Emergency Department
Oliver 10 year old PHx: autistic spectrum disorder Having a blood test Becomes very agitated Bites the doctor doing the test
Emergency Department
Chelsea 14 year old PHx: in state care, substance use, social Becomes angry and aggressive in rooms Screaming and shouting Raises a chair above her head
Emergency Department
Xavier 16 year old Found wandering outside a party Shouting, swearing, coherent Lashing out with his fists
Emergency Department
Mr Jones Around 40 years old Child has leukaemia Upset by the wait in clinic Yelling at the receptionist
Emergency Department
Sam 13 year old PHx: acquired brain injury, seizures, OSA, obese Seizure at his accommodation As he’s waking up he shows a fearsome display
of aggression
Emergency Department
Behavioural disturbance
Autonomy
Duty of care Beneficence
Mental Health law Zero tolerance
OH&S
Emergency Department
Describe an approach to acute behavioural disturbances
Prevention
Management- Verbal de-escalation Restraint Use of medication
Emergency Department
Universal approach
Acute brain/ intoxicated
Verbal de-escalation
Collaborative sedation
Behavioural Resuscitation Team approach Verbal De-esc Show of force Physical restraint Mechanical restraint Chemical sedation Containment Ejection
Actively violent
fails
Y
N fails
Y
Reception and assessment
N
After Hilt RJ, 2008
Emergency Department
de-escalation Non-verbal: position, posture, body language Verbal style: low slow and quiet Verbal content: care and understand, appeal to
reason
Emergency Department
understand the problem I am here to help you.
Tell me how I can help
Tell me what’s bothering you
Emergency Department
externalise the problem behaviour
The anger I am seeing here makes it hard for me to help you.
Emergency Department
externalise your response The law tells me/ it is my job to make sure you
are OK, so I need to…… before you can….
I am not happy about the long wait either. It is very frustrating for me too.
Emergency Department
become part of the solution If you help me to make sure you are safe, then I
can……
Emergency Department
suggest/request an alternative, positive solution
It’s OK to be angry/disappointed/frustrated. Tell me how angry… you are.
Emergency Department
offer choices to give control Cool drink/warm drink Orange/ lemon Straw/ no straw Sitting down/ standing up
Emergency Department
Universal approach
Acute brain/ intoxicated
Verbal de-escalation
Collaborative sedation
Behavioural Resuscitation Team approach Verbal De-esc Show of force Physical restraint Mechanical restraint Chemical sedation Containment Ejection
Actively violent
fails
Y
N fails
Y
Reception and assessment
N
After Hilt RJ, 2008
Emergency Department
Collaborative medication
Whatever they are on Whatever worked last time
Diazepam, Olanzapine
Emergency Department
Universal approach
Acute brain/ intoxicated
Verbal de-escalation
Collaborative sedation
Behavioural Resuscitation Team approach Verbal De-esc Show of force Physical restraint Mechanical restraint Chemical sedation Containment Ejection
Actively violent
fails
Y
N fails
Y
Reception and assessment
N
After Hilt RJ, 2008
Emergency Department
Behavioural Resuscitation Enhanced verbal de-escalation A show of overwhelming force Containment Ejection Physical restraint Mechanical restraint Chemical restraint
Emergency Department
Enhanced verbal de-escalation A show of overwhelming force
Require a reasonable person
Emergency Department
Ejection/ Police behaviour is unequivocally not due to mental
health or medical concern.
“Acting out” Criminality
Emergency Department Chemical restraint
O vs S/L vs IM vs IV Choice of agent: Midazolam Diazepam Haloperidol Droperidol Olanzapine
Emergency Department
Midazolam: rapid onset, short duration, amnestic, commonly used in acute health
Diazepam: longer acting, oral or IV, not IM Haloperidol: onset 20’, duration 2 hrs, sedating,
risks EPS and NMS Droperidol: shorter acting than HPD, ?risk of
long QT? Olanzapine: similar profile to HPD perhaps less
sedating, less EPS, NMS
Emergency Department
Choice of agent Anxiety, acute brain, intoxication : benzo All others: benzo plus antipsychotic
Emergency Department
Olanzapine vs Haloperidol Khan: Olanzapine: effective in 90%, no AEs
apart from sedation, restraint time 40 minutes Sonnier: EPS less common in atypicals- 8%
(?long term use)
All give rise to sedation, all can prolong QT
Bottom line: Olanzapine is a little less unpleasant, and possibly safer
Emergency Department
Sedation: complications Respiratory depression hypotension, tachycardia. Extra pyramidal reactions
Titrated to effect Close care: monitoring, 1:1 nursing
Emergency Department Mechanical restraint
Slow to settle: whilst waiting for chemical restraint to take effect
Likely to wake up agitated or violent
Sole method in special circumstances
Emergency Department
Mechanical restraint: complications
Distressing and crude Caution with risk of vomiting, aspiration,
asphyxiation. Attention to skin and elimination
Close care: monitoring, 1:1 nursing
Emergency Department
Universal approach
Acute brain/ intoxicated
Verbal de-escalation
Collaborative sedation
Behavioural Resuscitation Team approach Verbal De-esc Show of force Physical restraint Mechanical restraint Chemical sedation Containment Ejection
Actively violent
fails
Y
N fails
Y
Reception and assessment
N
After Hilt RJ, 2008
Emergency Department Summary
Prevention Environment, Self Verbal de-escalation
Behavioural resuscitation Ejection Containment Restraint Use of medication
Emergency Department
Acute brain syndrome Drugs, infection most common
Suspect when delirium, young, rapid onset, no
psychosocial setup, abnormal examination
Emergency Department
references 1 Correll CU, Penzner JB, Parikh UH et al. Recognizing and monitoring adverse events
of second-generation antipsychotics in children and adolescents. Child Adolesc Psychiatr Clin N Am. 2006;15:177-206.
2 Grover S, Malhotra S, Bharadwaj R et al. Delirium in children and adolescents. Int J Psychiatry Med. 2009;39:179-187.
3 Hilt RJ, Woodward TA. Agitation treatment for pediatric emergency patients.[Erratum appears in J Am Acad Child Adolesc Psychiatry. 2008 Apr;47(4):478]. J Am Acad Child Adolesc Psychiatry. 2008;47:132-138.
4 Twomey B. Code Grey Procedure. 2010 [accessed 2011 25 August 2011]; Available from: http://www.rch.org.au/policy_rch/index.cfm?doc_id=10197
5 Downes MA, Healy P, Page CB et al. Structured team approach to the agitated patient in the emergency department. Emerg Med Australas. 2009;21:196-202.
6 Stewart C, Spicer M, Babl FE. Caring for Adolescents with Mental Health Problems : Challenges in the Emergency Department. J. Paediatr. Child Health. 2006;42:726-730.
7 Dorfman DH, Mehta SD. Restraint use for psychiatric patients in the pediatric emergency department. Pediatr. Emerg. Care. 2006;22:7-12.
Emergency Department
references 8 Clinical Practice Guideline Group of Royal Children's Hospital Melbourne. Emergency
Restraint & Sedation- Code Grey. 2006 [accessed 02 February 2010]; Available from: http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5243
9 Victorian taskforce on violence in nursing. Final report: Victorian taskforce on violence in nursing. 2005 [accessed 20 July 2010]; Available from: http://www.health.vic.gov.au/__data/assets/pdf_file/0007/17674/victaskforcevio.pdf
10 Policy and Strategic Projects Division DoHS, Victorian Government , Melbourne, Victoria, Australia. Occupational violence in nursing: An analysis of the phenomenon of code grey/black events in four Victorian hospitals. 2005 [accessed 20 July 2010]; Available from: http://www.health.vic.gov.au/__data/assets/pdf_file/0008/17585/codeblackgrey.pdf
11 Woolfenden S, Dossetor D, Nunn K et al. The Presentation of Aggressive Children and Adolescents to Emergency Departments in Western Sydney. J. Paediatr. Child Health. 2003;39:651-653.
12 Dorfman DH. The Use of Physical and Chemical Restraints in the Pediatric Emergency Department. Pediatr. Emerg. Care. 2000;16
13 Brayley J, Lange R, Baggoley C et al. The violence management team. An approach to aggressive behaviour in a general hospital. Med. J. Aust. 1994;161:254-258.
Emergency Department
references Khan SS, Mican LM.A naturalistic evaluation of intramuscular
ziprasidone versus intramuscular olanzapine for the management of acute agitation and aggression in children and adolescents. J Child Adolesc Psychopharmacol. 2006 Dec;16(6):671-7.
Sonnier L, Barzman D. Pharmacologic management of acutely agitated pediatric patients. Paediatr Drugs. 2011 Feb 1;13(1):1-10.
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