Acute Behavioural Disturbance

Transcription

1 Acute Behavioural Disturbance Sandy Hopper RCH, Melbourne

2 Oliver 10 year old PHx: autistic spectrum disorder Having a blood test Becomes very agitated Bites the doctor doing the test

3 Chelsea 14 year old PHx: in state care, substance use, social Becomes angry and aggressive in rooms Screaming and shouting Raises a chair above her head

4 Xavier 16 year old Found wandering outside a party Shouting, swearing, coherent Lashing out with his fists

5 Mr Jones Around 40 years old Child has leukaemia Upset by the wait in clinic Yelling at the receptionist

6 Sam 13 year old PHx: acquired brain injury, seizures, OSA, obese Seizure at his accommodation As he s waking up he shows a fearsome display of aggression

7 Autonomy Duty of care Beneficence OH&S Behavioural disturbance Zero tolerance Mental Health law

8 An approach to acute behavioural disturbances

9 Describe an approach to acute behavioural disturbances Prevention Management- Verbal de-escalation Restraint Use of medication

10 Prevention Prediction: Not always possible Environment Systems

11 Acute behavioural disturbance Imminent or actual

12 Reception and assessment Universal approach Actively violent N Acute brain/ intoxicated Y Y Behavioural Resuscitation Team approach Verbal De-esc Show of force Physical restraint Mechanical restraint Chemical sedation Containment Ejection N Verbal de-escalation fails fails Collaborative sedation After Hilt RJ, 2008

13 Verbal de-escalation You cannot reason with an unreasonable person

14 de-escalation Non-verbal: position, posture, body language Verbal style: low slow and quiet Verbal content: care and understand, appeal to reason

15 understand the problem I am here to help you. Tell me how I can help Tell me what s bothering you

16 active listening I can see you want to. That must really upset you

17 clarify goals I can help you. But first I need to make sure you are safe.

18 simply rephrase Let s make sure you are OK and then you can.

19 externalise the problem behaviour Emergency Department The anger I am seeing here makes it hard for me to help you.

20 externalise your response The law tells me/ it is my job to make sure you are OK, so I need to before you can. I am not happy about the long wait either. It is very frustrating for me too.

21 become part of the solution If you help me to make sure you are safe, then I can

22 suggest/request an alternative, positive solution Emergency Department It s OK to be angry/disappointed/frustrated. Tell me how angry you are.

23 meet some needs Food Nicotine Water Elimination

24 offer choices to give control Cool drink/warm drink Orange/ lemon Straw/ no straw Sitting down/ standing up

25 Reception and assessment Universal approach Actively violent N Acute brain/ intoxicated Y Y Behavioural Resuscitation Team approach Verbal De-esc Show of force Physical restraint Mechanical restraint Chemical sedation Containment Ejection N Verbal de-escalation fails fails Collaborative sedation After Hilt RJ, 2008

26 Collaborative medication Whatever they are on Whatever worked last time Diazepam, Olanzapine

27 Reception and assessment Universal approach Actively violent N Acute brain/ intoxicated Y Y Behavioural Resuscitation Team approach Verbal De-esc Show of force Physical restraint Mechanical restraint Chemical sedation Containment Ejection N Verbal de-escalation fails fails Collaborative sedation After Hilt RJ, 2008

28 Behavioural Resuscitation Enhanced verbal de-escalation A show of overwhelming force Containment Ejection Physical restraint Mechanical restraint Chemical restraint

29 Team approach Emergency Department 7-8 persons skill mix Trained Equipped

30 Enhanced verbal de-escalation A show of overwhelming force Require a reasonable person

31 Ejection/ Police behaviour is unequivocally not due to mental health or medical concern. Acting out Criminality

32 Containment: A goldilocks option Emergency Department

33 Seclusion Not too sleepy Emergency Department Not too agitated Must be searched

34 Most patients will require physical and chemical restraint

35 Physical restraint Emergency Department 5 person Trained Universal precautions Supine

36 Chemical restraint Emergency Department O vs S/L vs IM vs IV Choice of agent: Midazolam Diazepam Haloperidol Droperidol Olanzapine

37 Midazolam: rapid onset, short duration, amnestic, commonly used in acute health Diazepam: longer acting, oral or IV, not IM Haloperidol: onset 20, duration 2 hrs, sedating, risks EPS and NMS Droperidol: shorter acting than HPD,?risk of long QT? Olanzapine: similar profile to HPD perhaps less sedating, less EPS, NMS

38 Choice of agent Anxiety, acute brain, intoxication : benzo All others: benzo plus antipsychotic

39 Olanzapine vs Haloperidol Khan: Olanzapine: effective in 90%, no AEs apart from sedation, restraint time 40 minutes Sonnier: EPS less common in atypicals- 8% (?long term use) All give rise to sedation, all can prolong QT Bottom line: Olanzapine is a little less unpleasant, and possibly safer

40 Sedation: complications Respiratory depression hypotension, tachycardia. Extra pyramidal reactions Titrated to effect Close care: monitoring, 1:1 nursing

41 Mechanical restraint Emergency Department Slow to settle: whilst waiting for chemical restraint to take effect Likely to wake up agitated or violent Sole method in special circumstances

42 Mechanical restraint: complications Distressing and crude Caution with risk of vomiting, aspiration, asphyxiation. Attention to skin and elimination Close care: monitoring, 1:1 nursing

43 Reception and assessment Universal approach Actively violent N Acute brain/ intoxicated Y Y Behavioural Resuscitation Team approach Verbal De-esc Show of force Physical restraint Mechanical restraint Chemical sedation Containment Ejection N Verbal de-escalation fails fails Collaborative sedation After Hilt RJ, 2008

44 ? Emergency Department

45 Summary Emergency Department Prevention Environment, Self Verbal de-escalation Behavioural resuscitation Ejection Containment Restraint Use of medication

46 Assessment By mental health staff. Downstream care

47 Background Epidemiology Administrative framework

48 Acute brain syndrome Drugs, infection most common Suspect when delirium, young, rapid onset, no psychosocial setup, abnormal examination

49 references 1 Correll CU, Penzner JB, Parikh UH et al. Recognizing and monitoring adverse events of second-generation antipsychotics in children and adolescents. Child Adolesc Psychiatr Clin N Am. 2006;15: Grover S, Malhotra S, Bharadwaj R et al. Delirium in children and adolescents. Int J Psychiatry Med. 2009;39: Hilt RJ, Woodward TA. Agitation treatment for pediatric emergency patients.[erratum appears in J Am Acad Child Adolesc Psychiatry Apr;47(4):478]. J Am Acad Child Adolesc Psychiatry. 2008;47: Twomey B. Code Grey Procedure [accessed August 2011]; Available from: 5 Downes MA, Healy P, Page CB et al. Structured team approach to the agitated patient in the emergency department. Emerg Med Australas. 2009;21: Stewart C, Spicer M, Babl FE. Caring for Adolescents with Mental Health Problems : Challenges in the Emergency Department. J. Paediatr. Child Health. 2006;42: Dorfman DH, Mehta SD. Restraint use for psychiatric patients in the pediatric emergency department. Pediatr. Emerg. Care. 2006;22:7-12.

50 references 8 Clinical Practice Guideline Group of Royal Children's Hospital Melbourne. Emergency Restraint & Sedation- Code Grey [accessed 02 February 2010]; Available from: 9 Victorian taskforce on violence in nursing. Final report: Victorian taskforce on violence in nursing [accessed 20 July 2010]; Available from: data/assets/pdf_file/0007/17674/victaskforcevio.pdf 10 Policy and Strategic Projects Division DoHS, Victorian Government, Melbourne, Victoria, Australia. Occupational violence in nursing: An analysis of the phenomenon of code grey/black events in four Victorian hospitals [accessed 20 July 2010]; Available from: data/assets/pdf_file/0008/17585/codeblackgrey.pdf 11 Woolfenden S, Dossetor D, Nunn K et al. The Presentation of Aggressive Children and Adolescents to Emergency Departments in Western Sydney. J. Paediatr. Child Health. 2003;39: Dorfman DH. The Use of Physical and Chemical Restraints in the Pediatric Emergency Department. Pediatr. Emerg. Care. 2000;16 13 Brayley J, Lange R, Baggoley C et al. The violence management team. An approach to aggressive behaviour in a general hospital. Med. J. Aust. 1994;161:

51 references Khan SS, Mican LM.A naturalistic evaluation of intramuscular ziprasidone versus intramuscular olanzapine for the management of acute agitation and aggression in children and adolescents. J Child Adolesc Psychopharmacol Dec;16(6): Sonnier L, Barzman D. Pharmacologic management of acutely agitated pediatric patients. Paediatr Drugs Feb 1;13(1):1-10.