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Jivalagian P, Gettel CJ, Smith CM, Robinson L, Brinker M, Shah D, Kumar A, Faustino IV, Nath B, Chang-Sing E, Taylor RA, Kennedy M, Hwang U, Wong AH. Racial, Ethnic, and Age-Related Disparities in Sedation and Restraint Use for Older Adults in the Emergency Department. Am J Geriatr Psychiatry 2024:S1064-7481(24)00398-1. [PMID: 39054237 DOI: 10.1016/j.jagp.2024.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 07/01/2024] [Accepted: 07/03/2024] [Indexed: 07/27/2024]
Abstract
OBJECTIVES Older adults may present to the emergency department (ED) with agitation, a symptom often resulting in chemical sedation and physical restraint use which carry significant risks and side effects for the geriatric population. To date, limited literature describes the patterns of differential restraint use in this population. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS This retrospective cross-sectional study used electronic health records data from ED visits by older adults (age ≥65 years) ranging 2015-2022 across nine hospital sites in a regional hospital network. Logistic regression models were estimated to determine the association between patient-level characteristics and the primary outcomes of chemical sedation and physical restraint. RESULTS Among 872,587 ED visits during the study period, 11,875 (1.4%) and 32,658 (3.7%) encounters involved the use of chemical sedation and physical restraints respectively. The populations aged 75-84, 85-94, 95+ years had increasingly higher odds of chemical sedation [adjusted odds ratios (AORs) 1.35 (95% CI 1.29-1.42); 1.82 (1.73-1.91); 2.35 (2.15-2.57) respectively] as well as physical restraint compared to the 65-74 group [AOR 1.31 (1.27-1.34); 1.55 (1.50-1.60); 1.69 (1.59-1.79)]. Compared to the White Non-Hispanic group, the Black Non-Hispanic and Hispanic/Latinx groups had significantly higher odds of chemical sedation [AOR 1.26 (1.18-1.35); AOR 1.22 (1.15-1.29)] and physical restraint [AOR 1.12 (95% CI 1.07-1.16); 1.22 (1.18-1.26)]. CONCLUSION Approximately one in 20 ED visits among older adults resulted in chemical sedation or physical restraint use. Minoritized group status was associated with increasing use of chemical sedation and physical restraint, particularly among the oldest old. These results may indicate the need for further research in agitation management for historically marginalized populations in older adults.
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Affiliation(s)
- Patelle Jivalagian
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - Cameron J Gettel
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - Colin M Smith
- Hubert-Yeargan Center for Global Health (CMS), Duke University, Durham, NC
| | - Leah Robinson
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - Morgan Brinker
- Department of Emergency Medicine, Yale School of Medicine (MB), New Haven, CT
| | - Dhruvil Shah
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - Anusha Kumar
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - Isaac V Faustino
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - Bidisha Nath
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - Erika Chang-Sing
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - R Andrew Taylor
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT; Department of Biomedical Informatics and Data Science (RAT), Yale School of Medicine, New Haven, CT
| | - Maura Kennedy
- Department of Emergency Medicine (MK), Massachusetts General Hospital, Boston, MA; Department of Emergency Medicine (MK), Harvard Medical School, Boston, MA
| | - Ula Hwang
- Department of Emergency Medicine (UH), New York University Grossman School of Medicine, New York, NY; Geriatric Research Education and Clinical Center (UH), James J. Peters VAMC, Bronx, NY
| | - Ambrose H Wong
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT.
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Ali AA. Pearls for Caring for the Boarding Psychiatric Patient in the Emergency Department. J Emerg Med 2024; 67:e42-e49. [PMID: 38816261 DOI: 10.1016/j.jemermed.2024.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 03/07/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Emergency department (ED) boarding of psychiatric patients is a national issue that continues to worsen at a disturbing rate. Implementing strategies in the ED to provide continuous care for patients can help secure patient safety. OBJECTIVE The objective of this review is to discuss the boarding of psychiatric patients and its implications. It will focus on executing best clinical practices in managing boarding psychiatric patients in the ED. It will not focus on the treatment of substance use disorders. DISCUSSION This article will address the pearls for management plans that can be implemented in the ED, alongside discussing pregnant and elderly patients. Risk factors, complications, and treatments for boarding psychiatric patients are discussed. CONCLUSIONS Patients with psychiatric disorders boarding in the ED need careful consideration of management plans to mitigate patient safety events.
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Affiliation(s)
- Afrah A Ali
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD.
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3
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Foster AA, Saidinejad M, Li J. Approach to acute agitation in the pediatric emergency department. Curr Opin Pediatr 2024; 36:245-250. [PMID: 38299972 DOI: 10.1097/mop.0000000000001337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
PURPOSE OF REVIEW The complexity of pediatric mental and behavioral health (MBH) complaints presenting to emergency departments (EDs) is increasing at an alarming rate. Children may present with agitation or develop agitation during the ED visit. This causes significant distress and may lead to injury of the child, caregivers, or medical staff. This review will focus on providing safe, patient-centered care to children with acute agitation in the ED. RECENT FINDINGS Approaching a child with acute agitation in the ED requires elucidation on the cause and potential triggers of agitation for optimal management. The first step in a patient-centered approach is to use the least restrictive means with behavioral and environmental strategies. Restraint use (pharmacologic or physical restraint) should be reserved where these modifications do not result in adequate de-escalation. The provider should proceed with medications first, using the child's medication history as a guide. The use of physical restraint is a last resort to assure the safety concerns of the child, family, or staff, with a goal of minimizing restraint time. SUMMARY Children are increasingly presenting to EDs with acute agitation. By focusing primarily on behavioral de-escalation and medication strategies, clinicians can provide safe, patient-centered care around these events.
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Affiliation(s)
- Ashley A Foster
- Department of Emergency Medicine, University of California, San Francisco
| | - Mohsen Saidinejad
- The Lundquist Institute for Biomedical Innovation at Harbor UCLA, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Joyce Li
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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4
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Marett BE, Manton AP. Emergency Nursing Review Questions: May 2024. J Emerg Nurs 2024; 50:473-475. [PMID: 38430097 DOI: 10.1016/j.jen.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/29/2024] [Accepted: 02/02/2024] [Indexed: 03/03/2024]
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5
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Araújo Pereira MO, Júnior ÁF, Batista Rodrigues ES, Mulser H, Nascimento de Mello E Silva G, Pio Dos Santos WT, de Souza Gil E. An impedimetric immunosensor for diagnosis of Brazilian spotted fever in blood plasma. ANALYTICAL METHODS : ADVANCING METHODS AND APPLICATIONS 2024; 16:189-195. [PMID: 38098444 DOI: 10.1039/d3ay01308a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Brazilian spotted fever (BSF) is a serious disease of medical importance due to its rapid evolution and high lethality. The effectiveness of the treatment mainly depends on the rapid diagnosis, which is currently performed by indirect immunofluorescence and PCR tests, which require high costs and laboratory structure. In order to propose an alternative methodology, we sought to develop an impedimetric immunosensor (IM) based on the immobilization of specific IgY antibodies for IgG anti Rickettsia rickettsii, using blood plasma from capybara (Hydrochoerus hydrochaeris), for characterization, validation and applications of the ready IM. IM selectivity was observed when comparing capybara reagent IgG (IgGcr) readings with non-reagent IgG (IgGnr). A reagent IgG calibration curve was obtained, from which the limits of detection (LOD) and quantification (LOQ) of 1.3 ng mL-1 and 4.4 ng mL-1 were calculated, respectively. The accuracy tests showed that different concentrations of IgGcr showed a maximum deviation of 20.0%, with CI between 90.00% and 95.00%. Intermediate precision tests showed a relative standard deviation of 2.09% for researcher 1 and 2.61% for researcher 2, and the F test showed no significant difference between the recovery values found between the two analysts, since Fcal 1.56 < 5.05 and P-value 0.48 > 0, 05. Therefore, an impedimetric immunosensor was developed to detect anti BSF IgG in capybara blood plasma, which greatly contributes to the improvement of diagnostic tests, cost reduction and ease of execution.
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Affiliation(s)
| | | | | | - Helena Mulser
- School of Pharmacy, Federal University of Goiás, Brazil.
| | | | - Wallans Torres Pio Dos Santos
- Chemistry Department, Federal University of Vales do Jequitinhonha e Mucuri, Campus JK, 39100000, Diamantina, Minas Gerais, Brazil
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Abstract
ABSTRACT The emergency department can be a particularly challenging environment for the care of pediatric patients presenting with acute agitation. Agitation is a behavioral emergency requiring prompt intervention. Timely recognition of agitation and proactive implementation of de-escalation strategies are critical for safe and effective management of agitation, as well as prevention of recurrent episodes. This article reviews the definition of agitation, explores the domains of verbal de-escalation, and considers multidisciplinary management strategies for children with acute agitation.
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Affiliation(s)
| | - Carl R Baum
- Professor, Section of Pediatric Emergency Medicine, Departments of Pediatrics and of Emergency Medicine, Yale School of Medicine, New Haven, CT
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Riccardi A, Guarino M, Serra S, Spampinato MD, Vanni S, Shiffer D, Voza A, Fabbri A, De Iaco F. Narrative Review: Low-Dose Ketamine for Pain Management. J Clin Med 2023; 12:jcm12093256. [PMID: 37176696 PMCID: PMC10179418 DOI: 10.3390/jcm12093256] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/14/2023] [Accepted: 04/28/2023] [Indexed: 05/15/2023] Open
Abstract
Pain is the leading cause of medical consultations and occurs in 50-70% of emergency department visits. To date, several drugs have been used to manage pain. The clinical use of ketamine began in the 1960s and it immediately emerged as a manageable and safe drug for sedation and anesthesia. The analgesic properties of this drug were first reported shortly after its use; however, its psychomimetic effects have limited its use in emergency departments. Owing to the misuse and abuse of opioids in some countries worldwide, ketamine has become a versatile tool for sedation and analgesia. In this narrative review, ketamine's role as an analgesic is discussed, with both known and new applications in various contexts (acute, chronic, and neuropathic pain), along with its strengths and weaknesses, especially in terms of psychomimetic, cardiovascular, and hepatic effects. Moreover, new scientific evidence has been reviewed on the use of additional drugs with ketamine, such as magnesium infusion for improving analgesia and clonidine for treating psychomimetic symptoms. Finally, this narrative review was refined by the experience of the Pain Group of the Italian Society of Emergency Medicine (SIMEU) in treating acute and chronic pain with acute manifestations in Italian Emergency Departments.
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Affiliation(s)
| | - Mario Guarino
- Emergency Department, Centro Traumatologico Ortopedico, Azienda Ospedaliera di Rilievo Nazionale dei Colli, 80131 Napoli, Italy
| | - Sossio Serra
- Emergency Department, Maurizio Bufalini Hospital, 47522 Cesena, Italy
| | | | - Simone Vanni
- Dipartimento Emergenza e Area Critica, Azienda USL Toscana Centro Struttura Complessa di Medicina d'Urgenza, 50053 Empoli, Italy
| | - Dana Shiffer
- Emergency Department, Humanitas University, Via Rita Levi Montalcini 4, 20089 Milan, Italy
| | - Antonio Voza
- Emergency Department, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Andrea Fabbri
- Emergency Department, AUSL Romagna, Presidio Ospedaliero Morgagni-Pierantoni, 47121 Forlì, Italy
| | - Fabio De Iaco
- Emergency Department, Ospedale Maria Vittoria, 10144 Turin, Italy
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8
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Jin RO, Anaebere TC, Haar RJ. Exploring Bias in Restraint Use: Four Strategies to Mitigate Bias in Care of the Agitated Patient in the Emergency Department. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2023; 21:100-105. [PMID: 37205039 PMCID: PMC10172532 DOI: 10.1176/appi.focus.23022007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Agitation is a routine and increasingly common presentation to the emergency department (ED). In the wake of a national examination into racism and police use of force, this article aims to extend that reflection into emergency medicine in the management of patients presenting with acute agitation. Through an overview of ethicolegal considerations in restraint use and current literature on implicit bias in medicine, this article provides a discussion on how bias may impact care of the agitated patient. Concrete strategies are offered at an individual, institutional, and health system level to help mitigate bias and improve care. Reprinted from Acad Emerg Med 2021; 28:1061-1066, with permission from John Wiley & Sons. Copyright © 2021.
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Affiliation(s)
- Rowen O. Jin
- Department of Emergency Medicine, LAC+USC Medical Center, Los Angeles, California, USA (Jin). Special Projects and Innovation, Emergency Medicine Residency Program, Dignity Health–St. Joseph’s Medical Center, Stockton, California, USA (Anaebere). Department of Epidemiology and Biostatistics, University of California at Berkeley, Berkeley, California, USA (Haar)
| | - Tiffany C. Anaebere
- Department of Emergency Medicine, LAC+USC Medical Center, Los Angeles, California, USA (Jin). Special Projects and Innovation, Emergency Medicine Residency Program, Dignity Health–St. Joseph’s Medical Center, Stockton, California, USA (Anaebere). Department of Epidemiology and Biostatistics, University of California at Berkeley, Berkeley, California, USA (Haar)
| | - Rohini J. Haar
- Department of Emergency Medicine, LAC+USC Medical Center, Los Angeles, California, USA (Jin). Special Projects and Innovation, Emergency Medicine Residency Program, Dignity Health–St. Joseph’s Medical Center, Stockton, California, USA (Anaebere). Department of Epidemiology and Biostatistics, University of California at Berkeley, Berkeley, California, USA (Haar)
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9
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Curry A, Malas N, Mroczkowski M, Hong V, Nordstrom K, Terrell C. Updates in the Assessment and Management of Agitation. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2023; 21:35-45. [PMID: 37205032 PMCID: PMC10172538 DOI: 10.1176/appi.focus.20220064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Agitated patients can be dangerous to themselves and others. In fact, severe medical complications and death can occur with severe agitation. Because of this, agitation is considered a medical and psychiatric emergency. Regardless of the treatment setting, identifying the agitated patient early is a necessary skill. The authors review relevant literature regarding the identification and management of agitation and summarize current recommendations for adults, as well as children and adolescents.
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Affiliation(s)
- Ashley Curry
- Department of Psychiatry, University of Colorado School of Medicine, Aurora (Curry, Nordstrom); Department of Psychiatry (Malas, Hong) and Department of Pediatrics (Malas), University of Michigan, Ann Arbor; Department of Psychiatry, Columbia University Irving Medical Center, New York City (Mroczkowski); Department of Psychiatry, University of Louisville, Louisville, Kentucky (Terrell)
| | - Nasuh Malas
- Department of Psychiatry, University of Colorado School of Medicine, Aurora (Curry, Nordstrom); Department of Psychiatry (Malas, Hong) and Department of Pediatrics (Malas), University of Michigan, Ann Arbor; Department of Psychiatry, Columbia University Irving Medical Center, New York City (Mroczkowski); Department of Psychiatry, University of Louisville, Louisville, Kentucky (Terrell)
| | - Megan Mroczkowski
- Department of Psychiatry, University of Colorado School of Medicine, Aurora (Curry, Nordstrom); Department of Psychiatry (Malas, Hong) and Department of Pediatrics (Malas), University of Michigan, Ann Arbor; Department of Psychiatry, Columbia University Irving Medical Center, New York City (Mroczkowski); Department of Psychiatry, University of Louisville, Louisville, Kentucky (Terrell)
| | - Victor Hong
- Department of Psychiatry, University of Colorado School of Medicine, Aurora (Curry, Nordstrom); Department of Psychiatry (Malas, Hong) and Department of Pediatrics (Malas), University of Michigan, Ann Arbor; Department of Psychiatry, Columbia University Irving Medical Center, New York City (Mroczkowski); Department of Psychiatry, University of Louisville, Louisville, Kentucky (Terrell)
| | - Kimberly Nordstrom
- Department of Psychiatry, University of Colorado School of Medicine, Aurora (Curry, Nordstrom); Department of Psychiatry (Malas, Hong) and Department of Pediatrics (Malas), University of Michigan, Ann Arbor; Department of Psychiatry, Columbia University Irving Medical Center, New York City (Mroczkowski); Department of Psychiatry, University of Louisville, Louisville, Kentucky (Terrell)
| | - Christina Terrell
- Department of Psychiatry, University of Colorado School of Medicine, Aurora (Curry, Nordstrom); Department of Psychiatry (Malas, Hong) and Department of Pediatrics (Malas), University of Michigan, Ann Arbor; Department of Psychiatry, Columbia University Irving Medical Center, New York City (Mroczkowski); Department of Psychiatry, University of Louisville, Louisville, Kentucky (Terrell)
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10
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Muacevic A, Adler JR, Nielson JA. An Uncontrollable, Aggressive Patient at a Free-Standing Emergency Department. Cureus 2022; 14:e32742. [PMID: 36686138 PMCID: PMC9851284 DOI: 10.7759/cureus.32742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
We present the case of an aggressive male patient who was unable to be successfully sedated with conventional medications in the ED and ultimately required intubation to ensure the safety of the patient himself and the staff. After admission to the ICU, he was found to have atrophy of the frontal and bilateral lobes secondary to a traumatic brain injury (TBI) 19 years prior. Managing the patient required collaboration with the intensivist, hospitalist, and psychiatry and neurology teams for 10 months, and he was refused admission to multiple psychiatric facilities due to safety concerns because of his high level of aggression and unpredictability. An out-of-state, high-security facility eventually accepted the patient. The second challenge was finding a highly trained medical team willing to transport the patient. This case illustrates the difficulty and safety concerns with regard to managing an aggressive patient with previous TBI when the commonly used medications do not produce the desired effect. A literature search did not reveal a standard protocol or consensus on managing these types of patients in emergent situations.
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Epidemiological and Psychopharmacological Study About Off-Label Treatment in Child and Adolescent Psychiatric Emergencies: A Tertiary/Single Center Experience. Pediatr Emerg Care 2022; 38:e1660-e1663. [PMID: 35686968 DOI: 10.1097/pec.0000000000002693] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The study used an epidemiological and pharmacological description of child and adolescent psychiatric emergencies (CAPEs), during which psychotropic medications are frequently administered as off-label therapies. METHODS We retrospectively describe CAPE in 190 patients (mean age, 14.7 years) referring in the emergency department of a single tertiary center, from June 2016 to June 2018, focusing on off-label administration rate, most of all in emergency setting. RESULTS An intrinsic fragility was observed in this population, where 28.4% of patients present a history of self-harm, 24.7% a concomitant neurodevelopmental disorder, and 17.3% a history of substance abuse. Psychomotor agitation was the most frequent referral reason, and it represents an unspecified clinical presentation of several conditions, while self-harm showed a stronger association with depressive disorders (55.2%).Globally, 811 medications were administered both as baseline therapy (67.8% of off-label rate) and/or in the emergency setting, where the off-label rate raised to 78.3%. Benzodiazepines had the highest rate of off-label use (98.2% as baseline therapy, 92.9% in acute context). Nevertheless, in 83.5% cases of acute administrations, a singular oral benzodiazepine (mostly lorazepam) guaranteed psychomotor agitation resolution, with a lower rate of adverse effects in contrast with atypical antipsychotics. CONCLUSIONS Off-label drug use in CAPEs is a recurrent clinical practice. An international agreement about off-label drugs is crucial to obtain standard long-term pharmacoepidemiological, safety, and efficacy data. Pharmacological pediatric trials and international guidelines are also required to regulate pharmacological treatments of CAPEs, most of all in emergency settings.
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Corwell BN, Motov SM, Davis N, Kim HK. Novel uses of ketamine in the emergency department. Expert Opin Drug Saf 2022; 21:1009-1025. [PMID: 35822534 DOI: 10.1080/14740338.2022.2100883] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION : Ketamine is gaining renewed interest among healthcare providers due to its novel clinical applications in the emergency department (ED) setting. AREAS COVERED : This article provides a comprehensive discussion of ketamine's pharmacological properties, including safety profile and adverse effects, in addition to an overview of current evidence for ketamine (racemic formulation) in the management of ED patients with acute agitation, pain, and depression/suicide ideation. EXPERT OPINION : Ketamine is an effective adjunct to opioids, providing greater pain relief than morphine alone. As an analgesic agent, administration of ketamine (0.1-0.3 mg/kg IV) alone can provide analgesia similar to that of morphine in patients with acute visceral and musculoskeletal pain. Moreover, ketamine provides equal analgesic efficacy to morphine in a variety of chronic painful conditions including pain associated with cancer, vaso-occlusive pain crisis associated with sickle cell disease, and in patients with high opioid tolerance and/or opioid dependency. Available literature shows that ketamine (1-2mg/kg IV or 4-5 mg/kg IM) is a safe, rapid (<5 minutes) and effective tranquilization agent for ED patients with acute agitation. Finally, there is growing evidence that suggests ketamine may have a potential utility in the management of patients with self-harm ideation or acute depressive episodes. Intravenous infusion of ketamine (0.5 mg/kg over 40 mins) has been shown to produce an antidepressant effect and decrease in suicidal ideation within 4 hours with effects lasting up to one week.
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Affiliation(s)
- Brian N Corwell
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Sergey M Motov
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY
| | - Natalie Davis
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Hong K Kim
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
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Zaki HA, Shaban E, Bashir K, Iftikhar H, Zahran A, Salem EEDM, Elmoheen A. A Comparative Analysis Between Ketamine Versus Combination of Midazolam and Haloperidol for Rapid Safe Control of Agitated Patients in Emergency Department: A Systematic Review. Cureus 2022; 14:e26162. [PMID: 35891834 PMCID: PMC9302860 DOI: 10.7759/cureus.26162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 01/08/2023] Open
Abstract
We aim to discuss the efficacy and adverse effects of using ketamine in agitated patients in the emergency department (ED) compared with the combination therapy of haloperidol with benzodiazepine. This systematic review followed Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. An electronic search from PubMed/Medline, Cochrane library, and Google Scholar was conducted from their inception to 30th April 2022. We included agitated patients in ED who were given infusion with ketamine only. Our comparative group was patients infused with combined therapy of haloperidol and benzodiazepine. We did not include letters, case reports, abstracts, conference papers, appraisals, reviews, and studies where full text was unavailable. We did not put any language restrictions. Three studies were selected in our manuscript (one cohort and two randomized controlled trials). All three studies showed that ketamine was used to achieve sedation in less time than the other group. However, two studies reported significantly more adverse effects in ketamine-infused groups. We concluded that ketamine use is superior when its primary focus is to sedate the patient as quickly as possible, but it carries some side effects that should be considered. However, we still need more studies assessing the efficacy of ketamine in agitated patients presenting in the ED.
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deSouza IS, Thode HC, Shrestha P, Allen R, Koos J, Singer AJ. Rapid tranquilization of the agitated patient in the emergency department: A systematic review and network meta-analysis. Am J Emerg Med 2021; 51:363-373. [PMID: 34823192 DOI: 10.1016/j.ajem.2021.11.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 10/29/2021] [Accepted: 11/04/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Safe and effective tranquilization of the acutely agitated patient is challenging, and head-to-head comparisons of medications are limited. We aimed to identify the most optimal agent(s) for rapid tranquilization of the severely agitated patient in the emergency department (ED). METHODS The protocol for systematic review was registered (PROSPERO; CRD42020212534). We searched MEDLINE, Embase, PsycINFO, and Cochrane Database/CENTRAL from inception to June 2, 2021. We limited studies to randomized controlled trials that enrolled adult ED patients with severe agitation and compared drugs for rapid tranquilization. Predetermined outcomes were: 1) Adequate sedation within 30 min (effectiveness), 2) Immediate, serious adverse event - cardiac arrest, ventricular tachydysrhythmia, endotracheal intubation, laryngospasm, hypoxemia, hypotension (safety), and 3) Time to adequate sedation (effect onset). We extracted data according to PRISMA-NMA and appraised trials using Cochrane RoB 2 tool. We performed Bayesian network meta-analysis (NMA) using a Markov Chain Monte Carlo method with random-effects model and vague prior distribution to calculate odds ratios with 95% credible intervals for dichotomous outcomes and frequentist NMA to calculate mean differences with 95% confidence intervals for continuous outcomes. We assessed confidence in results using CINeMA. We used surface under the cumulative ranking (SUCRA) curves to rank agent(s) for each outcome. RESULTS Eleven studies provided data for effectiveness (1142 patients) and safety (1147 patients). Data was insufficient for effect onset. The NMA found that ketamine (SUCRA = 93.0%) is most likely to have superior effectiveness; droperidol-midazolam (SUCRA = 78.8%) is most likely to be safest. There are concerns with study quality and imprecision. Quality of the point estimates varied for effectiveness but mostly rated "very low" for safety. CONCLUSIONS Available evidence suggests that ketamine and droperidol have intermediate effectiveness for rapid tranquilization of the severely agitated patient in the ED. There is insufficient evidence to definitively determine which agent(s) may be safest or fastest-acting. Further, direct-comparison study of ketamine and droperidol is recommended.
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Affiliation(s)
- Ian S deSouza
- Department of Emergency Medicine, SUNY Downstate Health Sciences University and Kings County Hospital Center, Brooklyn, NY, USA.
| | - Henry C Thode
- Department of Emergency Medicine, Stony Brook University, NY, USA.
| | - Pragati Shrestha
- Department of Emergency Medicine, Stony Brook University, NY, USA.
| | - Robert Allen
- Department of Emergency Medicine, SUNY Downstate Health Sciences University and Kings County Hospital Center, Brooklyn, NY, USA.
| | - Jessica Koos
- Department of Emergency Medicine, Stony Brook University, NY, USA.
| | - Adam J Singer
- Department of Emergency Medicine, Stony Brook University, NY, USA.
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15
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Claret PG, Giron A, Lopez-Castroman J, Zanker C, Chauvin A. [Physical restraint of the adult patient with uncontrollable agitation]. Soins Psychiatr 2021; 42:23-25. [PMID: 34763761 DOI: 10.1016/j.spsy.2021.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In the context of psychiatric emergencies, it is important to distinguish between so-called controllable agitation and uncontrollable agitation. In this context, physical restraint of the adult patient is sometimes necessary, but remain an exceptional measure. Restraints must be applied rapidly and in a protocolised manner. It should be used sparingly in the elderly patient. Physical restraint is a medical prescription that must be accompanied by chemical restraint.
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Affiliation(s)
| | | | - Jorge Lopez-Castroman
- Service d'urgences et liaison psychiatriques, service de pédopsychiatrie, centre hospitalier universitaire de Nîmes, hôpital Carémeau, place du Professeur-Robert-Debré, 30900 Nîmes, France
| | - Caroline Zanker
- Structures des urgences, centre hospitalier franco-britannique, 4 rue Kléber, 92300 Levallois-Perret, France
| | - Anthony Chauvin
- Structure des urgences, centre hospitalier universitaire Lariboisière, 2 rue Ambroise-Paré, 75010 Paris, France
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16
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Shastry S, Aluise ER, Richardson LD, Vedanthan R, Manini AF. Delayed QT Prolongation: Derivation of a Novel Risk Factor for Adverse Cardiovascular Events from Acute Drug Overdose. J Med Toxicol 2021; 17:363-371. [PMID: 34449039 PMCID: PMC8455785 DOI: 10.1007/s13181-021-00855-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/18/2021] [Accepted: 07/19/2021] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION In ED patients with acute drug overdose involving prescription medication and/or substances of abuse, severe QTc prolongation (> 500 ms) is predictive of adverse cardiovascular events (ACVE), defined as myocardial injury, ventricular dysrhythmia, shock, or cardiac arrest. However, it is unclear whether delayed severe QTc prolongation (dsQTp) is a risk factor for ACVE and if specific clinical factors are associated with occurrence of dsQTp. METHODS A secondary analysis of a prospective cohort of consecutive adult ED patients with acute drug overdose was performed on patients with initial QTc < 500 ms. The predictor variable, dsQTp, was defined as initial QTc < 500 ms followed by repeat QTc ≥ 500 ms. The primary outcome was occurrence of ACVE. Multivariable logistic regression was performed to test whether dsQTp was an independent predictor of ACVE and to derive clinical factors associated with dsQTp. RESULTS Of 2311 patients screened, 1648 patients were included. The dsQTp group (N = 27) was older than the control group (N = 1621) (51.6 vs 40.2, p < 0.001) and had a higher number of drug exposures (2.92 vs 2.16, p = 0.003). Following adjustment for age, sex, race/ethnicity, number of exposures, serum potassium, and opioid exposure, dsQTp remained an independent predictor of ACVE (aOR: 12.44, p < 0.0001). Clinical factors associated with dsQTp were age > 45 years and polydrug (≥ 3) overdoses. CONCLUSION In this large secondary analysis of ED patients with acute drug overdose, dsQTp was an independent risk factor for in-hospital occurrence of ACVE.
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Affiliation(s)
- Siri Shastry
- grid.416167.3Department of Emergency Medicine, Icahn School of Medicine At Mount Sinai, Mount Sinai Hospital, 555 West 57th Street, 5th Floor, New York, NY 10019 USA
| | - Eleanor R. Aluise
- grid.416167.3Department of Emergency Medicine, Icahn School of Medicine At Mount Sinai, Mount Sinai Hospital, 555 West 57th Street, 5th Floor, New York, NY 10019 USA
| | - Lynne D. Richardson
- grid.416167.3Department of Emergency Medicine, Icahn School of Medicine At Mount Sinai, Mount Sinai Hospital, 555 West 57th Street, 5th Floor, New York, NY 10019 USA ,grid.59734.3c0000 0001 0670 2351Department of Population Health Science and Policy, Icahn School of Medicine At Mount Sinai, New York, NY USA
| | - Rajesh Vedanthan
- grid.240324.30000 0001 2109 4251Department of Population Health, New York University Grossman School of Medicine, New York, NY USA
| | - Alex F. Manini
- grid.414488.50000 0004 0453 0340Division of Medical Toxicology, Department of Emergency Medicine, Icahn School of Medicine At Mount Sinai, Elmhurst Hospital Center, New York, NY USA
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17
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Jenkins M, Barrett MC, Frey T, Bouvay K, Barzman D, Kurowski EM. Adherence with an Acute Agitation Algorithm and Subsequent Restraint Use. Psychiatr Q 2021; 92:851-862. [PMID: 33219428 DOI: 10.1007/s11126-020-09860-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2020] [Indexed: 02/03/2023]
Abstract
Timely use of pharmacological interventions to treat acute agitation has the potential to decrease physical restraint use. The aim of this study is to determine if adherence to standardized pharmacological recommendations for the treatment of acutely agitated pediatric patients decreases physical restraint use. Additionally, this study aims to identify predictors of physical restraint use and describe treatment related adverse events. This is a retrospective chart review of patient visits between September 1, 2016 and August 31, 2017. Patient visits were included if the patient presented to the pediatric emergency department, met ICD-10 codes, and received pharmacologic management or physical restraint to treat acute agitation. The differences in rate of physical restraint was assessed between patients treated according to the standardized pharmacological recommendations and patients who were not. 447 patients were included with a mean age of 13 years. No significant difference in physical restraint use was found when standardized pharmacological recommendations were followed compared to when they were not (P = 0.16). Only presentation on day shift when compared to evening shift resulted in increased odds of being restrained (OR 2.03; 95% CI 1.18, 3.50). Nine adverse events possibly related to medications were identified with none considered to be of significant clinical concern. Standardized pharmacological treatment recommendations was not associated with a decrease in physical restraint use for agitated patients presenting to the pediatric emergency department. The pharmacologic strategies utilized were generally safe and well tolerated in this patient population.
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Affiliation(s)
- Meredith Jenkins
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH, 45229, USA.
| | - Michelle Caruso Barrett
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH, 45229, USA
| | - Theresa Frey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Kamali Bouvay
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Drew Barzman
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Division of Child Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Eileen Murtagh Kurowski
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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18
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Jin RO, Anaebere TC, Haar RJ. Exploring bias in restraint use: Four strategies to mitigate bias in care of the agitated patient in the emergency department. Acad Emerg Med 2021; 28:1061-1066. [PMID: 33977591 DOI: 10.1111/acem.14277] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/24/2021] [Accepted: 05/03/2021] [Indexed: 12/17/2022]
Abstract
Agitation is a routine and increasingly common presentation to the emergency department (ED). In the wake of a national examination into racism and police use of force, this article aims to extend that reflection into emergency medicine in the management of patients presenting with acute agitation. Through an overview of ethicolegal considerations in restraint use and current literature on implicit bias in medicine, this article provides a discussion on how bias may impact care of the agitated patient. Concrete strategies are offered at an individual, institutional, and health system level to help mitigate bias and improve care.
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Affiliation(s)
- Rowen O. Jin
- Department of Emergency Medicine LAC+USC Medical Center Los Angeles California USA
| | - Tiffany C. Anaebere
- Special Projects and Innovation Emergency Medicine Residency Program Dignity Health–St. Joseph’s Medical Center Stockton California USA
| | - Rohini J. Haar
- Department of Epidemiology and Biostatistics University of California at Berkeley Berkeley California USA
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19
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Chauvin A, Massoubre C, Gil-Jardine C, Sicot R, Le Conte P, Varin L, Lefort H, Camus V, Martinez M, Bied C, Oberlin M, Valdenaire G, Villoing B, Zanker C, Lopez-Castroman J, Claret PG. Recommandations de pratique clinique sur la prise en charge du patient adulte à présentation psychiatrique dans les structures d’urgences. ANNALES FRANCAISES DE MEDECINE D URGENCE 2021. [DOI: 10.3166/afmu-2021-0321] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
De nombreux patients consultant aux urgences souffrent de pathologies psychiatriques préexistantes ou ont une symptomatologie évocatrice d’une pathologie psychiatrique. En effet, les troubles psychiatriques touchent un adulte sur quatre, et 75%des affections psychiatriques débutent avant l’âge de 25 ans. Le parcours de soins d’un patient adulte à présentation psychiatrique dans les structures d’urgences concerne de multiples intervenants. La complexité inhérente à ces patients complexes ainsi qu’à l’interdisciplinarité induite dans la prise en charge impose un cadre de prise en charge clair et consensuel. Des experts de la psychiatrie, de la gérontopsychiatrie et de la médecine d’urgence se sont réunis pour émettre ces recommandations de bonnes pratiques. Le choix de présenter des recommandations de bonnes pratiques et non des recommandations formalisées d’experts a été fait devant l’insuffisance de littérature de fort niveau de preuve dans certaines thématiques et de l’existence de controverses. À travers ces recommandations de bonnes pratiques cliniques, ils se sont attachés à décrire la prise en charge de ses patients aussi bien en préqu’en intrahospitalier. Les objectifs de ces recommandations sont de présenter les éléments indispensables à l’organisation du parcours de soins de ces patients, la gestion de l’agitation ainsi que la prise en charge pharmacologique ou non. Une partie spécifique est consacrée aux aspects réglementaires.
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20
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Acute psychiatric illness and drug addiction during pregnancy and the puerperium. HANDBOOK OF CLINICAL NEUROLOGY 2021. [PMID: 32768084 DOI: 10.1016/b978-0-444-64240-0.00007-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Pregnancy and the puerperium do not protect against acute psychiatric illness. During puerperium, the chance of acute psychiatric illness, such as a psychotic episode or relapse of bipolar disorder, is greatly increased. Suicide is a leading cause of maternal death. Both psychiatric disease and ongoing drug addiction impact not only the pregnant woman's somatic and mental health but also impact short-term and long-term health of the child. Indeed, prompt recognition and expeditious treatment of acute psychiatric illness during pregnancy and the puerperium optimize health outcomes for two patients. Pregnancy and puerperium represent a stage of life of great physiologic adaptations, as well as emotional and social changes. This conjunction of changes in somatic, emotional health and social health may mitigate the occurrence, clinical presentation, and clinical course of acute psychiatric illness and call for a multidisciplinary approach, taking into account both the medical and social domains. This chapter describes acute psychiatric illnesses during pregnancy and the puerperium and illicit substance abuse, from a clinical perspective, while also describing general principles of diagnosis and clinical management during this stage of life, which is an important window of opportunity for both the pregnant woman and the child.
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21
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Carrarini C, Russo M, Dono F, Barbone F, Rispoli MG, Ferri L, Di Pietro M, Digiovanni A, Ajdinaj P, Speranza R, Granzotto A, Frazzini V, Thomas A, Pilotto A, Padovani A, Onofrj M, Sensi SL, Bonanni L. Agitation and Dementia: Prevention and Treatment Strategies in Acute and Chronic Conditions. Front Neurol 2021; 12:644317. [PMID: 33935943 PMCID: PMC8085397 DOI: 10.3389/fneur.2021.644317] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/12/2021] [Indexed: 01/11/2023] Open
Abstract
Agitation is a behavioral syndrome characterized by increased, often undirected, motor activity, restlessness, aggressiveness, and emotional distress. According to several observations, agitation prevalence ranges from 30 to 50% in Alzheimer's disease, 30% in dementia with Lewy bodies, 40% in frontotemporal dementia, and 40% in vascular dementia (VaD). With an overall prevalence of about 30%, agitation is the third most common neuropsychiatric symptoms (NPS) in dementia, after apathy and depression, and it is even more frequent (80%) in residents of nursing homes. The pathophysiological mechanism underlying agitation is represented by a frontal lobe dysfunction, mostly involving the anterior cingulate cortex (ACC) and the orbitofrontal cortex (OFC), respectively, meaningful in selecting the salient stimuli and subsequent decision-making and behavioral reactions. Furthermore, increased sensitivity to noradrenergic signaling has been observed, possibly due to a frontal lobe up-regulation of adrenergic receptors, as a reaction to the depletion of noradrenergic neurons within the locus coeruleus (LC). Indeed, LC neurons mainly project toward the OFC and ACC. These observations may explain the abnormal reactivity to weak stimuli and the global arousal found in many patients who have dementia. Furthermore, agitation can be precipitated by several factors, e.g., the sunset or low lighted environments as in the sundown syndrome, hospitalization, the admission to nursing residencies, or changes in pharmacological regimens. In recent days, the global pandemic has increased agitation incidence among dementia patients and generated higher distress levels in patients and caregivers. Hence, given the increasing presence of this condition and its related burden on society and the health system, the present point of view aims at providing an extensive guide to facilitate the identification, prevention, and management of acute and chronic agitation in dementia patients.
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Affiliation(s)
- Claudia Carrarini
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Mirella Russo
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Fedele Dono
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Filomena Barbone
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Marianna G Rispoli
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Laura Ferri
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Martina Di Pietro
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Anna Digiovanni
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Paola Ajdinaj
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Rino Speranza
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Alberto Granzotto
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.,Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology-CAST, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.,Institute for Mind Impairments and Neurological Disorders-iMIND, University of California, Irvine, Irvine, CA, United States
| | - Valerio Frazzini
- Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology-CAST, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.,Institut du Cerveau et de la Moelle épinière, ICM, INSERM UMRS 1127, CNRS UMR 7225, Pitié Salpêtrière Hospital, Paris, France.,AP-HP, GH Pitie-Salpêtrière-Charles Foix, Epilepsy Unit and Neurophysiology Department, Paris, France
| | - Astrid Thomas
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Andrea Pilotto
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Parkinson's Disease Rehabilitation Centre, FERB ONLUS-S. Isidoro Hospital, Trescore Balneario, Italy
| | - Alessandro Padovani
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Marco Onofrj
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.,Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology-CAST, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Stefano L Sensi
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.,Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology-CAST, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Laura Bonanni
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.,Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology-CAST, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
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22
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Cabilan CJ, Meyer A, Elmore R, Nash T, Eley R, Tuckett A. Sensory Devices for Older Adults With Behavioral Disturbance in the Emergency Department: A Descriptive Study. J Gerontol Nurs 2021; 47:22-27. [PMID: 34038252 DOI: 10.3928/00989134-20210309-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Nonpharmacological strategies are advocated for the management of behavioral disturbance in older adults due to risk of harm from pharmacological therapy; however, limited evidence supports their use in emergency departments (EDs). The current descriptive study was conducted to investigate the use of sensory devices for nonpharmacological management of behavioral disturbance and their perceived impact. Data were collected from the sensory device registry, electronic medical records, and survey. Patient-level data (N = 33) showed that sensory devices, such as tactile blankets or toys and music, can be used in EDs to alleviate behavioral disturbance among older adults. ED staff (n = 22) expressed an interest to increase device supply. A patient and caregiver (n = 2) suggested that the devices be initiated earlier in ED care. Further research is required to strengthen evidence on the impact of these devices on patient outcomes. [Journal of Gerontological Nursing, 47(4), 22-27.].
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23
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Eagles D, Khoujah D. Rapid Fire: Acute Brain Failure in Older Emergency Department Patients. Emerg Med Clin North Am 2021; 39:287-305. [PMID: 33863460 DOI: 10.1016/j.emc.2020.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Delirium is common in older emergency department (ED) patients. Although associated with significant morbidity and mortality, it often goes unrecognized. A consistent approach to evaluation of mental status, including use of validated tools, is key to diagnosing delirium. Identification of the precipitating event requires thorough evaluation, including detailed history, medication reconciliation, physical examination, and medical work-up, for causes of delirium. Management is aimed at identifying and treating the underlying cause. Meaningful improvements in delirium care can be achieved when prevention, identification, and management of older delirious ED patients is integrated by physicians and corresponding frameworks implemented at the health system level.
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Affiliation(s)
- Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Danya Khoujah
- Emergency Medicine, MedStar Franklin Square Medical Center, 9000 Franklin Square Dr, Baltimore, MD 21237, USA; Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA. https://twitter.com/DanyaKhoujah
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24
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Legambi TF, Doede M, Michael K, Zaleski M. A Quality Improvement Project on Agitation Management in the Emergency Department. J Emerg Nurs 2021; 47:390-399.e3. [PMID: 33648736 DOI: 10.1016/j.jen.2021.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 01/07/2021] [Accepted: 01/11/2021] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Agitation is common in the emergency department. When agitation is not detected early, patients can become aggressive and violent, potentially leading to restraint use and subsequent injury. The goals of the project were early detection and management of patient agitation, reduction of restraint use in the emergency department, and determination of the usability of the Behavioral Activity Rating Scale. METHODS This quality improvement project was assessed using a pre- and posttest single unit design, comparing 4 months of postimplementation data to historic controls at the same time of year in the previous year. The intervention was implementing the Behavioral Activity Rating Scale in the ED electronic medical record. Data were collected through retrospective chart review and nurse survey. From September through December of both 2017 and 2018, data were collected on restraint use. The 4-month 2018 data collection period included measures of Behavioral Activity Rating Scale documentation and the System Usability Scale survey for nurses to measure ease of usability of the Behavioral Activity Rating Scale. RESULTS The Behavioral Activity Rating Scale was documented frequently (n = 4 867 documentations) by emergency nurses to assess patients with behavioral health and medical complaints (n = 780). Nurses identified 18 episodes of violent behavior in behavioral health patients on the Behavioral Activity Rating Scale (2.31%) and applied restraints 18 times. The most common chief complaints for patients who were identified as violent was suicidal ideation (n = 6; 33.33%). In 2017, there were 20 episodes of restraint use during the same time period, a nonsignificant difference (χ2 = 0.72; P = 0.40). However, only 2 patients were kept in restraints longer than 1 day in 2018 compared with 8 in 2017. Emergency nurses found the Behavioral Activity Rating Scale to be usable in the structured usability assessment (μ = 83.46; SD = 11.73). DISCUSSION The Behavioral Activity Rating Scale is a usable tool for emergency nurses to assess for patient agitation. With the incorporation of agitation management interventions, the ED team can potentially manage agitation before violence occurs. Further studies are needed on the use of agitation or aggression assessment tools for managing patient behavioral activity such as aggression in the emergency department.
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25
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Kim HK, Leonard JB, Corwell BN, Connors NJ. Safety and efficacy of pharmacologic agents used for rapid tranquilization of emergency department patients with acute agitation or excited delirium. Expert Opin Drug Saf 2021; 20:123-138. [PMID: 33327811 DOI: 10.1080/14740338.2021.1865911] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Management of patients with acute agitation or aggressive behavior can pose a significant challenge to health-care providers in emergency departments. Areas covered: This article provides a comprehensive review of the pharmacologic properties, efficacy, and safety profiles of select intramuscular (IM) sedative agents (i.e., antipsychotics, benzodiazepines, and ketamine) for rapid tranquilization. Expert opinion: Using antipsychotics and benzodiazepines - whether a single agent or combined - will have similar efficacy in producing sedation. But there are differences in the time to sedation depending on which agent is used. Based upon the available studies, droperidol (5-10 mg IM) and midazolam (5-10 mg IM) have the fastest onset of sedation when either is used as a single agent. When combination therapy is used, using midazolam with an antipsychotic agent, instead of lorazepam, may result in faster sedative effect. QT prolongation and torsades de pointes are uncommon adverse drug effects of antipsychotic administration. Ketamine is often reserved as a second-line agent when antipsychotics and benzodiazepines fail to produce the desired tranquilization. However, ketamine (5 mg/kg IM) is more frequently associated with airway compromise requiring endotracheal intubation. A low-dose of ketamine (2 mg/kg IM) may reduce the risk of airway compromise while providing adequate sedation.
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Affiliation(s)
- Hong K Kim
- Department of Emergency Medicine, University of Maryland School of Medicine , Baltimore, MD, USA
| | - James B Leonard
- Maryland Poison Center, University of Maryland School of Pharmacy , Baltimore, MD, USA
| | - Brian N Corwell
- Department of Emergency Medicine, University of Maryland School of Medicine , Baltimore, MD, USA
| | - Nicholas J Connors
- Department of Emergency Medicine, HCA Healthcare Trident Medical Center , Charleston, SC, USA
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26
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Cioni G, Betti G, Vergara A. Massive pulmonary embolism masked as an episode of acute agitation in a psychiatric patient: a case report. ITALIAN JOURNAL OF MEDICINE 2020. [DOI: 10.4081/itjm.2020.1414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Management of the psychiatric diseases’ reacutization is a frequent occurrence in emergency medicine. During this coronavirus disease 2019 pandemic, a further increase in access to the emergency room was reported, and the reasons are numerous. Although the essential prerogative of the emergency department is to provide immediate clinical assistance by rapidly setting an effective diagnostic and therapeutic path, there are multiple obstacles to providing adequate care for Emergency Department patients with mental illness. In this report, we describe the case of a 65-year-old female patient with severe schizophrenia who was evaluated in the emergency room for acute agitation masking subtle, persistent dyspnea. The possibility of an underlying medical cause should not be underestimated or completely forgotten due to the difficult approach to the psychiatric patient.
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27
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Muir-Cochrane E, Oster C, Grimmer K. Interrogating systematic review recommendations for effective chemical restraint. J Eval Clin Pract 2020; 26:1768-1779. [PMID: 32059065 DOI: 10.1111/jep.13363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 01/12/2020] [Accepted: 01/16/2020] [Indexed: 02/01/2023]
Affiliation(s)
- Eimear Muir-Cochrane
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Candice Oster
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Karen Grimmer
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia
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28
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Schneider A, Mullinax S, Hall N, Acheson A, Oliveto AH, Wilson MP. Intramuscular medication for treatment of agitation in the emergency department: A systematic review of controlled trials. Am J Emerg Med 2020; 46:193-199. [PMID: 33071100 DOI: 10.1016/j.ajem.2020.07.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/01/2020] [Accepted: 07/03/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Severely agitated patients in the emergency department (ED) are often sedated with intramuscularly-administered medications. The evidence base underlying particular medication choices is surprisingly sparse, as existing reviews either have methodological limitations or have included data collected outside of emergent settings. OBJECTIVES The objective of this review was to examine all controlled trials in emergent settings that have used standardized scales to measure the effectiveness of intramuscular medication for the treatment of acute agitation. METHODS This review was registered in Prospero as CRD42018105745. PubMed, International Pharmaceutical Abstracts, Web of Science, PsycINFO, and clinicaltrials.gov were searched for prospective controlled trials investigating intramuscular antipsychotics for agitation. Articles were assessed for bias across five domains using the revised Cochrane Risk of Bias Tool. RESULTS Eight studies were eligible for inclusion in the systematic review, none of which had a low risk of bias. Five studies had a moderate risk of bias with heterogenous designs, populations, and treatments. These studies seemed to suggest that second generation antipsychotics (SGAs) likely reduce agitation as effectively as first generation antipsychotics (FGAs) plus an adjunctive medication with similar or lower risk of side effects. CONCLUSIONS Existing trials on the use of intramuscular antipsychotics in the ED/psychiatric ED setting were small, heterogenous, and at a moderate or high risk of bias. Given the clinical importance of this topic, further prospective investigations are desperately needed but are currently unfeasible under Food and Drug Administration Exception From Informed Consent regulations.
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Affiliation(s)
- Allison Schneider
- Division of Research and Evidence-Based Medicine, Department of Emergency Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Samuel Mullinax
- Division of Research and Evidence-Based Medicine, Department of Emergency Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Nathanael Hall
- Division of Research and Evidence-Based Medicine, Department of Emergency Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Ashley Acheson
- Center for Addiction Research, Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Alison H Oliveto
- Center for Addiction Research, Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Michael P Wilson
- Division of Research and Evidence-Based Medicine, Department of Emergency Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America.
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Muir-Cochrane E, Grimmer K, Gerace A, Bastiampillai T, Oster C. Safety and effectiveness of olanzapine and droperidol for chemical restraint for non-consenting adults: a systematic review and meta-analysis. Australas Emerg Care 2020; 24:96-111. [PMID: 33046432 DOI: 10.1016/j.auec.2020.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/24/2020] [Accepted: 08/27/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Chemical restraint (CR) is emergency drug management for acute behavioural disturbances in people with mental illness, provided with the aim of rapid calming and de-escalating potentially dangerous situations. AIMS To describe a systematic review of Randomised Controlled Trials (RCTs) reporting on short-term safety and effectiveness of drugs used for CR, administered to non-consenting adults with mental health conditions, who require emergency management of acute behavioural disturbances. A meta-analysis was conducted of those RCTs with comparable interventions, outcome measures and measurement timeframes. METHOD Academic databases were searched for RCTs published between 1 January 1996 and 20th April 2020. Relevant RCTs were critically appraised using the 13-item JBI checklist. All RCTs were described, and step-wise filters were applied to identify studies suitable for meta-analysis. For these, forest and funnel plots were constructed, and Q and I2 statistics guided interpretation of pooled findings, tested using MedCalc Version 19.1. RESULTS Of 23 relevant RCTs, 18 (78.2% total) had excellent methodological quality scores (at least 90%). Eight RCTs were potentially relevant for meta-analysis (six of excellent quality), reporting 20 drug arms in total. Adverse events for 6-36% patients were reported in all 20 drug arms. Four drug arms from two homogenous studies of N = 697 people were meta-analysed. These RCTs tested two antipsychotic drugs (droperidol, olanzapine) delivered intravenously in either 5 mgs or 10 mg doses, with outcomes of time to calm, percentage calm within five or 10 min, and adverse events. There were no significant differences between drug arms for either measure of calm. However, 5 mg olanzapine incurred significantly lower risk of adverse events than 10 mg olanzapine (OR 0.4 (95%CI 0.2-0.8)), although no dose differences were found for droperidol. CONCLUSION 5 mg intravenous olanzapine is recommended for quick, safe emergency management of people with acute behavioural disturbances associated with mental illness.
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Affiliation(s)
- Eimear Muir-Cochrane
- College of Nursing & Health Sciences, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia.
| | - Karen Grimmer
- College of Nursing & Health Sciences, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia
| | - Adam Gerace
- College of Nursing & Health Sciences, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia; School of Health, Medical and Applied Sciences, Central Queensland University, 44 Greenhill Rd, Wayville, South Australia, Australia
| | - Tarun Bastiampillai
- College of Medicine & Public Health, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia
| | - Candice Oster
- College of Nursing & Health Sciences, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia; College of Medicine & Public Health, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia
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Schnitzer K, Merideth F, Macias-Konstantopoulos W, Hayden D, Shtasel D, Bird S. Disparities in Care: The Role of Race on the Utilization of Physical Restraints in the Emergency Setting. Acad Emerg Med 2020; 27:943-950. [PMID: 32691509 DOI: 10.1111/acem.14092] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/19/2020] [Accepted: 06/23/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Race-based bias in health care occurs at organizational, structural, and clinical levels and impacts emergency medical care. Limited literature exists on the role of race on patient restraint in the emergency setting. This study sought to examine the role of race in physical restraint in an emergency department (ED) at a major academic medical center. METHODS Retrospective chart analysis was performed, querying all adult ED visits over a 2-year period (2016-2018) at Massachusetts General Hospital. The associations between race and restraint and selected covariates (sex, insurance, age, diagnosis, homelessness, violence) were analyzed. RESULTS Of the 195,092 unique ED visits by 120,469 individuals over the selected period, 2,658 (1.4%) involved application of a physical restraint by health care providers. There was a significant effect of race on restraint (p < 0.0001). The risk ratio (RR) for Asian patients compared to white patients was 0.71 (95% confidence interval [CI] = 0.55 to 0.92, p = 0.009). The RR for Black patients compared to white patients was 1.22 (95% CI = 1.05 to 1.40, p = 0.007). Visits with patients having characteristics of male sex, public or no insurance, younger age, diagnoses pertaining to substance use, diagnoses pertaining to psychotic or bipolar disorders, current homelessness, and a history of violence were more likely to result in physical restraint. CONCLUSIONS There was a significant effect of race on restraint that remained when controlling for sex, insurance, age, diagnosis, homelessness, and history of violence, all of which additionally conferred independent effects on risk. These results warrant a careful examination of current practices and potential biases in utilization of restraint in emergency settings.
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Affiliation(s)
- Kristina Schnitzer
- From the, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- and, Harvard Medical School, Boston, MA, USA
| | - Flannery Merideth
- From the, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- and, Harvard Medical School, Boston, MA, USA
| | - Wendy Macias-Konstantopoulos
- and, Harvard Medical School, Boston, MA, USA
- the, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
- the, Center for Social Justice and Health Equity, Massachusetts General Hospital, Boston, MA, USA
| | - Douglas Hayden
- and, Harvard Medical School, Boston, MA, USA
- and the, Department of Biostatistics, Massachusetts General Hospital, Boston, MA, USA
| | - Derri Shtasel
- From the, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- and, Harvard Medical School, Boston, MA, USA
| | - Suzanne Bird
- From the, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- and, Harvard Medical School, Boston, MA, USA
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Roppolo LP, Morris DW, Khan F, Downs R, Metzger J, Carder T, Wong AH, Wilson MP. Improving the management of acutely agitated patients in the emergency department through implementation of Project BETA (Best Practices in the Evaluation and Treatment of Agitation). J Am Coll Emerg Physicians Open 2020; 1:898-907. [PMID: 33145538 PMCID: PMC7593430 DOI: 10.1002/emp2.12138] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 12/26/2022] Open
Abstract
Agitated patients presenting to the emergency department (ED) can escalate to aggressive and violent behaviors with the potential for injury to themselves, ED staff, and others. Agitation is a nonspecific symptom that may be caused by or result in a life-threatening condition. Project BETA (Best Practices in the Evaluation and Treatment of Agitation) is a compilation of the best evidence and consensus recommendations developed by emergency medicine and psychiatry experts in behavioral emergencies to improve our approach to the acutely agitated patient. These recommendations focus on verbal de-escalation as a first-line treatment for agitation; pharmacotherapy that treats the most likely etiology of the agitation; appropriate psychiatric evaluation and treatment of associated medical conditions; and minimization of physical restraint/seclusion. Implementation of Project BETA in the ED can improve our ability to manage a patient's agitation and reduce the number of physical assaults on ED staff. This article summarizes the BETA guidelines and recent supporting literature for managing the acutely agitated patient in the ED followed by a discussion of how a large county hospital integrated these recommendations into daily practice.
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Affiliation(s)
- Lynn P. Roppolo
- University of Texas Southwestern Medical CenterDepartment of Emergency MedicineDallasTexasUSA
| | - David W. Morris
- University of Texas Southwestern Medical CenterDepartment of PsychiatryDallasTexasUSA
| | - Fuad Khan
- University of Texas Southwestern Medical CenterDepartment of PsychiatryDallasTexasUSA
| | - Rohini Downs
- Parkland Memorial HospitalPharmacy ServicesDallasTexasUSA
| | - Jeffery Metzger
- University of Texas Southwestern Medical CenterDepartment of Emergency MedicineDallasTexasUSA
| | - Tiffany Carder
- Parkland Memorial HospitalEmergency Services DepartmentDallasTexasUSA
| | - Ambrose H. Wong
- Yale School of MedicineDepartment of Emergency MedicineNew HavenConnecticutUSA
| | - Michael P. Wilson
- University of Arkansas for Medical SciencesDepartment of Emergency MedicineLittle RockArkansasUSA
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Muir-Cochrane E, Oster C, Grimmer K. International research into 22 years of use of chemical restraint: An evidence overview. J Eval Clin Pract 2020; 26:927-956. [PMID: 31318109 DOI: 10.1111/jep.13232] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 06/25/2019] [Accepted: 06/27/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chemical restraint (CR) (also known as rapid tranquilisation) is the forced (non-consenting) administration of medications to manage uncontrolled aggression, anxiety, or violence in people who are likely to cause harm to themselves or others. Our population of interest was adults with mental health disorders (with/without substance abuse). There has been a growing international movement over the past 22 years towards reducing/eliminating restrictive practices such as CR. It is appropriate to summarise the research that has been published over this time, identify trends and gaps in knowledge, and highlight areas for new research to inform practice. AIMS To undertake a comprehensive systematic search to identify, and describe, the volume and nature of primary international research into CR published since 1995. METHODS This paper reports the processes and overall findings of a systematic search for all available primary research on CR published between 1 January 1996 and 31 July 2018. It describes the current evidence base by hierarchy of evidence, country (ies) producing the research, CR definitions, study purpose, and outcome measures. RESULTS This review identified 311 relevant primary studies (21 RCTs; 46 non-controlled experimental or prospective observational studies; 77 cross-sectional studies; 69 retrospective studies; 67 opinion pieces, position or policy statements; and 31 qualitative studies). The USA, UK, and Australia contributed over half the research, whilst cross-country collaborations comprised 6% of it. The most common research settings comprised acute psychiatric wards (23.3%), general psychiatric wards (21.6%), and general hospital emergency departments (19.0%). DISCUSSION A key lesson learnt whilst compiling this database of research into CR was to ensure that all papers described non-consenting administration of medications to manage adults with uncontrolled aggression, anxiety, or violence. There were tensions in the literature between using effective CR without producing adverse events, and how to decide when CR was needed (compared with choosing non-chemical intervention for behavioural emergencies), respecting patients' dignity whilst safeguarding their safety, and preserving safe workplaces for staff, and care environments for other patients. The range of outcome measures suggests opportunities to standardise future research.
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Affiliation(s)
- Eimear Muir-Cochrane
- College of Nursing and Health Sciences, Flinders University, South Australia, Australia, 5042
| | - Candice Oster
- On-Line Education and Development, Flinders Human Behaviour and Health Research Unit (FHBHRU), College of Medicine and Public Health, Flinders University, South Australia, Australia, 5042
| | - Karen Grimmer
- College of Nursing and Health Sciences, Flinders University, South Australia, Australia, 5042.,Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Connor M, Armbruster M, Hurley K, Lee E, Chen B, Doering L. Diagnostic Sensitivity of the Dynamic Appraisal of Situational Aggression to Predict Violence and Aggression by Behavioral Health Patients in the Emergency Department. J Emerg Nurs 2020; 46:302-309. [DOI: 10.1016/j.jen.2019.12.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 11/20/2019] [Accepted: 12/03/2019] [Indexed: 10/25/2022]
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Page CB, Parker LE, Rashford SJ, Kulawickrama S, Isoardi KZ, Isbister GK. Prospective study of the safety and effectiveness of droperidol in elderly patients for pre-hospital acute behavioural disturbance. Emerg Med Australas 2020; 32:731-736. [PMID: 32216048 DOI: 10.1111/1742-6723.13496] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 02/06/2020] [Accepted: 02/19/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Acute behavioural disturbance in the elderly (≥65 years) is a significant issue for emergency medical services with increasing prevalence of dementia and aging populations. We investigated the pre-hospital safety and effectiveness of droperidol in the elderly with acute behavioural disturbance. METHODS This was a pre-hospital prospective observational 1-year study of elderly patients with acute behavioural disturbance. The primary outcome was proportion of adverse events (AEs) (airway intervention, oxygen saturation <90% and/or respiratory rate <12/min, systolic blood pressure <90 mmHg, sedation assessment tool score of -3 and dystonic reactions). Secondary outcomes included time to sedation, additional sedation, proportion with successful sedation. RESULTS There were 149 patients (males 78 [52%], median age 78 years; 65-101 years) presenting on 162 occasions. Dementia was the commonest cause (107/164 [65%]) of acute behavioural disturbance. There were six AEs in five patients (5/162 [3%]; 95% confidence interval 1-7). Three had hypotension, one with associated hypoxia (80%); and two had respiratory AEs (respiratory rate, 10/min [no hypoxia] and hypoxia [88%] which required oxygen). Median time to sedation was 19 min (interquartile range 12-29 min). Additional sedation was given in 2/162 patients during ambulance transfer and 16/162 within an hour of hospital arrival; 24/162 (15%) failed to sedate in the ambulance; 16 subsequently settled in ED and 8/24 received additional sedation. Of 162, 123 (76%) patients successfully sedated, without AEs or additional sedation. Of 162, 114 (70%) patients received 5 mg, 46 (29%) received two doses of 5 mg and two patients (1%) received three doses. CONCLUSIONS Droperidol appeared to be safe and effective for pre-hospital sedation of acute behavioural disturbance in elderly patients.
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Affiliation(s)
- Colin B Page
- Clinical Toxicology Research Group, The University of Newcastle, Newcastle, New South Wales, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Clincial Toxicology Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | | | | | - Sanjeewa Kulawickrama
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,Faculty of Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Katherine Z Isoardi
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Clincial Toxicology Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Queensland Ambulance Service, Brisbane, Queensland, Australia
| | - Geoffrey K Isbister
- Clinical Toxicology Research Group, The University of Newcastle, Newcastle, New South Wales, Australia.,Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
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Sullivan N, Chen C, Siegel R, Ma Y, Pourmand A, Montano N, Meltzer A. Ketamine for emergency sedation of agitated patients: A systematic review and meta-analysis. Am J Emerg Med 2020; 38:655-661. [DOI: 10.1016/j.ajem.2019.11.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 11/01/2019] [Accepted: 11/03/2019] [Indexed: 12/28/2022] Open
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Larson LA, Finley JL, Gross TL, McKay AK, Moenck JM, Severson MA, Clements CM. Using a Potentially Aggressive/Violent Patient Huddle to Improve Health Care Safety. Jt Comm J Qual Patient Saf 2019; 45:74-80. [PMID: 30638871 DOI: 10.1016/j.jcjq.2018.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 08/28/2018] [Accepted: 08/28/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Unexpected situations of workplace violence are occurring in the United States at increasing rates in health care environments, warranting increased attention to processes supporting safety for health care workers. At a large, academic hospital, two patient safety incidents had occurred in a two-year period in which a patient had become violent at the time of admission from the emergency department (ED) to the medical unit. METHODS A multidisciplinary quality improvement (QI) team was formed to address the risk of violent patient events. Using two iterative Plan-Do-Study-Act (PDSA) cycles, the QI team designed and tested a huddle handoff communication tool, the Potentially Aggressive/Violent Huddle Form. An ED nurse would initiate the huddle process by informing the admitting unit that a patient at risk for violence was being admitted. The admitting care team would then call the ED team so that both teams participated in the handoff call together. The huddle process occurred for 21 transfers in the first PDSA cycle and for 18 transfers in the second. RESULTS RNs from the ED and the six medical units reported feeling safe during the transfer process 100% of the time during both tests of change PDSAs (vs. 54.7% at baseline). In the ED, from the first test of change to the second test of change, satisfaction with the process improved from 53.3% to 75.0%. CONCLUSION The huddle handoff communication tool and other methods to facilitate the transfer of potentially violent patients have the potential to decrease the number and severity of violent incidents in the health care workplace.
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Acute Agitation as an Initial Manifestation of Neuro-Behçet's Disease. Case Rep Emerg Med 2018; 2018:5437027. [PMID: 30631606 PMCID: PMC6304506 DOI: 10.1155/2018/5437027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 10/21/2018] [Indexed: 11/21/2022] Open
Abstract
Managing acutely agitated or violent patients in the emergency department (ED) represents a significant challenge. Acute agitation as an initial manifestation of neuro-Behcet's disease (NBD) is an extremely rare clinical entity. A 44-year-old male, who had been complaining about a severe headache and fever for several days, was admitted to our ED due to acutely presented incontinence and agitation. On admission, physical restraint and sedation with sevoflurane and propofol were required for his combative and violent behavior. Cerebrospinal fluid examination revealed increased cell count. Fluid attenuated inversion recovery magnetic resonance imaging showed a high intensity signal in the left parietal lobe and bilateral occipital lobe. As infectious meningoencephalitis was suspected, empirical therapy was immediately started. He recovered uneventfully without neurological defect in seven days. Based on positive human leukocyte antigen B-51 and clinical manifestations, the diagnosis of NBD was made and remitted by steroid therapy. Although acute NBD commonly presents with focal neurological symptoms, psychiatric symptoms could be considered the first manifestation. A focused and thorough examination coupled with appropriate management strategies can assist emergency clinicians safely and effectively manage these patients.
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