On the Road Again by liaoqinmei


									The Agitated Patient
       Wild and Crazy

Randall Berlin, MD
         Learning Objectives
Review the toxic causes of agitated delirium.

Recognize and treat life threatening complications.

Sedation of the agitated patient.

Recognize and treat rhabdomyolysis.
            Case 1 - Form 10
• Police attended the house of patient X after
  complaints from the neighbors that he was
  screaming all night. Neighbors and his live
  in landlord stated that he had not slept at all
  and was not making any sense. Pt X
  followed one of his neighbors home and
  pushed him on his lawn.
            Form 10 (cont’d)
• Pt X is currently on medication, however has not
  been taking his medications. Pt X’s landlord said
  that he has been selling his valium and filled all
  his meds - no other meds available to pt X for 3
  weeks. Pt X threatened to kill everyone/have them
  murdered/shot/poisoned. He is a danger to himself
  and others.
• Your thoughts?
• Schizophrenia
• Drug withdrawal
  – Benzodiazepines
• Personality Disorder
• Illicit Drug Use
                 In the ED
•   Pt yelling and aggressive.
•   Security required to restrain.
•   BP 113/59; P 79; T 37 C; 94% RA
•   Pharmacologic sedation
    – Versed 5 mg IM
    – Olanzapine 10 mg IM
                 Old chart
• Schizoaffective
• Marijuana and cocaine abuse
• Antisocial personality disorder

• Dispostion
  – Admit to psychiatry
                 Patient 2
30 year old, 100 kg male bodybuilder is brought
to the Emergency Department. He was arrested
by the police after running naked down the
middle of a major road. Two paramedics and
four police are having trouble holding him down
on the stretcher. Earlier that day the patient had a
major motor seizure.
     What are some causes of agitation?
             Causes of agitation
• Personality disorders
    – Borderline, antisocial
•   Ethanol enhanced personality disorders
•   Medical causes of delirium
•   Psychiatric causes of psychosis and agitation
•   Dementia

• What drugs can cause agitated delirium?
Toxic causes of agitated delirium
•   Anticholinergics: antihistamines, antipyschotics etc
•   Sympathomimetics: cocaine, amphetamines
•   PCP
•   Hallucinogens: LSD, mushrooms
•   Salicylates
•   Withdrawal states: ethanol, benzodiazepines
          Back to the Case
• P: 140; BP 150/95;   • Life threats?
  RR 24; SaO2 98%;
  T 39.5 C
• Agitated
• Pupils 7 mm,
• Diaphoretic
              Life threats
• Sudden cardiac death
• Hyperthermia
        Sudden cardiac death
             Typical scenario
• 29 yo male pulled over by police for driving
  erratically. He was agitated and confused
  and resisted arrest. He was pepper sprayed
  and continued to resist. He was physically
  subdued and continued to struggle despite
  being placed in 4-point restraints on the
  ambulance stretcher and suddenly stopped
      Typical scenario (cont’d)
• As he was being loaded into the ambulance,
  he was found to be pulseless and apneic.
  His passenger reported that he had been
  sniffing cocaine just prior to being stopped.
       Sudden Cardiac Death
 Associated with Agitated Delirium

• “Sudden In-Custody Death”
• “Restraint Associated Cardiac Arrest”
        Sudden Cardiac Death
           Similarities with most cases

• Presence of excited delirium
• Continued maximal struggle despite
  attempts at maximal restraint
• Clear association exists between illicit drug
  use and the syndrome but not universal.
• Non-drug related causes are almost always
  psychotic (schizophrenia, bipolar)
        Sudden Cardiac Death
              Mechanism of Death
• No definite etiology usually found at autopsy
• Profound metabolic acidosis likely leading to
  cardiac arrest
• Hyperthermia often contributory
• Convulsions often contributory
• Hyperkalemia often contributory
• Restraint asphyxia unlikely explanation
       Sudden Cardiac Death
• Dr. Chris Linden:
  – “I constantly and emphatically remind our
    residents and fellows that the patient with
    agitated delirium, particularly one who is
    actively and persistently struggling against
    restraint, should be treated as a true emergency
    - a cardiac arrest waiting to happen.”
          Back to the Case
• P: 140; BP 150/95;   • Life threats?
  RR 24; SaO2 98%;
  T 39.5 C
• Agitated
• Pupils 7 mm,
• Diaphoretic
              Life threats
• Sudden cardiac death
• Hyperthermia
Recognize the life threat!
     (not the drug)

   How important is hyperthermia?
• 75% of drug overdose patients with a
  temperature greater than 40.5 C for greater
  than one hour die or have permanent
  neurologic sequelae
             Back to the case
• Wildly agitated

Movie Trivia: “If you cut
 their tendons, even the
 largest elephant will
                   Movie Trivia
• The Protector (2006)
• Tony Jaa

                                        QuickTime™ and a
                              TIFF (Un compressed) decompressor
                                 are neede d to see this picture.

  How can we control our
  wildly, agitated patient?
        Control of the patient
• Physical restraints

• Chemical sedation

• Intubation and paralysis
              Code Black
• Standardized approach
• Standardized team
          QuickTime™ and a
TIFF (Un compressed) decompressor
   are neede d to se e this picture.
          QuickTime™ and a
TIFF (Un compressed) decompressor
   are neede d to se e this picture.
          Physical restraints
• Short term solution to gain IV access and
  treat with pharmaceutical agents
• 5 or more people
• Monitoring protocol
• Documentation
          Chemical sedation
• Control psychomotor agitation while
  minimizing drug related complications
• Identify and treat life threats

What drugs can we use?
• Benzodiazepines   • Antipsychotics
  – Lorazepam       • Paralytics
  – Diazepam          – Succinylcholine
  – Midazolam         – Rocuronium
• Advantages
  – Treats hyperthermia
  – Prevents or treats seizures
  – Decreases mortality in animal studies of
    cocaine intoxication
• Disadvantages
  – Respiratory depression
• Onset: IV - 1-5 minutes
• Dose: 2.5-5.0 mg IV/IM q3-5min
• Elderly: reduce dose
             Boxed Warning
• May cause severe resp depression, resp.
  arrest or apnea
• Initial doses in the elderly or debilitated
  should be conservative
• Parental form contains benzyl alcohol;
  avoid rapid injection in neonates or
  prolonged infusions
• Advantages
  – No respiratory depression
• Disadvantages
  – Anticholinergic side effects
       • Impair heat dissipation
  –   Lower the seizure threshold
  –   Prolong the QT interval
  –   Dystonic reactions
  –   Increased mortality in animal studies of cocaine
•   Peak: 10-20 minutes
•   Duration: days
•   Dose: 2-5 mg IV/IM q20min
•   Elderly: reduce dose
             Boxed Warning
• None

  – Cases of QT prolongation and torsades de
    pointes, including some fatal cases, have been
•   Peak: 15-45 minutes
•   Duration: days
•   Dose: 5-10 mg IM/SL q2-4h
•   Elderly: Reduced doses
            Boxed Warning
• Increased risk of death in pts with dementia
  related behavioral disorders
• Increased risk of CVAs in elderly pts with
  dementia related psychosis
      Intubation and Paralysis
• Ultimate control
• Consider in patients with
  – Risk of C-spine injury
  – Hyperthermia
• In most cases it will be safe
• Hyperkalemia is a risk in the patient with a
  protracted and fulminant course
    Treatment of Hyperthermia
• Mist and fan
• Ice packs to groin and axilla
          Back to the Case
• P: 140; BP 150/95;   • What toxidrome
  RR 24; SaO2 98%;
  T 39.5 C               is this?
• Agitated
• Pupils 7 mm,
• Diaphoretic
    Sympathomimetic Toxidrome
•   Hyperdynamic vitals
•   Agitated mental status
•   Dilated pupils
•   Diaphoresis
What are the causes of death in
   cocaine intoxication?
         Cocaine related deaths
•   Seizures
•   CVA
•   MI
•   Aortic dissection
•   Dysrhythmias
How does cocaine cause hyperthermia?
      How does cocaine cause
• Psychomotor agitation --> increased heat
• Vasoconstriction-->decreased heat
• A direct central effect
• A metabolic effect
            Back to the Case
• The patient is physically restrained, an IV is
  started and midazolam is titrated.
• Thirty minutes later, 30 mg of midazolam
  has been given, the patient is still agitated
  and his temp is 40 C
• A RSI is done and the patient is paralyzed.
              My approach
• Midazolam 2.5 - 5.0 mg IV q3-5min
• Endpoints
  – Control of patient
  – Control of hyperthermia
• Ativan 2 mg IV
   That should be the worst of it
• Review differential diagnosis
• Look for complications
• Collateral history from police, paramedics,
  friends or family
  – Medical and psych history, alcohol and drug
    usage, medications
• Previous medical records
• Toxidromes
• Signs of infection
  – Meningismus, cellulitis, pneumonia, etc
• Trauma
• Thyroid disease
• CBC, electrolytes, renal function, CK,
  EKG, urine dip
• When indicated
  –   LFTs, Ca, Mg, Phos, TSH, T4,
  –   CXR,
  –   LP,
  –   head CT
            Back to the case
• A Foley catheter is inserted and tea colored
  urine comes out.
• How do we explain this finding.
         How can we
        confirm the
• Urine                   • Blood
  – Urine dipstick          – Myoglobin
  – Urine for myoglobin     – Creatine Kinase

• Treatment
  – Hydration and electrolyte management
  – ? Alkalinization
  – ? Mannitol
• Hydration
   – Goal: urine output: 1-2 cc/kg/hr
• Alkalinization
   –   Implement when CK greater than 5000
   –   1 amp bicarb IV push
   –   1 L of D5W (remove 150 cc) and add 3 amps of bicarb
   –   Run at 100-150 cc/hr
   –   Goal: urine pH > 6
• Monitor serial CK
   – If still rising look for a compartment syndrome
• Drain the bladder
• Look and treat for causes of pain
• Re-assess need for restraints and document
         Summary of Approach
•   Control
•   Life threats
•   Differential Diagnosis
•   Complications
      Summary of Drug Therapy
•   Drug induced: benzodiazepines
•   Drug withdrawal: benzodiazepines
•   Psychiatric: antipsychotic
•   Dementia: antipsychotic
•   Unknown: benzodiazepines
                        Tox Trivia
                      Name the Movie
• Tagline for this 1994 movie
   – Girls like me don't make invitations like this to just anyone!
• Directed by Quentin Tarratino
• Starred John Travolta, Uma Thurman, Samuel L. Jackson
• The stories of two mob hit men, a boxer and a pair of diner
  bandits intertwine in four tales of violence and redemption.
Uma Thurman overdoses on
what drug and how do they
revive her?


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