Care of the Acutely Agitated Patient Objectives

Home , Emergency psychiatry

Dealing with combative patients is one of the most difficult challenges an emergency physician encounters. Often brought in against Care of the Acutely Agitated their will, such patients may be agitated, Patient confrontational, and nearly impossible to examine. If not controlled, they may harm themselves or others, including the emergency James C. Hardy, MD department staff, other patients, and visitors. ’ Assistant Professor of Emergency Medicine -Rosen s Textbook of Emergency Department of Emergency Medicine, UCSF Medicine

Objectives Case 1: The Universal Agitated Patient

• Prevent escalation • 30 y M, unknown hx, “acting crazy!” • Tips for de-escalation • Recommendations for meds

3 4

1 Warning Signs Prevention • See them fast • Angry • Private but not isolated • Pacing, changing positions frequently • Security nearby • Clenched fists or tight grip on rails • Keep door open • Loud speech • You and Pt equidistant to door • Previous history • Be disarming • Sometimes there is no warning • Safe rooms 6

5 6

De-escalation

• Saves time, money, adverse outcomes, and injuries • Under-emphasized in ED training • Act as an advocate. • Strengthens “therapeutic alliance ”

7 8

2 De-escalation: “10 Domains ” Offer Meds Early!

• Respect Personal • Listen Closely • This is really a stressful situation, would you Space • Agree or Agree to like a medicine to help?.. • Do Not Be Provocative Disagree • Do you normally take a medicine or is there • • Establish Verbal Lay Down Law and Set one you’re supposed to be on? Contact Clear Limits • What has worked for you in the past? • Be Concise • Offer Choices and • • Identify Wants and Optimism What has NOT worked for you? Feelings • Debrief Pt and Staff

9 10 Glick RL et al, Emergency Psychiatry; Principles and Practice . Lippincott, 2008.

Strengthen the therapeutic alliance! PO is preferred route

• Offers patient choice and control • Strengthens therapeutic alliance • Can be given in elixirs or ODT • Can even be given to pts in restraints • Some are quite fast acting • Generally preferred by patients

“““ ’’’ ””” 11 He s a very controlling person 12

3 What KIND of medicine should I give a patient with undifferentiated agitation?

Allen et al. What do consumers say they want and need during a psychiatric emergency?. Journal of Psychiatric Practice (2003) vol. 9 (1) pp. 39-58 13 14

ACEP Clinical Policy Cast of Characters Level B/ C Recommendations

• Lorazepam (Ativan) • Ziprasidone* (Geodon) • Benzo OR a conventional antipsychotic • Midazolam (Versed) • Olanzapine* (Zyprexa, • Zydis) Diazepam (Valium) • If rapid sedation is required, consider • Risperidone (Risperdal) • Haloperidol (Haldol) droperidol* instead of haloperidol. • Droperidol (Inapsine) • Aripiprazole* (Abilify) • • Quetiapine (Seroquel) Diphenhydramine • (Benadryl) Oral benzodiazepine + oral antipsychotic if cooperative patients. • Benztropine (Cogentin)

• HAC may be faster than monotherapy

Lukens et al. Clinical Policy: Critical Issues in the Diagnosis and Management of the 15 Adult Psychiatric Patient in the Emergency Department. Annals of Emergency 16 Medicine . Vol 47, No 1, January 2006.

4 Why BZNs are Preferred for Expert Consensus Guideline 2005 Undifferentiated Agitation • “BNZs are recommended when no • Safe. No EPS. No Sz. No QT problems data are available, when there is no • Easy to titrate specific treatment (e.g., personality • Preferred for intoxications disorder), or when they may have • Preferred for seizure, etoh w/d. specific benefits (e.g., intoxication). ” • Works some for psychosis • Preferred by patients

Allen et al. The Expert Consensus Guideline Series: Treatment of Behavioral Emergencies 2005. Journal of Psychiatric Practice . Vol 11, Suppl 1 17 18

Consumers ’ Wants and Needs During a Psychiatric Emergency Consumers ’ Wants and Needs During a Psychiatric Emergency

Allen et al. What do consumers say they want and need during a psychiatric emergency?. Journal of Psychiatric Practice (2003) vol. 9 (1) pp. 39-58

19 20

5 What if really really agitated? Midazolam 5mg vs Lorazepam 2mg vs Haloperidol 5mg (IM) • PO still preferred route if possible • Time to Time to Benzodiazepines still preferred class Sedation Arousal • Lorazepam most widely used Midazolam IM 18 min 81 min Lorazepam IM 32 min 217 min -Reliable IM absorption Haloperidol IM 28 min 126 min -No metabolites • Nobay et al. A Prospective, Double-blind, Randomized Trial of Midazolam versus Consider Midazolam Haloperidol versus Lorazepam in the Chemical Restraint of Violent and Severely Agitated 21 Patients Academic Emergency Medicine (2004) 22

Just really drunk? Psychotic from meth?

• Benzos vs antipsychotics? • Ativan still good • Project BETA recommends haldol • SGAs effective against meth psychosis. • I’ll stick with ativan and avoid midazolam

Shoptaw SJ, Kao U, Ling W. Treatment for amphetamine psychosis. Cochrane Database Syst Rev . 2009; 1: CD003026. Wilson MP, Pepper D, Currier GW, Holloman GH, Feifel D. The Psychopharmacology of Agitation: Consensus statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup. West JEM. In press. 23 24

6 Decompensated psych disease? ACEP Level B: Known Psych dz

• Use an antipsychotic alone

• Or use oral benzo + antipsychotic

Lukens et al. Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult 25 Psychiatric Patient in the Emergency Department. Annals of Emergency Medicine . Vol26 47, No 1, January 2006.

Expert Consensus Guideline Project BETA Recommendations • “Within the limits of expert opinion and with the expectation that future • SGAs recommended over haldol research data will take precedence, these guidelines suggest that the • Risperidone or olanzapine if will take oral. SGAs are now preferred for agitation in the setting of primary psychiatric • Ziprasidone or olanzapine if IM illnesses but that BNZs are preferred Wilson MP, Pepper D, Currier GW, Holloman GH, Feifel D. The in other situations .” Psychopharmacology of Agitation: Consensus statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup. West JEM. Feb 2012. Allen et al. The Expert Consensus Guideline Series: Treatment of Behavioral Emergencies 2005. Journal of Psychiatric Practice . Vol 11, Suppl 1 27 28

7 First Generation Antipsychotics • Powerful, effective, Dopamine antagonists • Long history • Cheap • Narrower range of sx • Not favored by pts • Not used long term • High EPS

29 30

Extrapyramidal Symptoms Second Generation Antipsychotics

• Dystonia • Broad range of sx, • Oculogyric crisis multiple receptors • Akinesia • Effective single • Akithesia agent • Parkinsonism • Low EPS • Tardive dyskinesia • Preferred by pts and psychiatrists • Shorter history • Expensive

31 32

8 Citrome. Comparison of intramuscular ziprasidone, olanzapine, or aripiprazole for agitation: a quantitative review of efficacy and safety. The Journal of Clinical Psychiatry (2007) vol. 68 (12) pp. 1876-85

NNT IM Ziprasidone, Olanzapine, Aripiprazole, Halopidol, Drug Dose Unit cost ($) Ratio Lorazepam Geodon 20mg IM 145 3.3 Zyprexa 10mg IM 369 8 Risperdone 2mg po 100 2.3

Haloperidol 5mg IM 11 Ativan 2mg IM - 25 Benadryl 50mg IM- 8 Regimen cost 44 1

33 34

NNH: Olanzapine vs Haloperidol

• Parkinsonism: Avoided every 7 pts • Acute Dystonia: Avoided every 14 pts • EPS: Avoided every 21 pts What if that didn’t work? • Anticholinergic Rx: Avoided every 7 pts Change class? Add more benzo? Benzo after IM zyprexa? Citrome. Comparison of intramuscular ziprasidone, olanzapine, or aripiprazole for agitation: a quantitative review of efficacy and safety. The Journal of clinical Psychiatry (2007) vol. 68 (12) pp. 1876-85 35

9 Take-Down team

• “Code 100 ” • 6 staff + 1 physician • Nurse #1 runs the code • Nurse #2 gets the meds • Nurse #3 gets restraints • 1 staff per limb • Physician to determine meds.

37 38

What should I give the elderly agitated Elderly and Agitated patient? • Wait for it… • Haloperidol low dose = first line • Quiet room, low lights • Extensive history (but not FDA-labeled) • Language? • Negligible anticholinergic effects • Family and familiarity • Minimal hypotension • BZNs and anticholinergics can worsen sx

39 40

10 Based on the evidence and view that IV QTc? haloperidol was a highly effective and preferred treatment for delirium, the • All antipsychotics can prolong QTc and committee approved the use of IV haloperidol predispose to torsades de pointes in doses < 2mg with cumulative dose of • Beware if baseline EKG = QTc >500 20mg/24 hours without 12-lead ECG • Droperidol received controversial FDA Black monitoring. Telemetry and daily ECGs would Box Warning be required for single doses > 2 mg or cumulative doses of > 20 mg/day. • Haldol IV route not FDA approved 2/2 QTc…but everyone uses it. Pharmacy and Therapeutics Committee University of California, San Francisco and Mount Zion Medical Center Wednesday, October 8, 2008

41 42

While you ’re worrying What about Parkinson ’s?

• EPS, acute dystonia, • What do you give? • Neuroleptic Malignant Syndrome • Quetiapine (Seroquel) is most widely used antipsychotic for dopaminergic-induced • Olanzapine-->hypotension psychosis. • Olanzapine + BZN co-administration not advised. • Ziprasidone-->More QTc prolongation but no recorded bad outcomes

43 44

11 Summary

• Acute agitation is dangerous for you and pt • Prevention and de-escalation is key • Oral route preferred when possible • BZN ’s preferred for undifferentiated agitation in healthy adults • Controversy over atypical vs typical antipsychotics in psychotic agitation • Haloperidol most widely accepted in elderly with delirium (quetiapine in Parkinson ’s)