Take home points
- Always try to find the cause of agitation and talk the patient down if possible.
- Call for security or police early. Better to over-call than under-call.
- Sometimes it is good just to step back and wait. Sometimes you need to intervene early before things escalate further.
- You have a responsibility to restrain / sedate unwell or injured patients who may be a risk to themselves or others.
- Ketamine is a great sedative but it is not generally accepted for behaviour control yet, especially by unsupervised junior doctors. If you are in a small hospital with no seniors on site – phone a senior for advice, if time allows. Once you have given someone ketamine you are committed to finding the cause of the agitation and to keeping them sedated, usually overnight, until the precipitant has worn off. You don’t want them waking up from a bad ketamine trip on your shift.
- Haloperidol is a good sedative and doesn’t cause airway or respiratory depression. This is particularly useful when the patient has a large quantity of airway depressant on board eg alcohol ie most aggressive people in Australasian EDs
- Benzodiazepines are good sedatives but may cause loss of airway control and respiratory depression especially for patients with lots of alcohol onboard. Benzodiazepines are the drug of choice for alcohol withdrawal and for agitation due to stimulants such as methamphetamine.
- Often we use haloperidol and midazolam – probably without good reason
- If you need to take a patient down get as many people to help as possible – preferably 5 + one ready with sedative medication. Failing that a rugby tackle may work.
- Don’t restrain patients face down – they may suffocate.
- If you have given the patient lots of sedative put them in the recovery position and monitor their oxygen saturation continuously. They will need one-on-one nursing until you are happy the patient can safely maintain their own airway.
- If using physical restraints (eg leather wrist and ankle straps) use chemical sedation as well to ensure the patient isn’t straining against the restraints (which could make them more agitated and may rarely lead to rhabdomyolysis). In many hospitals use of physical restraint needs to be recorded on particular forms and obs documented regularly.
- It is acceptable to leave physical restraints on a patient overnight if you consider them to be high risk.
- RSI is not good for first line behaviour control. Sedate the person then, if needed to a “delayed sequence intubation” or DSI
Sometimes we have to restrain and sedate the crap out of aggressive patients.
In some hospitals we have little or no security assistance and doctors will be expected to take control of an aggressive patient.
The question is often asked: can we sedate or restrain a patient against there will if they don’t have a psychiatric problem? The answer is usually yes.
If you believe the patient may have a medical problem that’s putting themselves or others at risk, be it intoxication, head injury, sepsis, hypoxia or psychiatric disorder, you have a responsibility, also called a “duty of care”, to do what is needed to keep the patient and/or others safe.
If they are bad rather than sick or mad, you need to get police or security to deal with them. If in doubt assume the patient is unwell.
A gang member in his 50s, 160kg of lard and muscle, was in ICU on BiPAP for an exacerabation of COPD. I was called into help at 6am. He was in the ED waiting room when I arrived. We tried reasoning with him to no avail. He was mildly agitated and sick of being in hospital. The police sent one 60kg unarmed officer to help.
Another gang member arrived to collect the and we elected to allow him to leave – for our safety and so as not to inflame the situation. We asked the associate to try and convince the patient to return.
The patient and associate returned 20 minutes later as the patient had become more short of breath. He tolerated BiPAP and an IV line and we transferred him to ICU.
He was seen by the duty anaesthetist who wanted to place an arterial line but quickly backed off when the patient became stroppy.
He was given a small prophylactic dose of 3mg haloperidol. A short time later he became agitated again, ripped off his BiPAP and was thrashing around and being quite scary. His associate tried to calm him down. We kept our distance and waited.
About 30 minutes later the patient was asleep or unconscious. I snuck into his room and gave him a massive dose of IV ketamine. I would normally give a patient 1mg/kg of IV ketamine to completely flatten them. I gave this 400mg of ketamine. I wanted to be sure he was dissociated quickly and completely. He quickly woke up and looked like a sterotypical zombie: arms stretched out in front of him staring into space and looking confused. We were able to get the BiPAP on him. 5 minutes later he was still moving. I gave him another 200mg of IV ketamine and started a ketamine infusion at 200mg an hour, 5 mg IV haloperidol. He settled briefly. 5 minutes later he was getting agitated again and I gave him 5mg of midazolam. Then he finally stopped moving and tolerated the BiPAP
We converted him slowly to fentanyl for sedation. Fentanyl and/or propofol are probably the best medium term sedatives once you have the patient under control. There is less chance the patient will wake up delerious than with ketamine or even benzodiazepines.
The patient needed to be heavily sedated for behaviour control and probably needed to be intubated as he was going to need ventilatory support for days. The patient was in ICU so I needed to run this past an anaesthetist. I spoke to the anaesthetist who had seen the patient earlier who suggested we needed to wake the patient up and have that discussion with the patient. I invited him to have that discussion with the patient and went home to bed.
When I arrived for my shift a few hours later the patient was intubated.
I saw the pateint a few days later. He recognised me, thanked me for caring for him. He had no recollection of a bad ketamine trip.
Bottom line: some patients need massive doses of anaesthetics and sedatives to control their agitation so they can be safely managed. For patients like this get senior help early.
Later that day a man in his late 20s was brought in by ambulance and police, drunk after putting his arm through a window. His father said the patient had only used alcohol. The patient was handcuffed, agitated and abusive and bleeding quite a bit from a forearm laceration. A CAT tourniquet was applied. The patient was given 10mg IM haloperidol and 5mg IM midazolam with little effect. 10 minutes later he was given another 10mg IM haloperidol and settled. He was kept on oximetry without supplemental oxygen. He was restrained with leather wrist and ankle restraints. IV access was obtained and further boluses of 10mg haloperidol or 2.5 midazolam were given as required. A nasophyaryngeal airway was inserted. His wound was loosely sutured then dressed to control the bleeding. He was kept sedated and restrained overnight and then taken to theatre for definitive management the next day.
Case two could have been controlled with ketamine but I think it would have been overkill. Case one needed to be immobilised completely, very quickly. Partial sedation may have left him still able to inflict serious harm to staff. I wanted an agent that worked quickly, totally immobilised him but wouldn’t stop him breathing. Ketamine was ideal.
A chap in his late 30s was in ICU with a delirium of unknown cause: toxicology screen, CT, LP, bloods were normal. Formal toxicology and a brain MRI was pending. He heard someone talking about the psychiatric unit and thought he was going to be sent there and went ballistic. He hit 3 staff, made many holes in the walls and smashed a window with a drip pole. Luckily the was a visitor in the unit his 50s who had been a rugby player in his younger days. He did what was reported as a stunning tackle on the patient.
A bit like this one by one of my daughter’s friends:
I arrived a minute later. The patient was being restrained by the visitor and a couple a male nurse. The patient still had an IV line in place. He was given 10mg of IV haloperidol, 5mg of IV midazolam which settled him well. He was bound with leather restraints and charted PRN haloperidol and midazolam and a security guard was assigned to watch him.
A 93-year-old was in an orthopaedic ward post hip replacement. He was delirious and whacking everything and everybody in site with his crutches.
We formed a 5 person team. A sixth person was standing by with 3mg of IM haloperidol. I was at the point of the chevron shaped formation, armed with a pillow to take the blows from the crutches. The person on my left and right were assigned to an upper limb each, the people behind them were assigned to a lower limb each. We heroically over powered the old gentleman and lowered him onto his bed. The people on upper limbs grab a shoulder and a wrist. The people on lower limbs hold a knee and ankle. People are best held down on their backs as they have less purchase. Avoid face down due to risk of suffocation. If the patient is given lots of chemical sedatives it is best to have the patient in the recovery position if possible. The lead person quickly changes position and restrains the head to prevent biting.
We then did a thorough assessment to see if there was a cause for his agitation: hypoxia, fever, fluid overload inadequate analgesia, excess analgesia, full bladder. Often it is just post operative delirium.
There has been a belief, which I have believed, that antipsychotics are slow acting in acute agitation. This paper, discussed in Life in the Fast Lane Research and Reviews, argues otherwise:
“Calver L et al. Droperidol v. haloperidol for sedation of aggressive behaviour in acute mental health: randomised controlled trial. Br J Psychiatry 2014. PMID: 25395689
- Although not widely available, droperidol is often used for the management of agitated delirium. This paper compares droperidol (10mg IM) in 118 patients vs. haloperidol (10mg IM) in 100 patients. Appropriate sedation within 120 seconds occurred in 92% of patients without differences between agents. While sedation with droperidol required less rescue doses, it also had higher adverse events (5% vs 1%).” [emphasis mine]
Behavioural Emergencies by Kane Guthrie in Life in the Fast Lane
Grumpy old man image from http://stupend.us/2014/02/14/old-man-winter-reinforcing-grumpy-old-man-stereotype/