PSYCHIATRY
AGGRESSIVE PATIENT
PromptNon pharmacologic strategies for agitation (original question was for developmentally delayed - doesn’t really fit anywhere in notes)
ResponseFamiliar people and objects, involve carer, familiary toys
Distraction eg screen time, music via headphones
Low stimulus environment - minimise distractions, noise and lights
Explain procedure in simple language and diagrams
Minimise staff involve to build relationships
Distraction eg screen time, music via headphones
Low stimulus environment - minimise distractions, noise and lights
Explain procedure in simple language and diagrams
Minimise staff involve to build relationships
PromptManagement of aggressive patient
ResponsePASTED
Patient - Attempt verbal de-escialtion
Area - Appropriate location (resus/MH assessment room)
Staff - Show of force - Security presence at bedside
Teams - Mental health, Security
Equipment
Drugs
Offer oral chemical restraint/medications/sedatives - Diazepam 5-10 mg, Olanzapine 10mg
If above measures fail - physical restrained followed promptly by chemical sedation with Droperidol 10 mg IMI/Midazolam 5mg IV/olanzapine 10 mg IM
Patient - Attempt verbal de-escialtion
Area - Appropriate location (resus/MH assessment room)
Staff - Show of force - Security presence at bedside
Teams - Mental health, Security
Equipment
Drugs
Offer oral chemical restraint/medications/sedatives - Diazepam 5-10 mg, Olanzapine 10mg
If above measures fail - physical restrained followed promptly by chemical sedation with Droperidol 10 mg IMI/Midazolam 5mg IV/olanzapine 10 mg IM
PromptList options for first line sedation options including kids doses + adverse effects
ResponseLorazepam 1-2mg PO - resp depression, paradoxical effect
Diazepam (0.2-0.4mg/kg to 10mg) - resp depression, paradoxical effect
Olanzapine 5-10 mg PO/SL - EPSE, NMS, Anticholinergic, QTc prolongation
Risperidone 0.02-0.04 mg/kg (to 2mg) PO - EPSE, NMS
Diazepam (0.2-0.4mg/kg to 10mg) - resp depression, paradoxical effect
Olanzapine 5-10 mg PO/SL - EPSE, NMS, Anticholinergic, QTc prolongation
Risperidone 0.02-0.04 mg/kg (to 2mg) PO - EPSE, NMS
PromptLIst options for parenteral chemical restraint with doses + kids doses
ResponseMidazolam 2.5-10 mg IV (0.1-0.2mg/kg IM/IV) - Resp depression/apnoea/ Paradoxical
Droperidol 10 mg IMI (0.1-0.2mg/kg), repeat 15 mins - EPSE
Olanzapine 10 mg IM - EPSE, NMS, Anticholinergic, Hyperglycaemia, long QT
Haloperidol 5mg IV repeat 15 mins to max 10 mg
Ketamine - 4mg/kg (max 200 mg) IM or 1mg/kg (max 50 mg) IV - Vomiting, emergence, laryngospasm (if IV), compliance with scales if you want to get a weight
Droperidol 10 mg IMI (0.1-0.2mg/kg), repeat 15 mins - EPSE
Olanzapine 10 mg IM - EPSE, NMS, Anticholinergic, Hyperglycaemia, long QT
Haloperidol 5mg IV repeat 15 mins to max 10 mg
Ketamine - 4mg/kg (max 200 mg) IM or 1mg/kg (max 50 mg) IV - Vomiting, emergence, laryngospasm (if IV), compliance with scales if you want to get a weight
PromptPros/cons of chemical restraint
ResponsePro:
Sedating + anxiolytic
Antipsychotic treatment (in psychosis)
Multiple routes
Can de-escilate (ie: remove physical restraints)
Less risk of physical injury
Cons
Airway compromise/aspiration, depressoin of ventilation/CVS
Can require one on one monitoring (especially with the doses I give)
Decreased ability for assessment due to sedation
Drug reactions and interactions (anaphylaxis, dystonic reactions, oculogyric crisis)
Slower time to control than physical restraint
Sedating + anxiolytic
Antipsychotic treatment (in psychosis)
Multiple routes
Can de-escilate (ie: remove physical restraints)
Less risk of physical injury
Cons
Airway compromise/aspiration, depressoin of ventilation/CVS
Can require one on one monitoring (especially with the doses I give)
Decreased ability for assessment due to sedation
Drug reactions and interactions (anaphylaxis, dystonic reactions, oculogyric crisis)
Slower time to control than physical restraint
PromptPros/cons of physical restraints
ResponsePro:
Protection to patient/staff/other patients
Safer access to give IV/IM Drugs
Last resort option
Gains immediate control once team assembled
Cons
Risk to patient and staff (Airways, injuries, sympathetic response)
Requires training
Minimum 5-6 people required
Needs degree of chemical restraint also
Ongoing 1:1 monitoring
Protection to patient/staff/other patients
Safer access to give IV/IM Drugs
Last resort option
Gains immediate control once team assembled
Cons
Risk to patient and staff (Airways, injuries, sympathetic response)
Requires training
Minimum 5-6 people required
Needs degree of chemical restraint also
Ongoing 1:1 monitoring
PromptResponse to mum who’s pissed off you droperidolled her abusive 14 yo daughter.
ResponseDone under guardianship act to maintain patient and staff safety
Necessary to allow further mental health assessment of child
Reassurance of safety process in place to ensure it was performed safely
Likely timeframe in which child will wake
Allow mother to remain with child in ED
Documentation of above.
Necessary to allow further mental health assessment of child
Reassurance of safety process in place to ensure it was performed safely
Likely timeframe in which child will wake
Allow mother to remain with child in ED
Documentation of above.
PromptED department design features to minimise violence
ResponseWell lit + minimise hiding spaces
Positive distractions in waiting room (TV, play area for children, art works)
Clear signs
Visible waiting area/CCTV
Duress alarms
Controlled/swipe access to clinical areas
Separate access + non clinical break areas for staff
Behavioral assessment rooms/safe assessment spaces
Positive distractions in waiting room (TV, play area for children, art works)
Clear signs
Visible waiting area/CCTV
Duress alarms
Controlled/swipe access to clinical areas
Separate access + non clinical break areas for staff
Behavioral assessment rooms/safe assessment spaces
PromptHospital wide approaches to mitigate violence
ResponseAdequate staffing models
Hospital security
Staff training (de-escalation, violence recognition + Prevention, reporting)
Violence response policy (code black/security response/police response)
Standardised reporting system/risk management/IIMS
Supporting staff taking legal action
Hospital security
Staff training (de-escalation, violence recognition + Prevention, reporting)
Violence response policy (code black/security response/police response)
Standardised reporting system/risk management/IIMS
Supporting staff taking legal action