7. Case
13 year-old autistic male here for
surgical repair of pectus, now yelling,
throwing things at nurses
8. Initial Approach To The
Agitated/Assaultive Patient
Call security
Assess Environment, Physical demeanor
Take verbal threats seriously
Remain several feet away
Know where the patient is at all times
Clear the area of other patients
Remain calm, maintain confident and
competent demeanor
Avoid arguing with staff in front of patient
Restraints
10. CHEMICAL RESTRAINT
Involuntary use of psychoactive
medication in a crisis situation to help
a patient contain out-of-control
aggressive behavior
Necessary for safety of patient and
staff when other methods of calming
are inappropriate or not successful
Parental consent not required due to
emergent circumstances
IM/IV/PO 8
11. Symptom Focused Treatment
With Medication
Treatment provided with the consent
of the patient’s legal guardian and the
age-appropriate assent of the child
Usually PO
9
12. Characteristics of Ideal Medication
Used for Acute Aggression
Rapid onset
Medium-long duration
Multiple formulations
Low interaction with other
medications
Low adverse reactions
Broad anti-aggressive property
23. Neuroleptic Malignant Syndrome
(NMS)
Idiosyncratic response to anti-
psychotics
Have been reported with all types of
antipsychotics, including atypicals
Prevalence - 0.07-0.2%
5-30% mortality
Can occur within hours of the first
dose but usually 4-14 days
Caused possibly by decreased
dopamine
28. Treatment
Stop antipsychotic
Consider other medical causes
Supportive care, IV hydration
Benzodiazepines (Ativan)
Dopamine agonists - Bromocriptine,
Levodopa
Muscular skeletal relaxant -
Dantrolene
29.
30. Case Example
16 year-old oncology patient recently
discharged from OICU after 4 month
stay now in clinic with psychosis,
agitation after being home for less
than a week. No personal or family
history of psychotic disorder.
31. Alcohol/Benzo Withdrawal
Can occur 12-24 hours after last drink
Tremor (“shakes”)
Tachycardia, diaphoresis, anorexia,
insomnia
Generalized seizures after 1-3 days
Delirium tremens after 3-5 days
Fever, disorientation, visual
hallucinations, autonomic instability,
agitation
Need to be monitored in ICU setting
32. Treatment
Thiamine to prevent Wernicke
Encephalopathy (confusion, ataxia,
ophthalmoplegia)
IV hydration
Electrolytes replacement
Benzodiazepines
Librium (25-50 mg PO PRN)
Lorazepam (1-2 mg PO PRN)
33. Delirium
Disturbance of consciousness (i.e.,
reduced clarity of awareness of the
environment)
Reduced ability to focus, sustain, or shift
attention.
A change in cognition (such as memory
deficit, disorientation, language
disturbance)
Development of a perceptual disturbance
The disturbance develops over a short
period of time (usually hours to days) and
tends to fluctuate during the course of the
day.
34. Treatment
Treatment of the underlying cause
Assessment of clinical status-harm to self
or others
Environmental manipulation (Calendar,
Newspaper, Blinds opened/closed
appropriately)
Restraints
Pharmacological
Antipsychotics
Haldol 0.5 – 5 mg po q6 prn (PO/IV/IM)
Risperidone 0.5 – 2.0 mg po q6 prn (PO/SL)
Benzodiazepines – not recommended
35. Treatment of Agitated Patient
Treat any underlying medical
pathology
Non-Pharmacological Interventions
Symptom Focused Treatment
Chemical Restraint
33
Notas do Editor
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Intoxication, withdrawals from substances\nPsychiatric disorders\nPersonality disorders\nEnvironmental factors\nMedical disorders\n
Intoxication, withdrawals from substances\nPsychiatric disorders\nPersonality disorders\nEnvironmental factors\nMedical disorders\n
