Case continued: going up in smoke
Recognizing Mr. A’s arousal, ED staff tries to reassure him and offers him food, something to drink, a phone Call, and a magazine. When these attempts fail to de-escalate his agitation, staff offers to make him more comfortable by giving oral lorazepam, which he adamantly refuses. He is told again that he must stay until a transfer facility is found for him.
Mr. A then demands to go outside “for a smoke.” When he is told ED patients cannot leave to smoke and is offered nicotine replacement, he begins to scream and lunges at one of the security officers. He is extremely strong, and additional officers are summoned. He retreats inside the room, slams the door, shatters the door window with a chair, and begins punching the broken glass. He slides to the floor in a vasovagal reaction at the sight of his bleeding hands but soon becomes combative again.
Staff give Mr. A IM haloperidol, 10 mg, and lorazepam, 2 mg, to manage his extreme agitation and place him in physical restraints to protect him and others. Within 25 to 30 minutes he is calm, and a safe environment has been re-established. The lacerations on his hands are sutured, and he is admitted to an inpatient psychiatric hospital for further stabilization and treatment.
No place for complacency
Mr. A’s experience illustrates how situations can become dangerous when precautions are not taken. Five steps can help you prepare and protect yourself when evaluating patients in the ED:
- seek the patient history
- evaluate the context in which the patient is being assessed
- identify arousal states (fear, anger, confusion, and humiliation)
- structure the interview for safety
- keep your guard up during the clinical encounter.9
Risk is high when law enforcement officers bring a patient to the ED. Be on guard, even if the patient is 80 years old and in a wheelchair. Complacency has no place in the ED; prepare as much as you can before interviewing the patient.
When restraints are needed. Involuntary medication and/or restraints may be necessary when reasonable interventions have failed, the patient will not cooperate, and he or she is exhibiting behavior/symptoms that could result in injury. Approximately 10% to 20% of psychiatric patients require physical or chemical restraint in the ED.10
Expert consensus guidelines suggest starting with verbal intervention, voluntary medication, and show of force, although emergency medication may be a reasonable first treatment (Algorithm).11 Offer oral medication first; IM medications carry risks including acute dystonia and akathisia, although these can be treated.
Lorazepam, 1 to 2 mg oral/IM, combined with haloperidol, 2 to 5 mg oral/IM, is a reasonable start in most cases. If the patient remains extremely agitated, the same medications and dosages can be repeated 30 to 60 minutes after the initial administration.12
Conventional oral/IM agents are usually more readily available in the ED than atypical antipsychotics, which must be ordered from the pharmacy. Recent FDA black-box warnings also emphasize that atypical antipsychotics are approved only for treating schizophrenia, acute manic and mixed episodes of bipolar I disorder, and for maintenance treatment in bipolar disorder. When compared with placebo, atypical antipsychotics have been associated with:
- increased risk for cerebrovascular events in elderly patients with dementia
- death in elderly patients with dementia-related psychosis.
Atypicals may be more appropriate than conventional antipsychotics for emergency treatment of agitation and aggression in some patients with complicating medical conditions or histories. For example, avoid high-potency conventional antipsychotics in patients with a history of extrapyramidal side effects and in those with mental retardation/developmental delay.11 Similarly, avoid benzodiazepines in patients with chronic obstructive pulmonary disease (COPD) or a history of drug-seeking behavior or drug abuse.
Of course not all psychiatric interventions in the ED are involuntary. For example, the ED physician may start an antidepressant for a patient diagnosed with mild to moderate depression for whom hospitalization is not indicated. Characteristics of patients who may be good candidates for starting antidepressants in the ED include a clear diagnosis, no substance abuse, low suicide risk, no psychosis or agitation, available social supports, clear follow-up plan, desire to begin treatment, and ability to pay for and obtain medications.13
Algorithm Consensus guideline for treating a behavioral emergency
Related resources
- Allen MH, Currier GW, Hughes DH, et al. The Expert Consensus Guideline Series: Treatment of behavioral emergencies. Postgrad Med 2001;May(Spec No):1-88.
- American College of Emergency Physicians. www.acep.org
- National Alliance on Mental Illness. www.nami.org
Drug brand names
- Fluoxetine • Prozac
- Haloperidol • Haldol
- Lorazepam • Ativan
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.