
Antipsychotics - risperidone or
olanzapine
Allen, MH, Currier. GW, Hughes, DH, Reyes, Harde, M, Docherty, JP: Treatment of behavioral
emergencies. Post grad Med 2001; S1-88.