Guidelines on emergency control of the acutely disturbed adult patient

GUIDELINES ON EMERGENCY CONTROL OF THE ACUTELY DISTURBED ADULT PATIENT
These guidelines are for use when a patient is acutely, and severely, ‘disturbed’, that is, physically aggressive, or threatening to become so, a danger to him or herself, staff, visitors or other patients, or exhibiting behaviour disruptive to the functioning of the ward, and with a presumed medical or psychiatric cause. Consent is generally required for treatment. If the patient is not competent to give or refuse consent (see notes 1 and 2), act on your judgement of what is in the patient’s best interest.
Think of the possibility of a treatable medical cause for the disturbance (e.g. hypoglycaemia, pain, hypoxia, urinary retention).
For guidance only – rigid adherence may not be appropriate. Seek more senior advice, at any stage, if in doubt.
ACTION
1. Use non-drug measures first. Remain calm and do not get angry (it never helps). Avoid direct confrontation and provocation. Find out what is worrying the patient and what they want done about it. Offer to help. Reassure patient that he or she is not going to be harmed. Negotiate a return to room/chair/bed or try distraction (watch TV, have a drink). If necessary, use physical restraint - the minimum practicable for the minimum length of time. Call Security to assist with restraint if required.
2. Offer oral medication, preferably in liquid form, HALOPERIDOL 5 mg, or LORAZEPAM 2 mg (crush tablets and dissolve in a small volume of water). Halve doses if elderly and frail.
3. If rapid, parenteral, sedation with drugs is required look at the table. Use your clinical judgement to decide what category of patient you are dealing with.
Get the patient safely restrained. Give first suggested drug intramuscularly. Wait 20-30 minutes. If no, or inadequate, response give second suggested drug. Repeat these at intervals of 20-30 minutes until control is achieved or maximum dose is reached.

Patient group	Try first	Try second	maximum dose in first 6h	NOTES
Already on depot/regular high dose antipsychotics	Lorazepam 2mg IM	Repeat lorazepam, then try haloperidol 5mg IM	Lorazepam 4mg + Haloperidol 18mg	3-7
Acute alcohol withdrawal	Lorazepam 2mg IM	Repeat	Lorazepam 8mg	3,4,5,8
Frail elderly OR Severe respiratory disease	Haloperidol 2.5mg IM	Lorazepam 1mg IM	Lorazepam 4mg + Haloperidol 10mg	3-7, 9-10
Highly aroused, physically robust, adult	Lorazepam 2mg IM + Haloperidol 5mg IM	Repeat	Lorazepam 4mg + Haloperidol 18mg	3-7,9,10

If control has not been achieved 30 minutes after reaching maximum doses, inform a consultant. Transfer to High Dependency Unit (or resuscitation room if in A&E). Ensure patient is safely restrained, secure IV access and give MIDAZOLAM as intravenous boluses of 1-2mg, at 2 minute intervals, maximum 20mg (see note 11). Monitor respiratory rate, oxygen saturation and blood pressure. If respiration cannot be maintained at the level of sedation required, call an anaesthetist.
AFTERCARE
Nurse in a light, quiet room. Separate from other patients. Nursing observation should be appropriate to the level of sedation. Nurse in the recovery position, and continue to observe respiratory rate and oxygen saturation. Once awake, offer glasses and hearing aid, if worn.
A diagnosis for the behavioural disturbance must be made, and the underlying cause treated. Consider drugs (including illicit), alcohol, hypoglycaemia, infection, metabolic disturbance, acute neurological disease (including trauma, infections, vascular and space-occupying lesions), pain, urinary retention, constipation. Urgently get a third party history of previous psychiatric problems and previous cognitive function (use the phone; relatives, GP).
Record the treatment given, and the basis of the decisions taken, in the medical notes. Consider the need for starting or increasing regular oral medication before emergency sedation wears off. Be wary, however, of regular sedation without a good explanation of what is going on medically. Review all sedative drugs daily.
BE CAREFUL. READ THE NOTES OVER THE PAGE. YOU MAY BE UNFAMILIAR WITH THE DRUGS USED.

NOTES
1. Capacity for consent requires that an adult (18 years of age or over) can understand the purpose, nature and effects of the proposed treatment, including adverse effects and the consequences of refusal; retain the information; weigh up and make a judgement about it; and communicate a decision. Capacity can be lost temporarily for psychological reasons, including severe anxiety. An adult who does not have capacity to consent can be given medical treatment in an emergency, in their best interests. A parent may consent for a young person under 18. If unavailable, in an emergency proceed in the patient’s best interest as for an adult.
2. Sedation must have therapeutic intent, e.g. to prevent harm to the patient, other patients, staff or visitors; to permit the administration of other definitive treatment in the patient’s best interest; or to relieve distressing symptoms like psychosis, fear or severe anxiety. If there is doubt, consult a senior colleague or a psychiatrist. A section of the Mental Health Act (1983) may need to be applied, but do not allow this to delay treatment which is immediately necessary. Some conflict situations may be managed best by acceding to the patients demands (e.g. to be allowed to leave hospital).
3. Benzodiazepines depress respiration. FLUMAZENIL should be available. Give if respiratory rate is < 10 breaths/minute (200micrograms IV, then 100microg at 60 second intervals, if required, maximum dose 1mg). It is short-acting and may need repeating or infusing (100-400microg/hour).
4. For IM use, LORAZEPAM should be diluted with an equal volume of water for injection or 0.9% NaCl, immediately before injection.
5. Combinations of benzodiazepines and antipsychotics have an additive effect allowing smaller doses of each to be used.
6. Never mix LORAZEPAM (or DIAZEPAM) with any other drugs in the same syringe. Give separate injections.
7. PROCYCLIDINE (5mg IM) injection must be available for acute dystonias. Repeat, if necessary, after 20 minutes. Maximum dose 20mg in 24 hours.
8. Avoid phenothiazines or other antipsychotics in acute alcohol withdrawal. There are separate guidelines for non-emergency alcohol withdrawal and detoxification. Oral CHLORDIAZEPOXIDE is the drug of first choice.
9. Use small doses for small people. Required dose of neuroleptic depends on age, body build, physical frailty, co-morbid diagnoses, severity of management problem, previous exposure/response to neuroleptics, skill of nurses.
10. Patients with dementia, especially Lewy body dementia, are particularly prone to side-effects. If antipsychotics are given at all, very low doses should be used.
11. MIDAZOLAM comes as 10mg in a 5ml ampoule. Dilute with an equal volume of 0.9% NaCl for IV use to make a solution of 1mg/ml. (It also comes as 10mg in 2ml; make sure you have the right one). Normal dose is up to 7.5mg, but in exceptional circumstances more may be used.
There are Trust policies on Aggression, Violence and Harassment; Consent; and Restraint which must be observed. This guideline is consistent with these in the emergency situation.

SUPPORTING INFORMATION - GUIDELINES ON RAPID CONTROL OF THE ACUTELY DISTURBED ADULT PATIENT
These are not for issue with the guidelines, but provide justification and references, such as they are, in case of challenge or to aid future revision.

1. These guidelines were based on guidelines adopted by the Nottingham Healthcare NHS Trust Drugs and Therapeutics Committee in 1999, and the Nottingham Healthcare Trust psychiatric trainees’ handbook (intended mainly for use in psychiatric settings, including liaison psychiatry). Additional information was drawn from the opinions of consultants and junior doctors in general internal medicine, geriatric medicine, adult general-, liaison- and old age-psychiatry, accident and emergency medicine, orthopaedic surgery and neurosciences. Pharmacists and senior nurses were also consulted.

2. The legal basis of treatment in an emergency without consent is complicated, and may change in the next few years [1,2]. A competent adult has the right to refuse medical treatment. Capacity to consent will vary according to the degree of mental disability prevalent at the time, and the nature and complexity of the proposed treatment. Understanding of the purpose, nature and effect of treatment need only be in broad terms, however. In general, the Courts appear to be protective of doctors acting in an emergency, in good faith, in what is perceived to be the patients’ best interest.
3. Whether aggression or violence has a medical/psychiatric basis, or whether it is due to provocation, stress, bereavement, personality, voluntary or criminal action is a matter of clinical judgement, on the basis of circumstances and an examination of the mental state, insofar as this is possible.
4. ‘Talking down’ is widely used in psychiatric practice where highly skilled nursing and medical staff attempt to prevent, defuse or manage potential conflict situations with minimum recourse to drug therapy. Its applicability in general medical settings is less certain, but avoidance of provocation may prevent escalation, and alternative means of management should be tried before parenteral sedation is used.
5. The drugs and doses chosen are on the basis of consultant opinion, recommendations of the Drugs and Therapeutics Bulletin [3], a textbook of general psychiatry [4], the British National Formulary [5], a handbook of psychiatric pharmacology [6] and a published review [7]. There are two randomised controlled trial suggesting the superiority of droperidol over haloperidol [8,9], but parenteral droperidol was withdrawn in January 2001 for commercial reasons, following safety concerns over the use of long-term oral droperidol.
6. Although benzodiazepines are respiratory depressants and may exacerbate hypoxia, relief of severe dyspnoea in an agitated or delirious patient with severe respiratory disease justifies their use so long as respiratory function is monitored and facilities for resuscitation are available.
7. Midazolam has been chosen over possible alternative drugs (amylobarbitone IV, paraldehyde IM, diazepam IV) for use at the stage when all else has failed, on the basis of availability, familiarity amongst many staff in an acute hospital setting, short duration of action, and safety. Patients will already have had the BNF limit dose of lorazepam by this stage, so short duration of action may be an advantage. There is a case series describing successful use of midazolam in acute psychosis [10].
References
1. Davis M. Textbook on medical law. London; Blackstone Press, 1996, pp 116-163.
2. Code of practice for the Mental Health Act 1983. Chapter 15: Medical treatment. London; Department of Health.
3. Management of behavioural emergencies. Drugs and Therapeutics Bulletin 1991; 29:62-64.
4. Gelder M, Gath D, Mayou R, Cowen P. Oxford Textbook of Psychiatry, 3rd edition. Oxford, OUP, 1996.
5. British National Formulary, September 1999. London: BMA, RPSGB.
6. Bazire S. Psychotropic drug directory. Quay Books, Dinton (Nr. Salisbury) 1989.
7. Kerr IB, Taylor D. Acute disturbed or violent behaviour: principles of treatment. Journal of Psychopharmacology 1997; 11: 271-277
8. Resnick M, Burton BT. Droperidol vs haloperidol in the initial management of acutely agitated patients. Journal of Clinical Psychiatry 1984; 45:298-299.
9. Thomas H, Schwartz E, Petrilli R. Droperidol vs haloperidol for chemical restraint of agitated or combative patients. Annals of Emergency Medicine 1992; 21: 407-413.
10. Mendoza R, Djenderedjian AH, Adams J, Anath J. Midazolam in acute psychotic patients with hyperarousal. Journal of Clinical Psychiatry 1987; 48:291-292.