Agitated And Suicidal Patients

Educational Objectives

The goal of this program is to improve the management of acutely agitated and suicidal patients. After hearing and as­similating this program, the clinician will be better able to:

1.   Utilize techniques for de-escalation in managing an agitated patient.

2.   Prescribe appropriate drug therapy, based on the degree of agitation and associated conditions present.

3.   Discuss the characteristics and side effects of the drugs used in the management of an agitated patient.

4.   Utilize the Modified Sad Persons Scale in evaluating the potential for suicide in the emergency department (ED).

5.   Employ criteria, including requirements of the Joint National Commission, for ED discharge of patients after a suicide attempt.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committe reported nothing to disclose.

Acknowledgements

Dr. Hardy was recorded at Topics in Emergency Medicine, held October 19-22, 2009, in San Francisco, CA, and sponsored by the Department of Emergency Medicine, University of California, San Francisco, School of Medicine. Dr. Hockberger was recorded at Emergency Medicine 2009, held February 9-13, 2009, in Olympic Valley, CA, and sponsored by the Uni­versity of California, Davis, Health System, Office of Continuing Medical Education, and Department of Emergency Medi­cine. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Management Of The Acutely Agitated Patient

James C. Hardy, MD, Assistant Professor of Emergency Medicine, University of California, San Francisco, School of Medicine

Strategies for managing agitated patients: important to pay early attention to agitated patients (see them first); dis­arm patient; use metal detector in emergency department (ED) if available; if none available, have patient remove clothes and put on gown; make patient feel comfortable; place patient in room where presence seen but private; ideally, in room where patient not heard if screaming loudly; room should not be isolated; should not place pa­tient in room where objects present that could be used as weapons; keep door open; keep security nearby; keep patient and physician equidistant to door; not all possible events preventable; should learn to de-escalate

De-escalation: experts recommend that ED physician enter with different mindset; act as patient’s advocate; make patient as comfortable as possible (ask patient whether he or she needs anything; strengthens therapeutic alli­ance); underemphasized in training

Ten domains of de-escalation: 1) respect patient’s personal space; 2 arm lengths between physician and patient (more if patient paranoid); give patient line of egress; 2) do not be provocative; have soft and caring demeanor, with relaxed physical pose; 3) make normal eye contact; 4) establish verbal contact (orient and advise patient on situation); advisable for only one person to talk (less confusing); 5) be concise; keep statements short and repeat yourself; 6) channel “inner psychiatrist”; should not be afraid to identify patient’s wants and feelings; 7) listen closely to patient; 8) find things to agree on; avoid arguments (agitating); 9) offer choices and optimism to pa­tient; 10) debrief patient and staff when patient calmed down

Physical restraints: classic choices leather and vinyl; leather strong but difficult to clean; vinyl slippery (allows pa­tient’s hand to slide out); Velcro easy to slip on but allows patient’s hands to wiggle out; soft restraints for older weaker patients; if possible, organize takedown team; in speaker’s institution, “code 100” called; team includes 6 staff members and physician; one nurse runs procedure, and another nurse assigned to obtain medications and re­straints; once team assembled, staff member designated for each limb of patient to control joints; physician deter­mines which medications to use

Pharmacologic management of agitation: ideally, fast-acting, not labor-intensive to prepare, not too sedating, and safe for patient and staff; use of chemical or physical restraints means taking control for patient and assuming re­sponsibility for patient; be aware of unintended consequences; benzodiazepines  —  lorazepam (Ativan), mid­azolam (Versed), and diazepam (Valium); typical or first-generation antipsychotics  —  haloperidol (Haldol) and droperidol (Inapsine); anticholinergics  —  diphenhy-dramine (eg, Benadryl) and benztropine (Cogentin); atypical or second-generation antipsychotics  —ziprasidone (Geodon), olanzapine (eg, Zyprexa), risperidone (Risperdal), aripiprazole (Abilify), and quetiapine (Seroquel)

Slightly agitated patient: preferred route of administration of medication oral; attempt to start with oral route; offer choice and allow patient to participate in own care (strengthens therapeutic alliance); oral dissolving tablets  —  dissolve almost instantly in saliva upon hitting tongue; can be given to patient in restraints; do not pop into pa­tient’s mouth with finger (patient may bite); offer to patient on tongue blade; some fast-acting; survey found that most patients prefer oral form

American College of Emergency Physicians (ACEP) guidelines: benzodiazepine or conventional antipsychotic first-line treatment (level B recommendation); for rapid sedation, droperidol recommended (safety controver­sial); combination of oral benzodiazepine and oral antipsychotic also used if patient agrees; combination of halo­peridol and lorazepam level C recommendation

Expert consensus guidelines (2005): based on survey of 50 directors of psychiatric EDs (not evidence-based); benzodiazepines  —  preferred; reasons include safety (except for slight risk for respiratory depression), absence of extrapyramidal symptoms (EPS), do not cause seizures, and easy to titrate; preferred for intoxications (eg, co­caine, alcohol); effective for psychosis to certain degree; preferred by patients; survey of admitted patients in psychiatric hospitals found lorazepam most preferred, followed by combination of lorazepam and antipsychotic; antipsychotics least favored; when ranked by medication, most preferred lorazepam, followed by diazepam, clon­azepam, quetiapine, risperidone, and olanzapine (atypical antipsychotics)

Severely agitated patient: potentially violent; oral route still preferred; benzodiazepines still preferred class; loraze­pam most widely recommended (reliable absorption, with no build-up of metabolites); consider midazolam; study  —  compared midazolam, lorazepam, and haloperidol and measured time to sedation and time to arousal; time to sedation 18 min with midazolam (followed by haloperidol and lorazepam); time to arousal shorter with midazolam (81 min); study  —  compared midazolam, droperidol, and ziprasidone; found midazolam twice as fast as droperidol and ziprasidone; rescue medications given in almost 50% of cases (due to short duration); O₂ re­quired in 10 of 48 cases; none required bagging or intubation

Severely agitated patient with psychiatric disease: ACEP  —antipsychotic (typical or atypical) preferred as front-line treatment (level B recommendation); combination of benzodiazepine and antipsychotic if patient agrees; combination of haloperidol and lorazepam level C recommendation; psychiatrists  —  prefer atypical anti-psychot­ics; in patient with known psychiatric disease, start with second-generation antipsychotic (SGA); if not known, start with benzodiazepines; haloperidol  — recommended by ACEP but not preferred by psychiatrists; powerful and effective dopamine antagonist; well known and inexpensive; controls only narrow range of symptoms; does not control psychosis with negative symptoms effectively; not favored by patients; not used long-term due to poor side effect profile; high rate of EPS; EPS  —  dystonia (dystonia of eyes oculogyric crisis), akinesia, akathi­sia, parkinsonism, and tardive dyskinesia (long-term effect; fly-catching movement of tongue, involuntary tics)

Second-generation antipsychotics: defined by absence of EPS; olanzapine  —  dopaminergic antagonist (D₁, D₂, D₃, and D₄ receptors); serotonin (5-HT_2a and 5-HT_2c) antagonist; antimuscarinic and antihistaminic activity; long benzodiazepine-like g-aminobutyric acid “finish”; low EPS; preferred by patients and psychiatrists; short history; expensive; effective; number needed to treat (NNT)  —  ziprasidone (10 to 20 mg), 3; olanzapine, 3; aripiprazole, 5; haloperidol, 4; lorazepam, 4; number needed to harm (NNH)  —  better for second-generation antipsychotics; study showed that for olanzapine, NNH for parkinsonism 7 patients, for acute dystonia, 14 patients, for EPS, 21 patients; NNH for use of anticholinergics, 7 patients

Elderly and delirious patients: place in quiet room with family to orient them; haloperidol  —  first-line choice; long history of use; negligible anticholinergic effects; does not cause hypotension; benzodiazepines and anticholiner­gics worsen problem; corrected QT interval (QTc)  —  seen with all antipsychotics (predispose to prolongation of QT interval); black box warning for droperidol; reason for disapproval of intravenous (IV) haloperidol by Food and Drug Administration; in clinical practice, IV haloperidol <2 mg given, with cumulative dose <20 mg unless daily electrocardiographic monitoring performed

Atypical antipsychotics: 1.6 to 1.7 times greater mortality if provided on daily basis for psychosis, resulting in black box warning (also for typical antipsychotics)

Neuroleptic malignant syndrome: fever, autonomic dysregulation, and lead-pipe rigidity; seen with any antipsy­chotic agent; management supportive care; olanzapine  —  causes hypotension (systolic pressure drop of 20-30 mm Hg); not administered with benzodiazepine at same time (highly sedating); ziprasidone  —  causes more QTc prolon­gation than other atypical antipsychotics, but no adverse outcome reported so far; in demented patient with Parkin­son’s disease, quetiapine recommended (complicates Parkinson’s disease least)

Assessing Risk For Suicide

  Robert Hockberger, MD, Professor of Medicine, David Geffen School of Medicine at the University of Califor­nia, Los Angeles, and Chair, Department of Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles, CA

Suicidal patients in ED: many ED personnel do not exhibit positive, supportive, and nonjudgmental attitude toward suicidal patients

Clues to suicide potential: suicide attempt; suicidal ideation; severe depression; multiple physical complaints — up to two-thirds of those who commit suicide see physician (not psychiatrist) within previous month for complaints of, eg, headache, back pain, poor sleep; suspicious accidents — usually involve patient only; patient usually mildly intoxicated; usually car accident that involves running car into stationary object

Stepwise approach to talking about suicide: inform patient that people with similar symptoms sometimes depressed and ask whether he or she possibly suffering from depression; if patient answers affirmatively, inform patient that people who suffer from depression sometimes think about hurting themselves and ask patient whether he or she ever had such thoughts; if answer positive, ask about whether he or she has thought of specific ways of hurting self

Evaluation: first, stabilize patient’s medical condition; place patient in quiet area where he or she can be observed; minimize use of physical or chemical restraints; when possible, use “sitter”; evaluate nonintoxicated patients (in­toxicated patients score higher in screening tests for depression and ambivalence about future suicide attempts); confirm assessment with patient’s family or close friends; clinical experience and judgment essential part of sui­cide risk assessment, but should be informed by evidence-based research; unaided clinical experience not only insufficient in conducting suicide risk assessment, but often misguided by unyielding misconceptions, lore, and tradition

Sad persons scale: study found that psychiatric residents provided lecture and scoring tool more accurate at decid­ing which patients required admission than those who received lecture only; study of patients with previous sui­cide attempt, suicidal ideation, or severe depression followed for several years found only 3% to 4% ultimately commit suicide; modified sad persons scale (MSPS)  —  sex (women attempt suicide more frequently than men, but men more successful in attempt); age (<19 yr or >45 yr [due to incidence of depression]); depression or help­lessness; previous attempts or psychiatric care; excessive long-term alcohol or drug use; rational thinking loss (eg, schizophrenia, recent diagnosis of Alzheimer’s disease); separated, divorced, or widowed, particularly if re­cent; organized or serious attempt; no social supports; stated future intent; originally, 1 point given for each fac­tor; scale modified after analysis found that depression, loss of rational thought, organized or serious attempt, and stated future intent more highly correlated with decisions to admit

Study: analysis of admission decisions for 465 patients seen at 4 urban psychiatric EDs; 5 variables found highly as­sociated with decision to admit — 1) high level of danger to self, 2) high level of severity of psychosis, 3) high level of severity of depression, 4) low ability to care for self, and 5) poor impulse control

Another study: 509 patients; used Beck Suicide Intent Scale and other variables; 6 factors associated with increased chance of admission — 1) previous psychiatric hospitalization, 2) previous suicide attempt (particularly if  within 1 yr), 3) low psychosocial functioning, 4 ) high lethality of attempt, 5) plan to avoid discovery after suicide at­tempt, and 6) intent to repeat attempt; factors associated with decreased chance of admission — 1) availability (but not use) of lethal method, 2) relief that attempt unsuccessful, 3) belief that attempt would influence others, 4) realistic perspective about future, and 5) presence of family support

Hockberger et al study: 100 patients; found that no patient with score <6 admitted to hospital; if score 6 to 8, 50% admitted; if score >8, all admitted to hospital

Comparison of risk assessment tools: study found Beck Suicidality Scale specificity of 90% (19 variables, each with score of 1-5); MSPS 100% sensitive and 60% specific

Criteria for ED discharge of patients after suicide attempt: MSPS score <6 (document in medical record); stable and supportive home environment; patient contracts to return if situation worsens (controversial whether contract effective); family member or friend agrees to check on patient and assure compliance with follow-up; discuss case with physician providing follow-up care; patient given short-term appointment time-, place-, and person-specific (usually within 36 hr of ED visit); patient does not request immediate psychiatric evaluation

New Joint Commission standard: requirement that ED patients with primary psychiatric diagnosis, should be screened for presence of depression and suicide risk before admission to hospital or discharge from ED; based on fact that »5% of suicides occur in hospital, often on nonpsychiatric services; primary psychiatric diagnosis includes anxiety disorder and substance abuse disorder; approach  —  ask patient whether he or she feels depressed or having suicidal thoughts; if answer no, document response; if answer yes, perform more thorough assessment (MSPS ap­propriate); determine whether patient requires immediate psychiatric assessment before disposition, or if outpatient referral or inpatient consultation insufficient; if latter, notify admitting physician; document medical decision-mak­ing

Suggested Reading

Brungardt GS: Patient restraints: new guidelines for a less restrictive approach. Geriatrics 49:43, 1994; Cooper J et al: A clinical tool for assessing risk after self-harm. Ann Emerg Med 48:459, 2006; Correll CU et al: Lower risk for tardive dyskinesia associated with second-generation antipsychotics: a systematic review of 1-year studies. Am J Psy­chiatry 161(3):414, 2004; Dhossche DM: Suicidal behavior in psychiatric emergency room patients. South Med J 93:310, 2000; Gunnell D et al: Hospital admissions for self harm after discharge from psychiatric inpatient care: co­hort study. BMJ 337:a2278, 2008; Hillard JR et al: Determinants of emergency psychiatric admission for adoles­cents and adults. Am J Psychiatry 145:1416, 1988; Knott JC et al: Randomized clinical trial comparing intravenous midazolam and droperidol for sedation of the acutely agitated patient in the emergency department. Ann Emerg Med 47:61, 2006;.Kurlan R et al: Alzheimer's Disease Cooperative Study Group. Quetiapine for agitation or psychosis in patients with dementia and parkinsonism. Neurology 68:1356, 2007; Rosebush PI et al: Recognizing neuroleptic malignant syndrome. CMAJ170:1645, 2004; Sinha A et al: Pre-emptive use of haloperidol in ICU to prevent emer­gence agitation. Anaesthesia 62:753, 2007.