C.A.L.M. = Management of Agitated Patients in the Emergency Department
12/9/2015
Article Inspired by: Dr. Vincent Nguyen
THE CASES
- Young ~70kg male with 2 point restraints in a gurney, attempting to get over the handrails. EtOH level of 346 mg/dL.
- Middle-aged male brought in by NYPD after barricading himself in an apartment. He is talking nonstop about someone stealing all his belongings.
- Young make brought in handcuffs yelling racial insults at NYPD with BP noted to be 168/105 mmHg and HR of 136/min.
- 62 y/o M with known history of EtOH abuse who is standing naked next to his stretcher, tremulous, bleeding from his IV site (that he just removed) and urinating on the ground. BP of 156/92 mmHg and HR of 132/min.
THE TALK
Why would I use medical sedation?
- Acutely agitated patients pose a danger to the ED staff and to themselves.
- Even after physical restraints are applied, the patient may still struggle.
- Medical sedation allows the patient to become calm.
Which medications should I use?
Every physician has their “go-to” sedative, from single agent to combination therapies, using benzodiazepines, antipsychotics, antihistamines and even paralytics!
Here are a few examples when you ask ER docs about their preferred “takedown” medication:
- Ketamine 0.5-1 mg/kg IV
- Thiopental + succinylcholine (or rocuronium)
- Droperidol 5 – 10mg IV
- Droperidol 5mg IM
- Droperidol 5mg IM + midazolam 2mg IM
- Droperidol 5mg IM + midazolam 5mg IM
- Midazolam 2.5 – 5mg IV
- Midazolam 10mg IM
- Haloperidol
- Haloperidol + midazolam
- Haloperidol 5mg + lorazepam 4-8mg IV
- Haloperidol 5mg + lorazepam 2mg + diphenydramine 50mg IV
- Lorazepam 0.5 – 2mg PO
- Olanzepine 10mg PO
- Quetiapine
- Diazepam 10mg IV
- Diazepam 10mg IV + fentanyl 100mcg
REMEMBER: “One size does NOT fit all!” Patients are different. Their reason for agitation is different…their level of agitation varies…
Okay, what should I take into consideration when I choose medications?
- Type and Level of agitation
- Body size
- Age
- Medical history (e.g. drug dependence)
- Previous response to sedative drugs
What are some of the different types of agitation?
A brief clinical assessment can usually help you categorize the agitation into one of 4 groups:
- EtOH intoxication
- EtOH withdrawal
- Psychosis
- Stimulant/Undifferentiated
The key is to stay “C.A.L.M.” – it’s a mnemonic that’s easy to remember:
- Converse with patient
- Verbally engage the patient (frequently can be successful in <5 min)
- Establish a collaborative relationship (Offer food/drink or a chair)-
- Verbally de-escalate out of agitated state
- Respect personal space
- Do not be provocative
- Establish verbal contact
- Be concise
- Identify wants and feelings
- Listen closely to what the patient is saying
- Agree or agree to disagree
- Lay down the law and set clear limits
- Offer choices and optimism
- Debrief the patient and the staff
- Activate a team (treat the acutely agitated patient the same way you would a trauma notification)
- Minimum of 5 team members (preferably ED staff trained in handling behavioral problems)
- Overhead announcement (so team members know to go to the designated area)
- At least 1 team member should be female if the patient is female
- Team leader should clearly designate roles
- Team leader signals when to initiate contact
- DO NOT impair patient’s breathing (i.e. chest, neck or mouth)
- Explain to patient what is happening at all times
- Limits and Restraints
- Supine patient in 4-point restraints on a stretcher
- One arm up and one arm down
- Head of bed raised 30 degrees
- Medications
REMEMBER: An agitated patient doesn’t have to be “put to sleep.” They don’t have to “sleep it off” for 8 hours… Careful choice of medication can simply calm the patient, allowing for a meaningful exam, and disposition in a couple of hours.
What should I monitor after they are sedated?
- Pulse, RR
- Pulse Oximetry
- Blood Pressure
- Initial temperature should be recorded
- EKG (if patient is given a QT prolonging agent, especially if administered IV)
- Close monitoring of airway adequacy
- Neurovascular observations distal to restraints
- Remove restraints as soon as possible (start with one leg, then contralateral arm)
- Debrief patient when calm and explain what happened
TAKE HOME POINT:
Not all agitation is the same so … DON’T treat them all the same!
REFERENCES
Nguyen, V. “Conference: Chemical Sedation” Jacobi Medical Center. Jacobi/Montefiore Emergency Medicine Conference. Bronx. Dec 2015. Lecture
Lulla, Aditya Al, and Manpreet Singh. “The Art of the ED Takedown – FOAM EM RSS.” FOAM EM RSS, 04 Mar. 2015. Web.
Nickson, Chris. “Chemical Restraint.” Life in the Fast Lane, 7 Aug. 2014. Web.