Question 27

College answer

Call for help: Hospital emergency response (Code Black or equivalent)

 May be a medical illness (hypoxia, hypoglycaemia, metabolic disturbance), psychiatric disorder (acute psychosis, drug-induced psychosis, delusional state, mania or personality disorder) or drug intoxication or withdrawal causing the aggressive violence.

 Sedation to gain control of the situation may be required to allow such an assessment.

Acute Management

 De-escalation, containment and negotiation techniques if appropriate and most likely to work in a situation of low level threat (unlike this one).

Physical restraint – to allow delivery of drug therapy, need help / security team / police etc.

Chemical restraint:

i. Options:

1. Benzodiazepines:
   1. Diazepam / Midazolam / Lorazepam
   2. Advantages of rapid action, good safety profile
   3. Concern: Sedation / Drowsiness / Respiratory depression / hypotension/short acting
2. Anti-psychotics:
   1. Typical
      1. Haloperidol
      2. Droperidol (increasing profile for relatively safe emergency sedation)
   2. Atypical
      1. Olanzepine ii. Risperidone

1. 3. Advantages – less respiratory depression, can be given im.
   4. Concerns: Extra-pyramidal side effects / QT prolongation / hypotension /slow onset, may require repeated administration

3. NMDA-antagonist (Ketamine):
   1. Advantage: Can be given im, much less respiratory depression or hypotension, rapid onset
   2. Concern: Hallucinations / Hypertension, tachycardia / 

4. Intravenous anaesthetic agents (propofol, thiopentone)
   1. Advantage – very rapid action with guaranteed effect
   2. Concerns – apnoea, hypotension. May require intubation.

(B) Post-intervention considerations.

1. Assessment and investigation for medical / psychiatric cause of severe agitation
2. Adequate monitoring and support of vital signs
3. Monitoring for adverse effects of medications used to control the individual
4. Examination for injuries to the perpetrator
5. Documentation
6. Debrief – staff involved / perpetrator, when calm and rational other patients, perpetrator’s family
7. Disposition – monitored environment

Examiner Comments:

Most candidates omitted thinking about or looking for causes of aggression (e.g. hypoxia) and did not mention any post-intervention considerations.

Discussion

This is far from uncommon, and the level of detail invested into the scenario suggests that some lightly bruised veteran of the ICU wrote the question in memory of a particularly extreme confrontation. Fortunately, there is a NSW Health directive to guide this area of practice.

Ensuring safety of the patient and staff 

• Retreat to a safe place; remove staff to a safe area or to a safe distance, as much as possible
• Activate duress alarm
• Activate local emergency response (usually designated Code Black)

De-escalation technique

• An attempt to de-escalate the situation by engaging with the aggressive patient is one option, Some techniques have been suggested:
  • Respecting personal space
  • Appropriate body language using a non-confronting manner
  • Establishing appropriate verbal contact to engage with the person
  • Communicating in a clear and concise manner, avoiding repetition
  • Listening and acknowledging the person’s concerns
  • Identifying the person’s needs and feelings 
  • Setting clear limits and boundaries
  • Being respectful
  • etc etc
• Defusing the situation through conversation seems like an appropriate place to start. 
• However this would probably not be a reasonable thing to include in the answer to Question 27. Specific offensive behaviours were quoted by the college, likely as a means of communicating to the trainees that they were not dealing with a reasonable person. If the patient is headbutting the staff, we are probably no longer in conversation territory. 

Physical behavioural control measures

• The security team needs to nominate the team leader
• The team leader should assigns roles for each staff member
• One staff member should support or hold each limb
• One staff member should support or hold the head and continue to engage with the patient to "reassure and calm" them while they bite and spit.
  With the patient physically restrained, it may now be possible to administer chemical restraints.

Chemical behavioural control measures

• In Question 27 from the first paper of 2018, the college wanted a list of drugs and their advantages/disadvantages. To quote several classes and to write "sedation/drowsiness/respiratory depression" as the disadvantage for all of them would probably win few marks. All these drugs have "rapid onset|" as an advantage and "sedation/drowsiness" as a disadvantage because you are using them to rapidly sedate somebody. Thus, the following list is offered with the intention of making these drug classes look so sufficiently different that the choice of which drug to give is not rendered meaningless.
  • Benzodiazepines: Midazolam, diazepam, lorazepam, clonazepam
    • Advantages:
      • Rapid onset of effect
      • Safe to give IM
    • Disadvantages
      • When given IM, unpredictable pharmacokinetics
      • Prolonged duration of action and delayed peak effect may give rise to an inadvertent overdose ("he just won't stay down, give him more!")
      • Some of these patients may be multi-drug resistant organisms and may  be recreationally taking substantially more benzodiazepines than you would ever be willing to inject into them for behaviour control.
  • Classical antipsychotics: haloperidol, droperidol
    • Advantages:
      • Relatively short duration of action
      • Significant experience with their use
      • System-level support is strong- eg. many Australian health services have adopted droperidol as their drug of choice following the hilariously titled DORM trial (Isbister et al, 2010)
    • Disadvantages:
      • QT intervals will become prolonged with excess use
      • Extrapyramidal side effects may produce motor problems which may extend to such unpleasantness as respiratory arrest due to muscle rigidity
      • Most of these drugs are alpha-1 antagonists, which will cause hypotension
      • Anticholinergic side efects cause urinary retention and may exacerbate delirium
  • Atypical antipsychotics
    • Advantages:
      • Generally viewed as safer than the classical agents
      • Less anticholinergic and other side effects
      • Longer duration of action for sustained effect
    • Disadvantages:
      • Many agents are not available in IV/IM formulations, which means you will be relying on some degree of cooperation, to swallow the tablet.
      • Slow onset of antipsychotic effect; immediately useful effect is actually an antihistamine-like sedation which is probably no different to the classical agents in mechanism, except slower. 
  • Dissociative anaesthetics
    • Ketamine has been suggested as an agent for the "difficult to control" aggressive patients who have already had dangerous doses of other drugs. Data on this were publsihed by Isbister et al (2016), who gave their patients  a median dose of 300mg (!) of ketamine to chase the 25mg of droperidol which they have already had.
    • Advantages:
      • Airway reflexes are preserved
      • it is another class to use in a multimodal approach to behaviour control
    • Disadvantages:
      • Psychosis may get worse
      • The patient may hallucinate
      • Analgesic effect renders the patient immune to pain, which may result in self-harm
      • Agitation associated with ketamine may be difficult to distinguish from the pre-existing agitation 
  • General anaesthetics
    • The college answer to Question 27 recommends barbiturates or propofol, quoting rapid action and a "guaranteed" effect. One might also make the argument that 500mg of intramuscular suxamethonium might be similarly rapid in onset, and offer a similar certainty of behaviour control. 
    • Propofol has been used as an infusion in these cases (Chalwin et al, 2012)- apparently only 30-50mg/hr was required to sustain "conscious sedation, leading to satisfactory patient compliance with healthcare interventions".
    • The natural tendency of these situations to lead to intubation needs to be mentioned.

Investigations and post-sedation care

• Determine need for ongoing physical restraints
• Monitor vital signs
• Examine the patient for injuries
• Explore organic differentials (eg. meningitis, encephalitis, head trauma, hypoxia, pain, background of developmental delay, metabolic encephalopathy)

Post-event care of staff and family

• Debrief with staff
• Discussion with patient's family
• Escalation of incident to incident monitoring committee
• Institution-level interventions (eg. aggression management workshops and training in safe "take-down" techniques of physical restraint)