Psychiatric/Behavioral health emergency (< 18 years) - Curbside
Psychiatric/Behavioral health emergency (< 18 years)
Editors: Dan Imler, MD
Inclusion Criteria  (Any one criteria present)
  • Acute psychiatric concern (suicidal/homicidal ideation, psychosis, etc.)
  • Autism spectrum disorders or cognitive disabilities with acute exacerbation of symptoms
  • Active aggressive behavior
Exclusion Criteria
  • Acute, life threatening medical condition

Address acute medical condition

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Evidence
Total Notes: 4
Evidence

1 De-escalation techniques

Nearly all agitated patients should have the opportunity to calm themselves down prior to physical restraints or chemical sedation. Many patient's given this chance may avoid further intervention and improves the safety for the patient and the staff.



References:
  1. Learning and performance outcomes of mental health staff training in de-escalation techniques for the management of violence and aggression.
    Price O, Baker J, Bee P, Lovell K,
    Br J Psychiatry 2015 Jun;206(6):447-55.
  2. The violent patient.
    Hill S, Petit J,
    Emerg. Med. Clin. North Am. 2000 May;18(2):301-15, x.
  3. Management of the violent patient. Therapeutic and legal considerations.
    Rice MM, Moore GP,
    Emerg. Med. Clin. North Am. 1991 Feb;9(1):13-30.
  4. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup.
    Richmond JS, Berlin JS, Fishkind AB, Holloman GH, Zeller SL, Wilson MP, Rifai MA, Ng AT,
    West J Emerg Med 2012 Feb;13(1):17-25.
  5. Assaults against psychiatrists in outpatient settings.
    Dubin WR, Wilson SJ, Mercer C,
    J Clin Psychiatry 1988 Sep;49(9):338-45.
  6. Agitation treatment for pediatric emergency patients.
    Hilt RJ, Woodward TA,
    J Am Acad Child Adolesc Psychiatry 2008 Feb;47(2):132-8.

2 Restraints

Although restraints should be avoided if possible, they may be necessary in extremely agitated patients. Key things to remember when employing restraints are:

  • The team applying and maintaining restraints should be well organized and trained
  • Once the decision to apply restraints has been made the time for negotiation has past and the restraints should be applied even if the patient suddenly appears less violent
  • Patients in restraints are at higher risk of asphyxiation and death (especially since they may have other medical or substance issues). Care to apply and monitor restraints in these patients is of key importance.
  • Patients placed in prone position may be at higher risk of complications.


References:
  1. Managing the agitated psychotic patient: a reappraisal of the evidence.
    Allen MH,
    J Clin Psychiatry 2000;61 Suppl 14:11-20.
  2. The expert consensus guideline series. Treatment of behavioral emergencies 2005.
    Allen MH, Currier GW, Carpenter D, Ross RW, Docherty JP, Docherty JP,
    J Psychiatr Pract 2005 Nov;11 Suppl 1:5-108; quiz 110-2.
  3. Management of the violent patient. Therapeutic and legal considerations.
    Rice MM, Moore GP,
    Emerg. Med. Clin. North Am. 1991 Feb;9(1):13-30.
  4. Physical restraints versus seclusion room for management of people with acute aggression or agitation due to psychotic illness (TREC-SAVE): a randomized trial.
    Huf G, Coutinho ES, Adams CE, Adams CE,
    Psychol Med 2012 Nov;42(11):2265-73.
  5. Medicate, restrain or seclude? Strategies for dealing with violent and threatening behaviour in a Norwegian university psychiatric hospital.
    Wynn R,
    Scand J Caring Sci 2002 Sep;16(3):287-91.
  6. Management of the acutely violent patient.
    Petit JR,
    Psychiatr. Clin. North Am. 2005 Sep;28(3):701-11, 710.
  7. The violence management team. An approach to aggressive behaviour in a general hospital.
    Brayley J, Lange R, Baggoley C, Bond M, Harvey P,
    Med. J. Aust. 1994 Aug;161(4):254-8.
  8. Consent, involuntary treatment, and the use of force in an urban emergency department.
    Lavoie FW,
    Ann Emerg Med 1992 Jan;21(1):25-32.
  9. Factors associated with sudden death of individuals requiring restraint for excited delirium.
    Stratton SJ, Rogers C, Brickett K, Gruzinski G,
    Am J Emerg Med 2001 May;19(3):187-91.
  10. Excited delirium, restraints, and unexpected death: a review of pathogenesis.
    Otahbachi M, Cevik C, Bagdure S, Nugent K,
    Am J Forensic Med Pathol 2010 Jun;31(2):107-12.
  11. Positional asphyxia during law enforcement transport.
    Reay DT, Fligner CL, Stilwell AD, Arnold J,
    Am J Forensic Med Pathol 1992 Jun;13(2):90-7.
  12. Ventilatory and metabolic demands during aggressive physical restraint in healthy adults.
    Michalewicz BA, Chan TC, Vilke GM, Levy SS, Neuman TS, Kolkhorst FW,
    J. Forensic Sci. 2007 Jan;52(1):171-5.
  13. Weight force during prone restraint and respiratory function.
    Chan TC, Neuman T, Clausen J, Eisele J, Vilke GM,
    Am J Forensic Med Pathol 2004 Sep;25(3):185-9.
  14. Restraint position and positional asphyxia.
    Chan TC, Vilke GM, Neuman T, Clausen JL,
    Ann Emerg Med 1997 Nov;30(5):578-86.
  15. Agitation treatment for pediatric emergency patients.
    Hilt RJ, Woodward TA,
    J Am Acad Child Adolesc Psychiatry 2008 Feb;47(2):132-8.
  16. The use of restraint for pediatric psychiatric patients in emergency departments.
    Dorfman DH, Kastner B,
    Pediatr Emerg Care 2004 Mar;20(3):151-6.

3 Chemical sedation

Chemical sedation may become necessary in the agitated patient despite other measures. Medication choice is dependent on the specific characteristics of the patient and the context of their agitation.



References:
  1. Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department.
    Lukens TW, Wolf SJ, Edlow JA, Shahabuddin S, Allen MH, Currier GW, Jagoda AS, Jagoda AS,
    Ann Emerg Med 2006 Jan;47(1):79-99.
  2. The psychopharmacology of agitation: consensus statement of the american association for emergency psychiatry project Beta psychopharmacology workgroup.
    Wilson MP, Pepper D, Currier GW, Holloman GH, Feifel D,
    West J Emerg Med 2012 Feb;13(1):26-34.
  3. Long-acting antipsychotic medication, restraint and treatment in the management of acute psychosis.
    Fitzgerald P,
    Aust N Z J Psychiatry 1999 Oct;33(5):660-6.
  4. Pharmacological management of agitation in emergency settings.
    Yildiz A, Sachs GS, Turgay A,
    Emerg Med J 2003 Jul;20(4):339-46.
  5. Agitation treatment for pediatric emergency patients.
    Hilt RJ, Woodward TA,
    J Am Acad Child Adolesc Psychiatry 2008 Feb;47(2):132-8.
  6. The use of restraint for pediatric psychiatric patients in emergency departments.
    Dorfman DH, Kastner B,
    Pediatr Emerg Care 2004 Mar;20(3):151-6.

4 Laboratory testing

Patients without medical complaints are unlikely to have findings elucidated on labs. Limiting testing in these patients may be useful unless they have obvious medical complaints or high risk history (altered mental status, ingestion, hanging, traumatic injury, unrelated medical complaint, rape). In appropriate females, a pregnancy test may be useful.



References:
  1. Is medical clearance necessary for pediatric psychiatric patients?
    Santillanes G, Donofrio JJ, Lam CN, Claudius I,
    J Emerg Med 2014 Jun;46(6):800-7.
  2. Clinical utility of screening laboratory tests in pediatric psychiatric patients presenting to the emergency department for medical clearance.
    Donofrio JJ, Santillanes G, McCammack BD, Lam CN, Menchine MD, Kaji AH, Claudius IA,
    Ann Emerg Med 2014 Jun;63(6):666-75.e3.
  3. Medical clearance: time for this dinosaur to go extinct.
    Chun TH,
    Ann Emerg Med 2014 Jun;63(6):676-7.
  4. "Medical clearance" of psychiatric patients without medical complaints in the Emergency Department.
    Korn CS, Currier GW, Henderson SO,
    J Emerg Med 2000 Feb;18(2):173-6.
  5. Medical clearance of the psychiatric patient in the emergency department.
    Janiak BD, Atteberry S,
    J Emerg Med 2012 Nov;43(5):866-70.
  6. Pediatric and adolescent mental health emergencies in the emergency medical services system.
    Dolan MA, Fein JA, Fein JA,
    Pediatrics 2011 May;127(5):e1356-66.