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Complex Situations (SLO7)
A 23 year old man is brought to the Emergency Department by his girlfriend, complaining of hearing voices. Whilst in the department he is sweating profusely and becomes increasingly agitated and aggressive towards staff. Despite attempted de-escalation, the patient refuses oral treatment and it is decided that the patient requires rapid tranquilisation to keep both the patient, other patients and staff safe. Which of the following is most suitable to achieve rapid tranquilisation?
Answer:
For acute behavioural disturbance (ABD) in the ED setting, RCEM guidance recommends ketamine or droperidol as first-line agents, which in certain circumstances might be thought to be contrary to advice found in the BNF (e.g. hypertension, hypovolaemia, hallucinations). However, there is now extensive evidence to support ketamine or droperidol as first-line agents for rapid tranquilisation in patients presenting with ABD, including where there may be co-existing drug ingestions and/or head injuries. These recommendations are made anticipating that in patients presenting with ABD it may not be possible to establish clinical monitoring, undertake blood tests or venous access, and collateral history is often limited. These recommendations have come from a focus on achieving adequate rapid tranquilisation as quickly and safely as possible, while avoiding precipitating physiological collapse.Acute Behavioural Disturbance in ED
Complex Situations (SLO7) / Mental Health
Last Updated: 6th September 2022
Acute behavioural disturbance (ABD) is an umbrella term used to describe a presentation which may include abnormal physiology and/or behaviour. It is important to recognise that ABD should not be considered a diagnosis or syndrome, but rather a clinical picture with a variety of presenting features and potential causes.
ABD patients pose a significant management challenge in the ED when their behavioural disturbance may put them and/or those around them at risk of physical injury. It is also important to recognise that ABD can be a distracting presentation. Patients may have co-existing toxicological problems, or traumatic injuries which may not be immediately obvious.
Potential factors leading to ABD
- Substance intoxication*
- Mental health conditions*
- Substance withdrawal
- Serotonin syndrome
- Hypoxia
- Hypoglycaemia
- Electrolyte disturbance
- Sepsis
- Head injury
- Anticholinergic syndrome
- Neuroleptic malignant syndrome
- Thyroid storm
- Heat stroke
- Seizures
Presenting features
Features in ABD may include:
- Agitation
- Constant physical activity
- Bizarre behaviour (incl. paranoia, hypervigilance)
- Fear, panic
- Unusual or unexpected strength
- Sustained non-compliance with police or ambulance staff
- Pain tolerance, impervious to pain
- Hot to touch, sweating
- Rapid breathing
- Tachycardia
Pre-hospital management
ABD is a term which is now recognised across police, ambulance services, and emergency control room staff. Both JRCALC (for NHS ambulance services) and the College of Policing have issued specific guidance on ABD.
Police:
Police training on ABD aims to ensure that there are attempts to de-escalate where practicable, avoid any restrictions in breathing, minimise restraint time and any physical activity including exertion under restraint and to call for a 999 ambulance. The guidance for police, unless directed otherwise by healthcare professionals, is to take the person to an ED and not to police custody (if the person is already detained in police custody, there is guidance from the Faculty of Forensic and Legal Medicine for custody healthcare staff). Police are also expected to share all available information from family, members of the public or Police National Computer system, with any attending healthcare staff (such as medications, drugs and/or alcohol use, medical and/or psychiatric history). Patients may have been subject to control with a Controlled Energy Device (e.g. TASER), PAVA spray, or remain in restraints.
Health professionals:
Pre-hospital rapid tranquilisation may be provided by some ambulance services or prehospital critical care teams. Details of the medications used will be handed over on arrival in the ED. Custody healthcare staff (CHS) may have administered oral benzodiazepines. There is variation in clinical skills and prescribing ability amongst CHS. CHS are expected to obtain physical or visual observations where possible, such as temperature, oxygen saturations, pulse, blood pressure etc. and to share this and relevant history with attending ambulance clinicians/hospital staff.
De-escalation
Verbal de-escalation:
Verbal de-escalation is a valuable tool with which to facilitate patient care and potentially avoid any requirement for restraint. Staff should make attempts to verbally de-escalate the situation. If safe and available, friends and family may be able to assist. This may feel futile if a patient will not, or is unable to engage, but is an important step in ensuring that the use of restraint and rapid tranquilisation are justified. A clear record of de-escalation will also provide reassurance to family and the public in cases where an adverse outcome leads to a review. De-escalation is a continuous process and repeat attempts may be appropriate at any point in the patient’s care.
Domains of verbal de-escalation:
- Respect personal space
- Identify exits, stay out of arm's reach
- Do not be provocative
- Use non-confrontational body language, keep hands visible, do not engage in argument
- Establish verbal contact
- Avoid multiple staff talking, introduce yourself, explain situation, reassure patient
- Be concise
- Use short sentences, give time to respond, use repetition if needed
- Identify wants and feelings
- Identify expectations, empathise
- Listen closely
- Use clarifying statements
- Agree, or agree to disagree
- Consider fogging techniques
- Set clear limits
- Clearly inform patient as 'matter of fact'
- Offer choices and optimism
- Offer acts of kindness, offer oral sedation
- Debrief patient and staff
- Explain why intervention was necessary, restore therapeutic relationship
Environmental de-escalation:
EDs should identify a suitable environment in which to manage patients presenting with ABD to minimise the need for restraint, this may be the mental health room. A suitable environment can reduce the impact of the presentation on the patient, other patients, and staff. This environment may not be suitable for delivering parenteral rapid tranquilisation but can help to control the situation while a response is planned.
Features of ideal environment:
- Dedicated to management of patients with severe agitation
- Adequate and appropriately located exits so that staff can exit without being trapped by the patient
- Doors which open outwards
- Quiet, low stimulus
- Not too warm
- Absence of equipment/furniture and moveable objects that could be a potential weapon or used to barricade an exit
- Absence of potential ligature points
- Constantly observable
- Staff able to signal need for additional support easily
Restraint
Patients presenting with severe ABD are likely to lack mental capacity (which should be formally assessed and documented) to make treatment decisions and may require emergency treatment under the appropriate legislation. This may include restraint to allow treatment. Any interventions must be using the least restrictive intervention possible and should be applied for the shortest duration possible. Attempts should be made to remove any ongoing restraint at the earliest opportunity, prolonged restraint should prompt consideration of rapid tranquilisation.
It has previously been suggested that restraint in the prone position contributed to deaths. Although this theory has not been supported by recent research, it would be prudent to ensure that there is no obstruction to ventilation and to minimise the risk of asphyxiation.
Staff who have not had approved training should not be asked to restrain patients. Early escalation to on-site security services is recommended. Hospitals should have sufficient trained security staff available to be able to safely restrain a patient, to keep them from harm and to protect others. Do not attempt to restrain patients with insufficient numbers of staff. There are significant risks to staff when attempting to restrain patients, and these are compounded by insufficient team numbers.
While the police should not normally be called to undertake restrictive practices in healthcare settings solely to facilitate clinical interventions, it has been established that there are scenarios in which police support should be requested:
- if healthcare staff have been injured
- if appropriate support is not available from healthcare colleagues in a sufficiently timely manner to ensure the safety of all those affected
- where there is a risk of serious injury or damage, and safety is compromised
Rapid tranquilisation
Rapid tranquilisation in ABD is important to prevent further sympathetic overstimulation and excessive muscular activity from causing a metabolic storm and subsequent cardiovascular collapse. Rapid tranquilisation can also prevent the patient from causing physical harm to themselves or others and facilitate investigations and treatments. The use of rapid tranquilisation for more severe ABD presentations is associated with reduced mortality.
Staffing:
In the ED environment, the requirement to definitively investigate/manage the patient’s presentation, combined with the availability of staffing expertise and equipment, means that more potent sedatives (or higher sedative doses) than are typically used in other scenarios may be used in the management of ABD. It must be recognised that most sedative agents for ABD have been associated with apnoea, airway obstruction, or a requirement for subsequent intubation (while haloperidol has fewer cases of adverse drug events, it is also associated with fewer cases of successful rapid tranquilisation, and post-haloperidol apnoea has been documented). The practitioner delivering rapid tranquilisation must be capable of managing these complications if they arise. Care of the patient presenting with ABD should be provided by a senior Emergency Medicine practitioner, and early critical care support should be considered.
Indications:
The use of agitation scales to guide the initial decision to use rapid tranquilisation within the ED may be helpful where practicable. The need for rapid tranquilisation in ABD is defined by the inability to provide the patient with a safe assessment or essential treatment.
Parenteral rapid tranquilisation is more likely to be required if patients:
- lack capacity to refuse treatment and are non-compliant, AND
- pose a danger to themselves or others OR have a clear need for further treatment/investigation
Route:
Offer oral sedative agents in line with your local protocols as part of a verbal and environmental de-escalation strategy. This is an important step in establishing that you are using the least restrictive practice in a patient who lacks capacity.
In severely agitated patients (such as those requiring continuous restraint or containment), initial delivery of parenteral medications in ABD is rarely achievable intravenously, nor is the full application of standard monitoring/pre-oxygenation. Moving to a standardised intramuscular ABD rapid tranquilisation protocol is associated with reduced time to ABD control, fewer adverse reactions, and fewer injuries to staff.
Agent:
When deciding which parenteral agent to use, clinicians should be mindful not only of its speed of onset, potential side-effects, and volume of administration in the case of IM route but also their own experience of using a particular drug; in an emergency the safest drug to use may be the one the clinician is most familiar with.
- Ketamine
- First line agent for rapid tranquilisation in ABD in ED setting
- Associated with shorter times to adequate sedation than benzodiazepines or antipsychotics
- Dissociative effects of ketamine appear to reduce adrenergic features
- Cardiovascular stability, and preservation of respiratory drive/airway reflexes
- Droperidol
- Associated with fewer adverse events than lorazepam or midazolam, and fewer cases requiring additional sedatives compared to haloperidol or midazolam
- Less-suitable option if a patient is known to take antipsychotic medications, or if there is a suspicion of a presentation linked to antipsychotic use (e.g. anticholinergic syndrome or akathisia)
- Midazolam
- Associated with higher number of adverse events than droperidol but could be considered in patients whose history suggests a risk from sympathomimetic features, when transient increases in tachycardia or hypertension may be particularly relevant (e.g. ischaemic heart disease or possible cocaine-induced psychosis
- Haloperidol and lorazepam
- Demonstrated to have a longer time to successful rapid tranquilisation than midazolam.
- When used in combination (as haloperidol 5mg IM+ lorazepam 2mg IM) they appear to achieve better sedation (with no increase in adverse effects) compared to using haloperidol or lorazepam alone
N.B. RCEM guidance recommends ketamine or droperidol as first-line agents, which in certain circumstances might be thought to be contrary to advice found in the BNF (e.g. hypertension, hypovolaemia, hallucinations). However, there is now extensive evidence to support ketamine or droperidol as first-line agents for rapid tranquilisation in patients presenting with ABD, including where there may be co-existing drug ingestions and/or head injuries. These recommendations are made anticipating that in patients presenting with ABD it may not be possible to establish clinical monitoring, undertake blood tests or venous access, and collateral history is often limited. These recommendations have come from a focus on achieving adequate rapid tranquilisation as quickly and safely as possible, while avoiding precipitating physiological collapse.
Dosing:
Suggested dosing of agents for rapid early control:
- Ketamine 4mg/kg IM (or titrate to effect IV) OR
- Droperidol 5-10mg IM
If these agents are unavailable, consider:
- Midazolam (5-10mg IM) OR
- Lorazepam (4mg IM) OR
- Haloperidol (5mg IM +/- 2mg lorazepam IM)
Anaesthesia and intubation
Some patients should be considered for induction of anaesthesia and intubation. Early referral to critical care should be made if this appears likely. Indications include:
- Requirement to manage the airway
- Inadequate spontaneous ventilation to maintain oxygenation and prevent hypercapnia
- Severe agitation despite maximal safe sedative doses
- Persistent metabolic derangement
- Requirement to manage hyperthermia
- Requirement to support other interventions or investigations
Documentation
In ABD cases, appropriate documentation to support review is helpful. In addition to your standard notes, consider recording:
- relevant features from the collateral history
- features supporting the decision to manage as ABD
- attempts to achieve verbal/environmental de-escalation
- assessments of mental capacity
- restraint applied, duration and indication
- security or police involvement, including use of force, controlled energy device use, etc.
- sedative strategy and any adverse events
- involvement of other specialties
Frail or elderly patients
The differential diagnosis in this group is less likely to feature stimulant drugs, and more likely to feature hyperactive delirium. Sedative dose requirements are likely to be lower, and a ‘start low, go slow’ strategy may reduce risk. Droperidol (5mg) appears to be safe and effective for the rapid tranquilisation of undifferentiated agitated elderly patients. If there is particular concern regarding pre-existing QT interval prolongation, consider using a benzodiazepine cautiously as a first line sedative medication.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
