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Les Zun, MD, MBA, FAAEM Agitated Patients: Clinical Overview and Problem Definition Leslie Zun, MD, MBA, FAAEM Professor and Chair Rosalind Franklin University/Chicago.

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Presentation on theme: "Les Zun, MD, MBA, FAAEM Agitated Patients: Clinical Overview and Problem Definition Leslie Zun, MD, MBA, FAAEM Professor and Chair Rosalind Franklin University/Chicago."— Presentation transcript:

1 Les Zun, MD, MBA, FAAEM Agitated Patients: Clinical Overview and Problem Definition Leslie Zun, MD, MBA, FAAEM Professor and Chair Rosalind Franklin University/Chicago Medical School Department of Emergency Medicine Mount Sinai Hospital FERNE/MEMC Session:

2 Les Zun, MD, MBA, FAAEM Disclosures Alexza Pharmaceuticals Sanofi-Aventis FERNE/MEMC Session:

3 Les Zun, MD, MBA, FAAEM Agitation Definition – Excessive verbal and/or motor behavior Escalation – Verbal – Physical – Violence Signs of agitation – Pacing – Irritable – Affective liability – Verbal outbursts – Clenching fists or jaws – Threatening or destructive behavior – Slamming or banging objects

4 Les Zun, MD, MBA, FAAEM Prevalence Psychiatric patients in US – 4.3 million ED US visits per year – 5.4% of ED patients Prevalence of agitation in US – Up to 1.7 million ED visits Incidence of violence in US – 50% of healthcare providers in their career – 51% of MDs and 67% of nurses in ED were physically assaulted in the last 6 months – 2/3 containment and 1/3 random

5 Les Zun, MD, MBA, FAAEMEtiology Drug and alcohol intoxication or withdrawal Medical – Hypoglycemia – Hyperthyroidism – Delirium – Dementia – Head Trauma – Temporal Lobe Epilepsy Psychiatric – Schizophrenia – Mania – Agitated depression – Personality disorder – Antisocial, borderline – PT – Akathisia

6 Les Zun, MD, MBA, FAAEMEtiology Drug and alcohol intoxication or withdrawal Medical – Hypoglycemia – Hyperthyroidism – Delirium – Dementia – Head Trauma – Temporal Lobe Epilepsy Psychiatric – Schizophrenia – Mania – Agitated depression – Personality disorder – Antisocial, borderline – PTSD – Akathisia

7 Les Zun, MD, MBA, FAAEM Evaluation Differentiate medical from psychiatric etiology – Age – Prior history – Vital signs – Physical examination findings – Focal neurologic findings – Glucose – Oxygenation – Laboratories? – Radiography-CT Scan Delirium vs. dementia

8 Les Zun, MD, MBA, FAAEM Delirium vs. dementia DeliriumDementia OnsetAcuteSlow AwarenessReducedClear AlertnessFluctuatesNormal OrientationImpaired MemoryImpaired PerceptionHallucinationsIntact ThinkingDisorganizedVague LanguageSlowWord finding difficulty

9 Les Zun, MD, MBA, FAAEM Patient Identification Citrone, L, Volavka: Violent patients in the emergency setting. Psych Clinic NA 1999;22: High risk – Schizophrenia + substance abuse + medication non- compliance > Schizophrenia >Affective disorders 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

10 Les Zun, MD, MBA, FAAEM Chaotic Environment Level of Agitation From ED Arrival Zun, LS and Downey, LA: Level of agitation of patients presenting to an emergency department. Primary Care Companion J Clin Psychiatry 2008;10:

11 Les Zun, MD, MBA, FAAEM Progression Do all patients progress? Which patients progress? How to prevent progression?

12 Les Zun, MD, MBA, FAAEM Reason to treat agitated patients Prevent violence – Up to 75% ED staff victims of violence 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: – 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 work-up Begin therapeutic process Fishkind, AB: Agitation II: De-escalation of the aggressive patient and avoiding coercion. Emergency Psychiatry, – Collaborative interactions – Elicit information – Patients say all they want – Include patients in planning – Empathize

13 Les Zun, MD, MBA, FAAEM Treatment Treat medical condition Reduce stimulation Verbal de-escalation - Talk em down Alternatives to restraints Restrain – Physical – Chemical – Combination Seclusion

14 Les Zun, MD, MBA, FAAEM Prevent Violence Brasic, JR, Fogel, D:Clinical safety. Psych Clinic NA 1999;22: Identify violent patients Search patients for weapons Use a comprehensive, collaborative approach to the patient Strategies – Administrative – Behavioral – Environmental

15 Les Zun, MD, MBA, FAAEM Prevent Violence-Strategies Brasic, JR, Fogel, D:Clinical safety. Psych Clinic NA 1999;22: – Administrative Gangs involvement Evacuation plan Staff training – Behavioral 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 – Clinical training programs eg CPI Panic alerts

16 Les Zun, MD, MBA, FAAEM Agitated Patients: Clinical Overview and Problem Definition Summary Agitation and violence common in ED Evaluate for possible treatable conditions Apply techniques to reduce agitation – Identify agitated patients – Be pre-emptive – Utilize appropriate resources Employ strategies to prevent violence – Search all patients – Isolate and observe


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