Rural Emergency Medicine

Acutely agitated patients are uniquely challenging for Rural Hospitals who are often limited by the Health and Support Staff available. These patients can be at high risk of harm to themselves and others, if not managed carefully as several Coroner's cases in Australia have highlighted.

The major issues in assessment of the acutely agitated patient as outlined by the Consensus Statement on The Acutely Agitated Patient in a Remote Location are:
  1. Safety
  2. Medico-legal
  3. Medical assessment
  4. Mental health assessment
  5. Follow-up/Disposition

The objective of the initial evaluation is not a definitive diagnosis, but a differential diagnosis that informs immediate management of acutely agitate patient, so that more detailed evaluation, management and disposition are possible.

This is part of the Rural Emergency Module series (designed in particular for ACRRM Trainees).

Initial Assessment and Management

Recognition
  • Recognise, check for Danger and perform a Risk Assessment
  • Send for help, gather resources and appropriate equipment.
  • Move to appropriate area (e.g. quiet room, visible area, rooms with multiple exits, etc).
  • Monitoring if chemical sedation utilised prehospital: SpO2, HR, BP, Cardiac Monitoring, EtCO2
  • Consider whether this patient is voluntary vs involuntary.
  • Consider Telephysciatry Support and/or advice from Emergency/Anaesthetic Specialists
Provide Low Stimulus and a Calm Environment

Rapid ABCDE Assessment
Perform a Rapid ACBCE assessment in attempt to identify and manage easily reversible causes;
  • Assess for Hypoxia
  • Check for Hypoglycaemia
  • Provide analgesia for pain
  • Hunger/thirst (but keep in mind scenarios where fasting may be appropriate)
  • Empty bladder/bowels with adequate toileting
  • Nicotine addiction (offer nicotine replacement early)
  • Drug withdrawal 
Risk Assessment
  • Evaluate Safety for both the patient, clinician and others
  • Patient has weapons.
  • Previous History of Violence and/or Aggression
  • Intoxication / Drug Ingestion (e.g. Alcohol / Methamphetamine)
  • Known environmental stressors in last 7 days (personal loss, relationship crisis, financial crisis etc but excluding hospital admission.)
  • Previous sedative medication use
  • Past Medical History (see below)


Primary Assessment
When it is safe to do so (for both you and the patient) conduct a Primary Medical Assessment to ensure there are no other organic or immediately reversible causes for the patient's agitation.

 Again the patient may require chemical sedation before an initial assessment can be conducted.

 Airway:
  • Assess for airway patency (i.e. obstruction) and protection (decreased GCS)
Breathing:
  • Assess effort and efficacy of breathing, respiratory rate
  • Avoid hypoxia / hypercarbia which can predispose the patient towards agitation
  • Provide supplemental high flow oxygen as indicated, aim SpO2 >90%
Circulation:
  • Assess heart rate, blood pressure and capillary refill
  • ECG when safe to do so.
  • Gain IV Access when safe to do so
Disability:
  • Monitor patients level of consciousness and agitation (use of the Richmond Agitation-Sedation Score may be useful and allow for titration of medications). 
  • Check BSL + ketones
Exposure:
  • Check temperature
  • Check for signs of injury and/or infection

Mental Health Assessment
  • General appearance
  • Behaviour
  • Speech
  • Cooperativeness/level of insight
  • Specific thoughts of self harm or violence
  • Delusional ideation, hallucinations



History

Signs/symptoms
  • Seizure activity
  • Airway obstruction / compromise
  • Respiratory distress / hypoxia
  • Fevers
  • Features of Toxidromes
Allergies
Meds 
  • Antiepileptics
  • Antipsychotics, antidepressants,
  • Recreational drugs, drug withdrawal
PMHx:
  • Dementia
  • Acquired Brain Injury
  • Alcohol +/- drug abuse
  • Epilepsy
  • Mental Health
    • Schizophrenia
    • Bipolar Affective Disorder
  • Development Disorders: Intellectual Disability, Autism Spectrum Disorder
Last oral intake
  • Poison ingestion
Events
  • Events leading up to hospital presentation (e.g. Brought in by Police)

Investigations

Point of care
  • Blood Sugar Levels + Ketones
  • Arterial/Venous Blood Gas
  • Urine analysis and drug screen
  • ECG
Laboratory
  • FBC,  Urea and Electrolytes
  • Drug Levels
  • As available and indicated; B12/Folate, TFTs, ESR, CRP
Imaging (as indicated/available)
  • Bladder scan / Ultrasound
  • CXR
  • CT Head

Management

Verbal De-escalation

  • Find a calm and clear environment
  • Introduce self, explain your role.
  • Be emphatic, but direct in your language
  • Offer support; food, water, phone call
  • Utilise family, friends or social supports from the community
  • Assess responsiveness to verbal de-escalation

Physical Restraint

  • Call Security / Police / Support Staff - consider a show of force first
  • Use typically as an adjunct to Chemical Sedation.
  • Will normally require at least 5 people to hold down an individual safely. However in Rural settings may have insufficient staff to achieve this.
  • Formal restraints may required before, during and after chemical sedation to limit further harm to the patient and others.

Chemical Sedation

Queensland Health provide one of many algorithmic approaches to the acutely agitated patient which can be reviewed here -> QH-ASBD Algorithm. 

Monitoring
Use standard procedural sedation monitoring;
  • BP
  • ECG or Cardiac Monitoring
  • Pulse oximetry wiht SpO2 + HR
  • RR
  • EtCO2
  • Regular assessment of conciousness or RASS

Approach
Below are some suggested dosing regimes however check your local health-service's guidelines. 
Generally most clinicians will select one sedative agent (e.g. benzodiazepine) and one anti-psychotic (e.g. olanzapine) agent, and avoid mixing multiple agents.
Please also take the time to read up on the indications, contra-indications and side-effect profiles of each of the drugs.

 Oral Sedation
  • Olanzapine: 10mg wafer PO Stat (up to a maximum of 30mg/24hrs.)
  • Diazepam: 10-20mg PO Stat (up to a maximum of 60mg/24hrs.)
IM Sedation
  • Droperidol: 10mg IM, dose may be repeated after 15 mins (up to a maximum of 30mg/24hrs.)
  • Haloperidol: 10mg IM, an alternative to Droperidol. More side effects.
  • Ketamine: Failed sedation with above agents, consider 4-5mg/kg IM.
  • Midazolam: 2.5 (elderly, frial) to 10mg (young, large). IM effect in 3 minutes.
IV Sedation
  • Droperidol: 5-10mg IV, (up to a maximum of 20mg/24hrs.)
  • Haloperidol: 5-10mg IV, (up to a maximum of 20mg/24hrs.)
  • Ketamine: 1-1.5mg/kg, titrate to RASS or Sedation Score.

 General Anaesthesia and Intubation
Consider RSI only as last resort, bearing in mind the mental health risk vs the anaesthetic risk, and logistical factors.

References

Royal Flying Doctors Service The Acute Agitated Patient in a Remote Location
NSW Health: Management of Patients with Acute Severe Behavioural Disturbance in Emergency Departments
QLD Health: Management of Patients with Acute Severe Behavioural Disturbance in Emergency Departments
The Diagnostic Performance of the Richmond Agitation Sedation Scale for Detecting Delirium in Older Emergency Department Patients
PHARM: Surviving Sedation Guidelines 2015
KI Docs: Lessons for management of acute agitation in Rural EDs
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