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Treatment of Agitation: Restrain, Seclude

or Medicate
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


Reason to treat agitated


patients
Prevent violence
 Better able to assess the patient
 Begin therapeutic process


Prevent Violence
Citrone, L, Volavka: Violent patients
in the emergency setting.
Psych Clinic NA 1999;22:789-801.

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

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

Zun LS, Downey LV;


Level of agitation of psychiatric patients presenting to
an emergency department.
Prim Care Companion J Clin Psychiatry. 2008;10(2):108-13

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

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 workup

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.




Surveyed a random sample of ED and


all Psychiatric EDs in the country.
Survey tool to determine agitation
reduction techniques and reasons for
differing level of usage
40% response rate
Almost all EDs (90%) and Psych EDs
use alternatives (98%)

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.




The purpose of the study was to determine the


type and rate of complications of patients
restrained in the ED over 1 year.
221 patients were restrained in the ED
Mean of 4.78 hours
 (range .2-24 hrs)
Position
 supine position (87.1%)
 sitting (8.1%)
 prone (4.8%)
Chemical restraints were added (28.6%)

Results - Complications



Complication rate 5.4%


12 complications:

Getting out of restraints (6)


Injured others (2)
Vomiting (1)
Injured self (1)
Other (1)
Hostile or increased agitation (1)
Aspiration (0)
Spitting (0)

Death (0)









No major complications such as death or


disability

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.

Involuntary confinement of a patient alone in


a room, from which the patient is physically
prevented from leaving for any period of
time.
Variants




Did not differentiate locked versus unlocked


Free movement or no free movement
Separation from the group

Seclusion Use in Emergency


Medicine
Zun, LS and Downey, L : The use of seclusion in emergency medicine. Gen Hosp Psych 2005; 27:365371.





Survey study of a random sample of


1067 US EDs medical directors
Response from 443 (41.6%)
27.8% use seclusion
Reasons not to use seclusion




Problems with physical plant 50.2%


Concern over safety
36.5%
Too many regulations
19.7%

Seclusion Use in Emergency


Medicine
Zun, LS and Downey, L : The use of seclusion in emergency medicine. Gen Hosp Psych 2005; 27:365-371

Age placed in seclusion











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%

Use of Chemical Treatment




Diagnosis










Undifferentiated
Psychiatric disturbance
General medical etiology
Substance intoxication or withdrawal

Route Oral, IM, IV, Inhalational


Dosage - Single dose or multiple doses
Onset and Offset - Sedation
Safety




Hypotension
Respiratory depression
Increased violence

Neuroleptic malignant syndrome


Dystonic reaction
Akathisia

Choice of Medications


Use of typical antipsychotics








Haloperidol
Chlorpromazine
Droperidol
Loxapine
Thiothixene

Use of atypical antipsychotic








Risperidone
Olanzapine
Ziprasidone
Aripiprazole
Quetiapine

Increased violent behavior


Herrera, JN, Sramek, JJ, Costa, JF et al: High potency neuroleptics and violence in schizophrenics. J
Nervous Mental Dis 1988; 176:558-561.

16 male schizophrenic patients resistant


to previous neuroleptic treatment
Comparison of Haloperidol to Clozapine
or Chlorpromazine
Significantly more violent episodes
occurred with haloperidol than other
meds or placebo periods
Could this be from akathisia or druginduced behavioral toxicity

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.







33 patients got haloperidol and 35 got droperidol IM


Droperidol decreased combativeness significantly
more than IM haloperidol at 10 (p=.01) and 30
minutes (p=.04)
Sedation not studied
Hypotension found with equal doses of both drugs
in 8 patients
FDA States - ECG monitoring should be performed
prior to treatment and continued for 2-3 hours after
completing treatment to monitor for arrhythmias

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.

Prospective study of 98 agitated, aggressive


undifferentiated patients over 18 months
Used rapid tranquilization method
Given IM lorazepam (2 mg), haloperidol (5mg) or
combination
Haloperidol had more EPS symptoms
No difference in sedation amongst the groups
Most rapid RT with combination

Medications/Restraint/Seclusion combinations
 No study of combination of medications
and restrain or seclusion found

Problems with Current


Medications







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




Thioridazine is most marked assoc with Torsade


Haldoperidol can cause torsade and sudden death
Olanzapine, Risperidone and Quetiapine not
associated with Torsade

QT Prolongation


Young patients who have family history


of prolonged QT syndrome
Older patients with known heart disease
or drugs that prolong QT need a
pretreatment EKG
Electrolyte abnormalities may
predispose to QT - hypokalemia

Advantages of the New


Medications
Little hypotension
 Less sedation
 Few dystonic reactions
 Replacement for Droperidol?


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%

Undifferentiated Agitated Patients


in the ED
Marten, M el al: Management of acute undifferentiated agitation in the emergency department Academic Emer
Med 2005;12:1167-72.




144 patients randomized to either droperidol,


ziprasidone and midazolam
Sedation in 10% of droperidol, 20% ziprasidone and
50% of midazolam








At 15 min more agitation in the ziprasidone group


At 30 min no difference in agitation
At 45 min, more agitation in midazolam group

Respiratory depression noted in 8% droperidol, 15%


ziprasidone and 21% midazolam.
No cardiac arrhythmias found in any group
Adequate sedation is delayed with the use of
ziprasidone relative to the other agents

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.

Take Home Point


Physical restraint is probably safe
 Combination of haloperidol and
lorazepam may cause
oversedation
 Consider atypical antipsychotic
agents for the use in the
emergency department


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