1
|
Chokroverty L. Management of Psychiatric Emergencies Among Migrant Youth in Institutional and Community Settings. Child Adolesc Psychiatr Clin N Am 2024; 33:219-236. [PMID: 38395507 DOI: 10.1016/j.chc.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Migrant youth commonly access mental health care for the first time during emergencies, rather than through ambulatory means. Suicidal behaviors may occur more often among migrants than nonmigrant youth, and they may suffer from post-traumatic stress, depression, anxiety, and display disruptive behaviors more frequently than their nonmigrant counterparts. Brief emergency interventions include safety planning, psychoeducation, parent training on communication and establishing routines, and behavioral therapies like activity scheduling and sleep hygiene.
Collapse
Affiliation(s)
- Linda Chokroverty
- Department of Psychiatry and Behavioral Sciences, Montefiore Health Systems/ Albert Einstein College of Medicine, Bronx, NY, USA; Department of Pediatrics, Montefiore Health Systems/ Albert Einstein College of Medicine, Bronx, NY, USA.
| |
Collapse
|
2
|
|
3
|
Bilici R, Sercan M, Izci F. Levels of the Staff's Exposure to Violence at Locked Psychiatric Clinics: A Comparison by Occupational Groups. Issues Ment Health Nurs 2016; 37:501-6. [PMID: 27104294 DOI: 10.3109/01612840.2016.1162883] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This study explored the rates of exposure to violence among physicians, nurses, and other health care staff members working at the locked psychiatric clinics, to examine the quantity and types of violence exposed, and to compare occupational groups by the level of exposure to violence. In parallel with the existing literature, the present study supports the proposition that physicians and nurses working at psychiatric units represent a risky group in terms of exposure to violence. The survey found that 87.6% of staff members viewed security measures insufficient. It is considered by the authors that preventive actions should be taken to reduce the risk of exposure to violence against the staff members working at the locked psychiatric clinics.
Collapse
Affiliation(s)
- Rabia Bilici
- b Erenkoy Mental Health Training and Research Hospital , Department of Psychiatry , Istanbul , Turkey
| | - Mustafa Sercan
- c Abant Izzet Baysal University , School of Medicine, Department of Psychiatry , Bolu , Turkey
| | - Filiz Izci
- a Istanbul Bilim University , School of Medicine, Department of Psychiatry , Istanbul , Turkey
| |
Collapse
|
4
|
Garriga M, Pacchiarotti I, Kasper S, Zeller SL, Allen MH, Vázquez G, Baldaçara L, San L, McAllister-Williams RH, Fountoulakis KN, Courtet P, Naber D, Chan EW, Fagiolini A, Möller HJ, Grunze H, Llorca PM, Jaffe RL, Yatham LN, Hidalgo-Mazzei D, Passamar M, Messer T, Bernardo M, Vieta E. Assessment and management of agitation in psychiatry: Expert consensus. World J Biol Psychiatry 2016; 17:86-128. [PMID: 26912127 DOI: 10.3109/15622975.2015.1132007] [Citation(s) in RCA: 135] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Psychomotor agitation is associated with different psychiatric conditions and represents an important issue in psychiatry. Current recommendations on agitation in psychiatry are not univocal. Actually, an improper assessment and management may result in unnecessary coercive or sedative treatments. A thorough and balanced review plus an expert consensus can guide assessment and treatment decisions. METHODS An expert task force iteratively developed consensus using the Delphi method. Initial survey items were based on systematic review of the literature. Subsequent surveys included new, re-worded or re-rated items. RESULTS Out of 2175 papers assessing psychomotor agitation, 124 were included in the review. Each component was assigned a level of evidence. Integrating the evidence and the experience of the task force members, a consensus was reached on 22 statements on this topic. CONCLUSIONS Recommendations on the assessment of agitation emphasise the importance of identifying any possible medical cause. For its management, experts agreed in considering verbal de-escalation and environmental modification techniques as first choice, considering physical restraint as a last resort strategy. Regarding pharmacological treatment, the "ideal" medication should calm without over-sedate. Generally, oral or inhaled formulations should be preferred over i.m. routes in mildly agitated patients. Intravenous treatments should be avoided.
Collapse
Affiliation(s)
- Marina Garriga
- a Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clinic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
- b Barcelona Clinic Schizophrenia Unit (BCSU), Institute of Neuroscience, Hospital Clinic of Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
| | - Isabella Pacchiarotti
- a Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clinic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
| | - Siegfried Kasper
- c Department of Psychiatry and Psychotherapy , Medical University of Vienna , Vienna , Austria
| | | | - Michael H Allen
- e University of Colorado Depression Center , Denver , CO 80045 , USA
| | - Gustavo Vázquez
- f Research Center for Neuroscience and Neuropsychology, Department of Neuroscience , University of Palermo , Buenos Aires , Argentina
| | | | - Luis San
- h CIBERSAM, Parc Sanitari Sant Joan De Déu , Barcelona , Catalonia , Spain
| | - R Hamish McAllister-Williams
- i Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK; Northumberland Tyne and Wear NHS Foundation Trust , Newcastle upon Tyne , UK
| | - Konstantinos N Fountoulakis
- j 3rd Department of Psychiatry, School of Medicine , Aristotle University of Thessaloniki , Thessaloniki , Greece
| | - Philippe Courtet
- k Department of Emergency Psychiatry and Post Acute Care , Hôpital Lapeyronie , CHU Montpellier , France
| | - Dieter Naber
- l Department for Psychiatry and Psychotherapy , University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - Esther W Chan
- m Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine , the University of Hong Kong , Hong Kong , China
| | - Andrea Fagiolini
- n School of Medicine, Department of Molecular Medicine , University of Siena , Siena , Italy
| | - Hans Jürgen Möller
- o Department of Psychiatry and Psychotherapy , Ludwig Maximilian University , Munich , Germany
| | - Heinz Grunze
- p Paracelsus Medical University , Salzburg , Austria
| | - Pierre Michel Llorca
- q Service De Psychiatrie B , CHU De Clermont-Ferrand , Clermont-Ferrand , France
| | | | - Lakshmi N Yatham
- s Mood Disorders Centre, Department of Psychiatry , University of British Columbia , Vancouver , British Columbia , Canada
| | - Diego Hidalgo-Mazzei
- a Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clinic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
| | - Marc Passamar
- t Centre Hospitalier Pierre-Jamet, SAUS , Albi , France
| | - Thomas Messer
- u Danuvius Klinik GmbH, Pfaffenhofen an Der Ilm , Germany
| | - Miquel Bernardo
- b Barcelona Clinic Schizophrenia Unit (BCSU), Institute of Neuroscience, Hospital Clinic of Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
| | - Eduard Vieta
- a Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clinic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
| |
Collapse
|
5
|
Cheh RM, Selby PR, Abarno AC, Alderman CP. Outcomes of Pharmacological Management of Violent Behavioural Disturbances in Older Hospital Patients. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2010.tb00535.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Rachael M Cheh
- Quality Use of Medicines and Pharmacy Research Centre; University of South Australia; Adelaide South Australia
| | - Philip R Selby
- Quality Use of Medicines and Pharmacy Research Centre; University of South Australia; Adelaide South Australia
| | - Anita C Abarno
- Quality Use of Medicines and Pharmacy Research Centre; University of South Australia; Adelaide South Australia
| | - Christopher P Alderman
- Quality Use of Medicines and Pharmacy Research Centre; University of South Australia; Adelaide South Australia
| |
Collapse
|
6
|
Chan EW, Knott JC, Liew D, Taylor DM, Kong DCM. Cost-Minimisation Analysis of Midazolam versus Droperidol for Acute Agitation in the Emergency Department. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2012.tb00123.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Esther W Chan
- Centre for Medicine Use and Safety, Department of Pharmacology and Pharmacy; Monash University, University of Hong Kong
| | | | - Danny Liew
- Centre for Clinical Epidemiology, Biostatistics and Health Services Research; The University of Melbourne, The Royal Melbourne Hospital
| | | | - David CM Kong
- Centre for Medicine Use and Safety; Monash University; Parkville Victoria
| |
Collapse
|
7
|
Chan EW, Knott JC, Taylor DM, Kong DCM. Intravenous Olanzapine for Acute Agitation in the Emergency Department. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2011.tb00681.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Esther W Chan
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences; Monash University, and Department of Emergency Medicine, Austin Health
| | | | | | - David CM Kong
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences; Monash University; Parkville Victoria
| |
Collapse
|
8
|
Chan EW, Taylor DM, Knott JC, Phillips GA, Castle DJ, Kong DC. Intravenous Droperidol or Olanzapine as an Adjunct to Midazolam for the Acutely Agitated Patient: A Multicenter, Randomized, Double-Blind, Placebo-Controlled Clinical Trial. Ann Emerg Med 2013; 61:72-81. [DOI: 10.1016/j.annemergmed.2012.07.118] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 07/19/2012] [Accepted: 07/24/2012] [Indexed: 11/15/2022]
|
9
|
Chan EW, Taylor DM, Knott JC, Liew D, Kong DCM. The pharmacoeconomics of managing acute agitation in the emergency department: what do we know and how do we approach it? Expert Rev Pharmacoecon Outcomes Res 2012. [PMID: 23186399 DOI: 10.1586/erp.12.53] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The emergency department (ED) is commonly the first point of care for patients with acute behavioral issues from the community. Routinely, clinical management involves the use of benzodiazepine and/or antipsychotic drugs, when initial de-escalation strategies fail. There is currently scant literature available to inform the clinical management and resource utilization of acute agitation in the ED. This article discusses the approach to pharmacoeconomic studies of acute agitation management in the ED. It explores the conduct of such evaluations and highlights the cost and data sources required. The current difficulties experienced in conducting such evaluations are also discussed. Pharmacoeconomic studies related to the management of acute agitation in ED can be challenging. Robust clinical trials incorporating prospectively designed pharmacoeconomic studies will invariably contribute toward a better understanding of this therapeutic area and optimize the use of scarce resources.
Collapse
Affiliation(s)
- Esther W Chan
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 2/F Laboratory Block, 21 Sassoon Road, Pokfulam, Hong Kong
| | | | | | | | | |
Collapse
|
10
|
Isaksson U, Åström S, Graneheim UH. Being flexible and tuning in: professional caregivers' reflections on management of violent behaviour in nursing homes. Int J Older People Nurs 2012; 8:290-8. [PMID: 23051603 DOI: 10.1111/opn.12005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Accepted: 07/09/2012] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES This qualitative, descriptive study aimed to illuminate professional caregivers' reflections on managing residents' violent behaviour in nursing homes. BACKGROUND Violence towards caregivers in the care of older people is a challenge attracting increasing attention in nursing research. However, studies that focus on the approaches caregivers in nursing homes resort to and how they manage everyday care situations involving threats and violent situations are relatively few. METHODS The study was based on 41 interviews in which the caregivers reflected on their own courses of action in violent situations. The interviews were subjected to qualitative content analysis. RESULTS This study showed that caregivers were flexible and in tune with the resident by averting and defusing threatening and violent situations. The caregivers tried to give care in line with the residents' condition, control their own spontaneous reactions and interpret the residents' reactions as communicative signs indicating how they should interact with the resident in the situation. As a last resort, when previous approaches had been unsuccessful, the caregivers took a firm stand, confronted the resident and the violent behaviour more directly, but with respect and with the residents' best interests in mind. CONCLUSIONS These findings illuminate how caregivers successfully can manage threatening and violent behavior in nursing homes by being flexible and tuning in with the resident but also by taking a firm stand with the residents' best interests in mind. To be flexible and in tune with residents, it is important to know the residents' personal histories. This may mean involving stakeholders, such as family members and friends, in the care of residents with violent behaviour. IMPLICATIONS FOR PRACTICE We believe that it is important to involve stakeholders in the care of threatening and violent residents in nursing homes as it is important to get information on the residents' personal history. However, there are risks when interpreting residents' behaviour in light of their personal histories as relatives experiences may be subjective and the information may give the caregivers preconceived ideas about the resident.
Collapse
Affiliation(s)
- Ulf Isaksson
- Department of Nursing, Umeå University, Umeå, Sweden
| | | | | |
Collapse
|
11
|
Wilson MP, Pepper D, Currier GW, Holloman GH, Feifel D. The psychopharmacology of agitation: consensus statement of the american association for emergency psychiatry project Beta psychopharmacology workgroup. West J Emerg Med 2012; 13:26-34. [PMID: 22461918 PMCID: PMC3298219 DOI: 10.5811/westjem.2011.9.6866] [Citation(s) in RCA: 221] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 09/07/2011] [Accepted: 09/21/2011] [Indexed: 11/11/2022] Open
Abstract
Agitation is common in the medical and psychiatric emergency department, and appropriate management of agitation is a core competency for emergency clinicians. In this article, the authors review the use of a variety of first-generation antipsychotic drugs, second-generation antipsychotic drugs, and benzodiazepines for treatment of acute agitation, and propose specific guidelines for treatment of agitation associated with a variety of conditions, including acute intoxication, psychiatric illness, delirium, and multiple or idiopathic causes. Pharmacologic treatment of agitation should be based on an assessment of the most likely cause of the agitation. If agitation results from a delirium or other medical condition, clinicians should first attempt to treat the underlying cause instead of simply medicating with antipsychotics or benzodiazepines.
Collapse
Affiliation(s)
- Michael P Wilson
- UC San Diego Health System, Department of Emergency Medicine, San Diego, California
| | - David Pepper
- Hartford Hospital/Institute of Living, Department of Psychiatry, Hartford, Connecticut
| | - Glenn W Currier
- University of Rochester Medical Center, Departments of Psychiatry and Emergency Medicine, Rochester, New York
| | - Garland H Holloman
- University of Mississippi Medical Center, Department of Psychiatry, Jackson, Mississippi
| | - David Feifel
- UC San Diego Health System, Department of Psychiatry, San Diego, California
| |
Collapse
|
12
|
Chan EW, Taylor DM, Knott JC, Kong DCM. Variation in the management of hypothetical cases of acute agitation in Australasian emergency departments. Emerg Med Australas 2010; 23:23-32. [PMID: 21091874 DOI: 10.1111/j.1742-6723.2010.01348.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe the prescribing practice of emergency medicine clinicians in the management of highly agitated patients and to identify perceived barriers to management and the gaps in training. METHOD We undertook an anonymous cross-sectional mail survey of the Australasian College for Emergency Medicine (ACEM) members (fellows and advanced trainees) between June and September 2009. A questionnaire including a case vignette of a hypothetical patient and three clinical scenarios was employed to ascertain prescribing practice and assess perceived barriers to management, confidence and the perceived usefulness of existing and future Clinical Practice Guidelines (CPGs). RESULTS All 2052 ACEM members were surveyed. However, seven had incorrect postal addresses and could not be reached. Of the remaining 2045, 786/2052 (38.3%, 95% CI 36.2-40.5) responses were received. Of the 786 respondents, 783 were practicing clinicians. If monotherapy was chosen, 622/783 (79.4%, 95% CI 76.4-82.2) of respondents preferred midazolam to manage the common scenario where no history was available, followed by haloperidol 45/783 (5.8%, 95% CI 4.3-7.7) and olanzapine 38/783 (4.9%, 95% CI 3.5-6.7). Most respondents 500/783 (63.9%, 95% CI 60.4-67.2) would also administer another sedative (combination therapy). Important perceived barriers to agitation management included lack of both training (352/783 [45.0%, 95% CI 41.4-48.5]) and a national CPG (313/783 [40.0%, 95% CI 36.5-43.5]). Respondents were generally confident in all aspects of management, although relatively fewer trainees were confident in determining dosing. Institutional CPGs were considered most useful for 415/783 (53.0%, 95% CI 49.4-56.5) respondents. If an ACEM-endorsed CPG were to be developed in the future, 634/783 (81.0%, 95% CI 78.0-83.6) respondents would consider this useful. CONCLUSION There is considerable variation in the management of hypothetical cases of acute agitation in Australasian EDs. Benzodiazepines and antipsychotics, either alone or in combination, are commonly used. An ACEM-endorsed, Australasian CPG was perceived as useful.
Collapse
Affiliation(s)
- Esther W Chan
- Department of Pharmacy Practice, Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, VIC 3052, Australia
| | | | | | | |
Collapse
|
13
|
|
14
|
Thomas P, Alptekin K, Gheorghe M, Mauri M, Olivares JM, Riedel M. Management of patients presenting with acute psychotic episodes of schizophrenia. CNS Drugs 2009; 23:193-212. [PMID: 19320529 DOI: 10.2165/00023210-200923030-00002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The initial management of patients with schizophrenia presenting to psychiatric emergency departments with an acute psychotic episode requires rapid decisions to be made by physicians concerning the treatment of individuals who are likely to be relatively uncooperative, agitated and lacking insight. The treatment decision must be adapted to the individual characteristics and needs of each patient. This article reviews the issues from the perspective of the initial management of acute psychosis as it is currently practised in Europe, and discusses the pragmatic implications for initial treatment decisions and the elaboration of a long-term treatment plan. Initially, administration of antipsychotics to control psychotic symptoms and benzodiazepines to control agitation represents the cornerstone of treatment. Oral medication is preferable to injectable forms wherever possible, and atypical antipsychotics are to be preferred over conventional agents because of their lower risk of extrapyramidal adverse effects, which are a major determinant of poor adherence to treatment. Whatever antipsychotic is chosen by the physician during the initial period, it is likely that it will need to be continued for many years, and it is thus important to take into account the long-term safety profile of the drug chosen, particularly in relation to extrapyramidal adverse effects, metabolic complications and quality of life. Building a therapeutic alliance with the patient and his/her family or carers is an important element that should be included in the initial management of psychosis. The long-term goal should be to minimize the risk of psychotic relapse through adequate treatment adherence.
Collapse
Affiliation(s)
- Pierre Thomas
- Department of Psychiatry, University of Lille Medical School, Lille, France.
| | | | | | | | | | | |
Collapse
|
15
|
|
16
|
Children's mental health emergencies-part 3: special situations: child maltreatment, violence, and response to disasters. Pediatr Emerg Care 2008; 24:569-77. [PMID: 18708906 DOI: 10.1097/pec.0b013e318180fef2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Children may be exposed to or even be the victims of a violent situation, or a disaster, and the likelihood of a child's exposure to a violent situation or a disaster is increasing. METHODS A review of the literature was done to address key mental health issues occurring with child maltreatment, violence in the home, community, in the emergency department, and disasters. RESULTS Although pediatric mental health issues regarding violence, disasters, and child maltreatment have often been overlooked or unrecognized, the consequences for the child in such situations can be devastating. However, recognition and appropriate treatment can favorably impact the child's recovery from exposure to such violent events or disasters. CONCLUSIONS Recognition and early intervention to address the mental health issues of children in violent situations or disasters can help ameliorate the negative psychological sequelae of such events. The importance of providing mental health and social services to children exposed to disasters was recognized by the Pediatric Institute of Medicine Report.
Collapse
|
17
|
Tarzian AJ, Marco CA. Responding to Abusive Patients: A Primer for Ethics Committee Members. HEC Forum 2008; 20:127-36. [DOI: 10.1007/s10730-008-9066-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
18
|
Kim M, Hennes H. Prehospital Evaluation and Management of Violent or Agitated Children. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2007. [DOI: 10.1016/j.cpem.2007.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
19
|
Knott JC, Bennett D, Rawet J, Taylor DM. Epidemiology of unarmed threats in the emergency department. Emerg Med Australas 2006; 17:351-8. [PMID: 16091097 DOI: 10.1111/j.1742-6723.2005.00756.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the precipitants, subject characteristics, nature and outcomes of unarmed threats in the ED. METHODS A 12 month prospective survey of security codes precipitated by an unarmed threat (Code Grey). RESULTS Data were collected on 151 subjects. The Code Grey rate was 3.2/1000 ED presentations. They were most frequent on Saturday and in the late evening/early morning. There were verbal or physical threats of violence made to staff on 104 occasions (69%, 95% confidence interval [CI] 61-76) and a perceived threat of patient self-harm on 114 occasions (76%, 95% CI 68-82). Median time to be seen by a doctor was 8 min (interquartile range [IQR]: 2-21 min) and median time from presentation to Code was 59 min (IQR: 5-222 min). Sixteen subjects (11%, 95% CI 6-17) had a history of violence, 45 (30%, 95% CI 23-38) were affected by alcohol, 25 (17%, 95% CI 11-24) had used illicit drugs and 79 (52%, 95% CI 44-60) had a significant mental illness contributing to the Code Grey. Seventy-one patients (47%, 95% CI 39-55) required psychiatric admission, 49 (79%, 95% CI 66-88) involuntarily. CONCLUSION Acutely agitated subjects pose a threat to themselves and the staff caring for them. The reason for the agitation is multifactorial and the majority arrive in a behaviourally disturbed state requiring early intervention. The times most likely to result in a Code Grey coincide with least available resources: ED and hospital risk management policies must account for this. A coherent approach by ED to this population is required to optimize patient and staff outcomes.
Collapse
Affiliation(s)
- Jonathan C Knott
- Emergency Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia.
| | | | | | | |
Collapse
|
20
|
Jiménez Busselo MT, Aragó Domingo J, Nuño Ballesteros A, Loño Capote J, Ochando Perales G. [Management of agitated, violent or psychotic patients in the emergency department: an overdue protocol for an increasing problem]. An Pediatr (Barc) 2005; 63:526-36. [PMID: 16324619 DOI: 10.1016/s1695-4033(05)70253-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Patients with extreme agitation, delirium, violent behavior or acute psychosis are frequently evaluated in the emergency departments of general hospitals. However, the traditional infrequency of this type of situation in pediatric emergency services can lead to a certain lack of foresight and efficiency in the initial management of these patients. Because of the current known increase of psychosocial disorders in pediatric emergencies, new pharmacological treatments for juvenile psychotic processes, and particularly the lack of compliance with these treatments, as well as the earlier consumption of ever more varied illicit drugs among young people, the frequency and diversity of this kind of disorder is on the increase. The treatment of agitation, aggression and violence begins with successful management of the acute episode, followed by strategies designed to reduce the intensity and frequency of subsequent episodes. The key to safety is early intervention to prevent progression from agitation to aggression and violence. Consequently, urgent measures designed to inhibit agitation should be adopted without delay by the staff initially dealing with the patient, usually in the emergency unit. Patients with psychomotor agitation disorder (PMAD) may require emergency physical and/or chemical restraints for their own safety and that of the healthcare provider in order to prevent harmful clinical sequelae and to expedite medical evaluation to determine the cause. However, the risks of restraint measures must be weighed against the benefits in each case. This review aims to present the emergency measures to be taken in children with PMAD. The distinct etiological situations and criteria for the choice of drugs for chemical restraint in each situation, as well as the complications associated with certain drugs, are discussed. It is advisable, therefore, that health professionals become familiar with the distinct pharmacological options.
Collapse
Affiliation(s)
- M T Jiménez Busselo
- Area de Urgencias de Pediatría, Hospital Infantil Universitario La Fe, Valencia, Spain.
| | | | | | | | | |
Collapse
|
21
|
Marco CA, Vaughan J. Emergency management of agitation in schizophrenia. Am J Emerg Med 2005; 23:767-76. [PMID: 16182986 DOI: 10.1016/j.ajem.2005.02.050] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2005] [Revised: 02/20/2005] [Accepted: 02/25/2005] [Indexed: 10/25/2022] Open
Abstract
Schizophrenia is a common psychiatric condition, affecting approximately 1% of the population. Acute emergent presentations often include hallucinations, delusions, thought, and speech disorders. Agitation is common among emergency patients with schizophrenia. Decisional capacity should be assessed in all patients. Reversible causes of agitation should be ruled out, including infection, metabolic disorders, endocrine disorders, trauma, pain, noncompliance, toxicological disorders, and structural brain abnormalities. Agitation may be managed acutely using a combination of pharmacological agents and nonpharmacological interventions. Effective pharmacological agents include several classes of antipsychotic agents and benzodiazepines. Potential life-threatening complications of pharmacological therapy should be anticipated, which may include neuroleptic malignant syndrome (NMS), prolonged QT syndrome, and respiratory depression. Nonpharmacological interventions may include a quiet environment, physical restraints, and behavioral interventions. Disposition decisions should be made based on the etiology of agitation, effective management, decisional capacity, and presence of suicidal or homicidal intentions. Many patients who have required nonpharmacological or pharmacological management of agitation require inpatient psychiatric treatment, either voluntarily or involuntarily. Psychiatric consultation should be sought for patients with schizophrenia and uncertain disposition determinations, or those requiring other complex management decisions.
Collapse
Affiliation(s)
- Catherine A Marco
- Department of Emergency Medicine, St Vincent Mercy Medical Center, Toledo, OH 43608-2691, USA.
| | | |
Collapse
|
22
|
Abstract
Violence in the work place is a new but growing problem for our profession. It is likely that at some point a psychiatrist will be confronted with a potentially violent patient or need to assess a violent patient. Understanding predictors and associated factors in violence as well as having a clear and well-defined strategy in approaching and dealing with the violent patient, thus, are crucial. Ensuring patient, staff, and personal safety is the most important aspect in the management of a violent patient. All of the staff must be familiar with management strategies and clear guidelines that are implemented and followed when confronted with a violent patient. The more structured the approach to the violent patient, the less likely a bad outcome will occur. Manipulating one's work environment to maximize safety and understanding how to de-escalate potentially mounting violence are two steps in the approach to the violent patient. Restraint, seclusion, and psychopharmacologic interventions also are important and often are necessary components to the management of the violent patient.
Collapse
Affiliation(s)
- Jorge R Petit
- Bureau of Program Services, The New York City Department of Health and Mental Hygiene, New York, NY 10013, USA.
| |
Collapse
|
23
|
Sorrentino A. Chemical restraints for the agitated, violent, or psychotic pediatric patient in the emergency department: controversies and recommendations. Curr Opin Pediatr 2004; 16:201-5. [PMID: 15021203 DOI: 10.1097/00008480-200404000-00016] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Chemical restraint in the pediatric patient is an evolving clinical practice. Although a rare occurrence, chemically restraining a child may be necessary for the child's safety, healthcare worker's safety, and to expedite the medical evaluation. The purpose of this manuscript to review the definition and indications for chemical restraints, specific classes of drugs used for chemical restraints, and the legal implications associated with chemical restraints. RECENT FINDINGS Three classes of drugs will be reviewed: benzodiazepines, neuroleptics, and atypical antipsychotics, including side effects, dosages, and routes of administration. There are controversies surrounding some of these drugs. Very few recent studies have focused this topic on the pediatric patient. A recently published practice parameter will be reviewed that addresses the prevention and management of aggressive behavior in children and adolescents. In addition, specific studies looking at different drugs, particularly the newer atypical antipsychotics, will be reviewed. Literature discussing the controversies regarding droperidol usage in the emergency department will also be highlighted. SUMMARY The differential diagnosis for the agitated, violent, or psychotic patient is extensive and must be taken into consideration when deciding to use chemical restraints. When the decision is made to use chemical restraints, healthcare workers should be aware of the pharmacologic options as well as the complications associated with the agents.
Collapse
Affiliation(s)
- Annalise Sorrentino
- Department of Pediatrics, University of Alabama School of Medicine, Birmingham, Alabama 35233, USA.
| |
Collapse
|
24
|
Affiliation(s)
- Douglas F Kupas
- Department of Emergency Medicine, Geisinger Medical Center, Danville, Pennsylvania 17822-2005, USA. dkupas@geisinger,edu
| | | |
Collapse
|