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 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 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 (D 2) 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 (D 2) and serotonin (5 -HT 2) 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 2 nd 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 2 nd 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) Mc. Niel, 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.
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