Attempt to clarify and validate patient’s immediate concerns
Calmly explain potential need for a restraint if de-escalation is not successful
Offer patient choices when possible
Seclusion:
If an appropriate room is available, this may obviate the need for restraint
Physical restraint:
Follow your institutional protocol
Must document appropriate reason for restraint, attempts to verbally de-escalate, and plans for appropriate monitoring and reassessments
Whenever possible, treating physician should not be part of restraint team
Use leather restraints for combative patients; soft restraints for patients who are unlikely to be combative or try to elope
Supine position if patient needs to be examined; side position if aspiration risk is significant
If restraint in prone position is needed, ensure adequate airway is maintained
Chemical restraint:
Offer voluntary PO or IM sedative medication prior to initiating involuntary restraint
Avoid PO medications for involuntary restraint due to bite risk
Choice of medication should depend on underlying cause; either a benzodiazepine or a neuroleptic or both may be appropriate:
If agitation results from delirium or other medical condition, 1st attempt to treat the underlying cause
Consider benzodiazepines for hyperadrenergic (including cocaine) state or if there is a contraindication to neuroleptics
Consider neuroleptics for most primary medical or psychiatric causes, sedative intoxication, or primary behavioral cause
Often used in combination
Contraindications to neuroleptics:
Knowledge of or suspicion for Parkinson disease, dementia with Lewy bodies or frontotemporal dementia
Neuroleptic malignant syndrome, dystonic reaction, or catatonia
Prolonged QT
Anticholinergic overdose
Potential adverse effects:
Dystonia: Treat with IM benztropine 1 mg or IM diphenhydramine 50 mg
QTc prolongation and/or torsades de pointes (rare)
Neuroleptic malignant syndrome (rare): Stop all antipsychotics; begin intensive monitoring and supportive care
MEDICATION
ALERT
Patients who are elderly, have medical or neurologic illness, or have cognitive impairment are more vulnerable to adverse effects and may respond to lower doses (e.g., haloperidol 0.5 mg)
If 1st dose of IM haloperidol is ineffective, may be repeated after 30–60 min.
First line:
Haloperidol: 5–10 mg IV, IM, or PO
Lorazepam: 1–2 mg IV, IM, or PO
Second line:
Droperidol: 2.5–5 mg IV or IM; watch QTc
Olanzapine: 5–10 mg IM or PO; if IM, do not give with IM/IV benzodiazepines due to risk of respiratory depression
Risperidone: 0.5–1 mg PO
Ziprasidone: 10 mg IM every 2 hr, not to exceed 40 mg IM per day
FOLLOW-UP DISPOSITION Admission Criteria
Medical admission for medical conditions not temporary or reversible in the ED
Medical admission if further medical workup needed for which ED setting is not optimal
Psychiatric admission if patient has a treatable psychiatric illness appropriate for inpatient level of care
Involuntary admission for safety may be necessary according to criteria defined by individual state laws
Discharge Criteria
Underlying medical or psychiatric causes have been stabilized
Appropriate follow-up is in place
Access to weapons has been assessed
If intoxication played a role in presentation, sober re-evaluation should occur prior to discharge
Discharge to police custody may be appropriate if no psychiatric or medical issues remain
If patient elopes, must consider imminent danger to self or others; notify police if risk is high or if safety evaluation not complete
Duty to warn or protect 3rd parties from risk of harm: “Tarasoff” laws vary among states, so know yours
ADDITIONAL TREATMENT Issues for Referral
Psychiatric consultation in the ED can be helpful, especially if primary mental illness suspected
Other consultation may be indicated based on the underlying etiology
FOLLOW-UP RECOMMENDATIONS
Patients with psychiatric illness should follow-up with community mental health provider
Patients who are using substances should be offered counseling and/or detox
PEARLS AND PITFALLS
Do not assume that patients with violent behavior have only psychiatric problems
Patients who have been restrained require appropriate monitoring, including regular nursing checks and VS, and labs/ECG if chemical restraints are used
“Distracting staff” is annoying and may interfere with the care of other patients, but this is not an indication for restraints
Document need for restraints and renewal of restraints per your hospital’s protocol
ADDITIONAL READING
Coburn VA, Mycyk MB. Physical and chemical restraints. Emerg Med Clin North Am . 2009;27:655–667.
Lukens TW, Wolf SJ, Edlow JA, et al. Clinical policy: Critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med . 2006;47(1):79–99.
Richmond JS, Berlin JS, Fishkind AB, et al. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med . 2012;13(1):17–25.
Rossi J, Swan MC, Isaacs ED. The violent or agitated patient. Emerg Med Clin North Am. 2010;28:235–256.
Tishler CL, Reiss NS, Dundas J. The assessment and management of the violent patient in critical hospital settings. Gen Hosp Psychiatry . 2013;35:181–185.
Wilson MP, Pepper D, Currier GW, et al. The psychopharmacology of agitation: Consensus statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup. West J Emerg Med . 2012;13(1):26–34.
Zun LS. Pitfalls in the care of the psychiatric patient in the emergency department. J Emerg Med. 2012;43(5):829–835.
See Also (Topic, Algorithm, Electronic Media Element)
Psychosis, Acute
Delirium
CODES ICD9
292.89 Other specified drug-induced mental disorders
312.9 Unspecified disturbance of conduct
312.30 Impulse control disorder, unspecified
ICD10
F19.929 Oth psychoactive substance use, unsp with intoxication, unsp
F63.9 Impulse disorder, unspecified
R45.6 Violent behavior
VISUAL LOSS Jason Hoppe BASICS DESCRIPTION
Decrease in visual function (i.e., visual acuity, visual fields, blurry vision)
Visual loss has many etiologies and can be caused by multiple body systems