MANAGEMENT OF THE AGGRESSIVE PATIENT - PowerPoint Presentation

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MANAGEMENT OF THE AGGRESSIVE PATIENT

FAMILY MEDICINE 2021

Varsha Barnabas

Farzana Daya

Hawabibi Casmod

Presented by

AGGRESSION

The aggressive patient usually presents as a danger to others, to property and sometimes to themselvesAggression could occur in any setting (OPD,WARDS, HOSPITAL GROUNDS as well as COPC’S), therefore the policy applies to all these situations accordingly. It can also be either physical or verbal

“Feeling of anger or antipathy resulting in hostile or violent behaviour, readiness to attack or confront”

POSSIBLE CAUSES OF AGGRESSION

Delirium- hypoxaemia, metabolic, endocrine, post-ictal, sepsis, renal/organ failure :These cause clouding of consciousness, diminished comprehension, anxiety, perplexity, delusion of persecution and aggressionDementia-cerebral damage leading to decreased control and aggression

Medical

Antisocial & borderline personality disorderPsychosis Developmental disorders e.g. ID and autistic spectrum disorderHypomania or mania: the patient may become angry/hostile if obstructedSchizophrenia: patients may become aggressive due to delusional beliefs or in response to auditory hallucinations e.g. catatonic type: outbursts of over activity &/or aggressive behaviour seenSevere anxiety

Psychiatric

Alcohol, cannabis, mandrax, cocaine, methamphetamine & benzodiazepine withdrawal

Hypersensitive to reaction or insult

Poor frustration tolerance

Maladaptive coping skillsTrauma

PsychologicalSubstance use and withdrawal:POSSIBLE CAUSES OF AGGRESSION cont.

TBIsPTSD

POSITIVE PREDICTORS OF VIOLENCE

Male gender Prior history of violence Psychiatric illness Drug or ethanol abuse

PREVENTION POLICY

Never attempt to evaluate an armed patientCarefully search for any kind of offensive weapon( by security)Anticipate possible violence and treat such patients with understanding and gentlenessEnsure adequate security

Availability of more staffHave a clear exitRemain calm and non critical

BEFORE MANAGEMENT

Observe behaviour: often needs to be pre-emptive Try and gather as much information as possible on history: substance use, history of mental illness, sudden decline in function Visual examination of the patient , taking note of body language , clothing, eyes and speech (all of which can yield clues)

Try and take cognisance of any possible triggers (emotional/physical)

MANAGEMENT

Various avenues:Physical restraints

Seclusion Chemical restraints

MANAGEMENT – cont.

The rational for the use of seclusion is based on 3 therapeutic principles:

Containment

Restricted to a place where they are safe from harming themselves or others

IsolationAddresses the need for patients to distance themselves SeclusionProvides a decrease in sensory input for patients whose illness results in a heightened sensitivity to external stimulusPHYSICAL RESTRAINTSSECLUSION

Used as a last measure For the protection of the patient, other patients or health care worker Short duration as it can result in:Dehydration FracturesReduced perfusion Important to document Assign one team member to the pt’s head and each extremityBe humane but firmUse minimum force

Accomplish restraint quickly

Legality of physical restraint

Mental Healthcare Act no 17 of 2002

(Moosa and Jeenah, 2009; Policy Guidelines on Seclusion and Restraint of Mental Healthcare users 2012):Physical restraint is permissible Imperative to document details: duration, type of restraint and indication Patients who are likely to cause harm to themselves or others Only used when other methods of restraint fail (verbal) or if required to administer chemical/medical forms of restraintCertain conditions: not to be used any longer than absolutely necessary (ideally less than 4 hours for adults and a maximum of 2 hours for adolescents)When the desired effect is reached, it is no longer legal to continue physical restraintNever used as a form of punishmentAlways counsel family appropriately with regards to indications of use and duration Half hourly monitoring of patient condition Should not be used in children under the age of 12

BENZODIAZEPINES

PO DosingLorazepam 0.5- 2mg

Clonazepam 0.5-2 mgDiazepam 5-10 mgMidazolam 7.5-15 mg

IMI Dosing Lorazepam 0.5-2mgMidazolam 7.5-15 mg Clonazepam 0.5-2 mgANTI-PSYCHOTICS

Used in patients who are psychotic OR patients not responding to benzodiazepinesHaloperidol 2.5-5 mg IMIPromethazine(antihistamine) 25-50 mg IMI

POST SEDATION Reassess the situation Monitor vitalsSide effects Counsel family members if present CHEMICAL RESTRAINTS

Better than mechanical restraint as it maintains patient dignity

Rapid onset of action

Assess the patient

Age

Comorbidities

Cause of aggression

Monitor vitals

Single prescription

Always reassess between each prescription

Oral preparation

is

the

preferred route,

followed by intramuscular and then intravenous

Beware

of

drug side effects

Pharmacodynamics

Onset of action Duration of action

Benzos Diazepam (Valium)Rapid (within 15 minutes)1-3 days (LA)LorazepamRapid (within 15 minutes)10-20 hours (IMA)

Midazolam Most rapid 1-4 hours (SA)Clonazepam (Rivotril)Intermediate (15-30 minutes)1-2 days (IMA)Anti-psychoticsPromethazine (Phenergen)20-30 minutes 4-6 hours Haloperidol 30 seconds-1 minute4-6 hours

Side effects

Case study

A 28 year old male comes into the emergency department with his mother. The mother reports a 3 week history of “strange” behaviour: he has been talking to himself and starting arguments with his family.

When asked, the patient denies this accusation. He states that his mother is attempting to kick him out of the family home.

HX: no medical comorbidities, no history of acute illness O/E:General: the patient appears to be aggressive and uncooperativeVitals stableAll systems NADYou explain to the patient that in order to get him the right help, you need to take some bloods to do some tests. At this point, the patient starts screaming and threatening you. The other patients in the ED become concerned and he begins threatening other patients. The patient will not allow you to insert a drip nor will he allow you to approach him. How do you approach the situation?Be aware of environment/triggers of aggression in the patient e.g.: if you mention his mother, he suddenly becomes more angry. Avoid these triggersStay calm and do not shout at the patient, de-escalate the situation If communicating with him isn’t helping, consider asking for assistance with temporary physical restraint with the intention of sedating. Likely an IM method; inserting an IV line in this case may not be successful long-term Communicate calmly with his parent, explaining the need for restraint (or with anyone who may have escorted the patient)Sedate the patient and do necessary testing/sub-spec analysis Monitor patient’s general condition document clearly the need for sedation, counselling parent and duration of used method

Thank YOU

References

Buffett-Jerrott, S. E., & Stewart, S. H. (2002). Cognitive and sedative effects of benzodiazepine use. 

Current pharmaceutical design

, 8(1), 45-58Lader, M. H., & Petursson, H. (1981). Benzodiazepine derivatives—side effects and dangers. Biological PsychiatryMoosa, M. Y. H., & Jeenah, F. Y. (2009). The use of restraints in psychiatric patients. South African Journal of Psychiatry, 15(3)POLICY GUIDELINES ON SECLUSION AND RESTRAINT OF MENTAL HEALTHCARE USERS (2012) Department of Health RSA, p 5-13Standard Treatment Guidelines and Essential Medicines list for South Africa (2018) Department of Health RSA, Primary Healthcare Level, sections 16.2-16.5

Vgontzas, A. N., Kales, A., & Bixler, E. O. (1995). Benzodiazepine side effects: role of pharmacokinetics and pharmacodynamics. Pharmacology, 51(4), 205-223