The Agitated Patient Wild and Crazy

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The Agitated PatientWild and Crazy
Randall Berlin, MD
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Learning Objectives

• Review the toxic causes of agitated delirium.
• Recognize and treat life threatening
  complications.
• Sedation of the agitated patient.
• Recognize and treat rhabdomyolysis.

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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.

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Form 10 (contd)

• Pt X is currently on medication, however has not
  been taking his medications. Pt Xs 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?

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• Schizophrenia
• Drug withdrawal
• Benzodiazepines
• Personality Disorder
• Illicit Drug Use

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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

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Old chart

• Schizoaffective
• Marijuana and cocaine abuse
• Antisocial personality disorder
• Dispostion
• Admit to psychiatry

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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?

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Causes of agitation

• Personality disorders
• Borderline, antisocial
• Ethanol enhanced personality disorders
• Medical causes of delirium
• Psychiatric causes of psychosis and agitation
• Dementia
• DRUG INTOXICATION
• What drugs can cause agitated delirium?

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Toxic causes of agitated delirium

• Anticholinergics antihistamines, antipyschotics
  etc
• Sympathomimetics cocaine, amphetamines
• PCP
• Hallucinogens LSD, mushrooms
• Salicylates
• Withdrawal states ethanol, benzodiazepines

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Back to the Case

• P 140 BP 150/95 RR 24 SaO2 98 T 39.5 C
• Agitated
• Pupils 7 mm, reactive
• Diaphoretic

• Life threats?

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Life threats

• Sudden cardiac death
• Hyperthermia

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Sudden cardiac deathTypical 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 moving.

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Typical scenario (contd)

• 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.

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Sudden Cardiac Death Associated with Agitated
Delirium

• Sudden In-Custody Death
• Restraint Associated Cardiac Arrest

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Sudden Cardiac DeathSimilarities 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)

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Sudden Cardiac DeathMechanism 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

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Sudden Cardiac DeathSummary

• 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.

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Back to the Case

• P 140 BP 150/95 RR 24 SaO2 98 T 39.5 C
• Agitated
• Pupils 7 mm, reactive
• Diaphoretic

• Life threats?

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Life threats

• Sudden cardiac death
• Hyperthermia

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Recognize the life threat!(not the drug)
How important is hyperthermia?
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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

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Back to the case

• Wildly agitated
• Movie Trivia If you cut their tendons, even the
  largest elephant will fall.

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Movie Trivia

• The Protector (2006)
• Tony Jaa

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

• Physical restraints
• Chemical sedation
• Intubation and paralysis

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Code Black

• Standardized approach
• Standardized team

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Physical restraints

• Short term solution to gain IV access and treat
  with pharmaceutical agents
• 5 or more people
• Monitoring protocol
• Documentation

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Chemical sedation

• Control psychomotor agitation while minimizing
  drug related complications
• Identify and treat life threats
• What drugs can we use?

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• Benzodiazepines
• Lorazepam
• Diazepam
• Midazolam

• Antipsychotics
• Paralytics
• Succinylcholine
• Rocuronium

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Benzodiazepines

• Advantages
• Treats hyperthermia
• Prevents or treats seizures
• Decreases mortality in animal studies of cocaine
  intoxication

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Benzodiazepines

• Disadvantages
• Respiratory depression

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Midazolam

• Onset IV - 1-5 minutes
• Dose 2.5-5.0 mg IV/IM q3-5min
• Elderly reduce dose

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MidazolamBoxed 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

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Antipsychotics

• Advantages
• No respiratory depression

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Antipsychotics

• Disadvantages
• Anticholinergic side effects
• Impair heat dissipation
• Lower the seizure threshold
• Prolong the QT interval
• Dystonic reactions
• Increased mortality in animal studies of cocaine
  intoxication

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Haloperidol

• Peak 10-20 minutes
• Duration days
• Dose 2-5 mg IV/IM q20min
• Elderly reduce dose

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Haloperidol Boxed Warning

• None
• However, DROPERIDOL
• Cases of QT prolongation and torsades de pointes,
  including some fatal cases, have been reported

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Olanzapine

• Peak 15-45 minutes
• Duration days
• Dose 5-10 mg IM/SL q2-4h
• Elderly Reduced doses

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Olanzapine Boxed Warning

• Increased risk of death in pts with dementia
  related behavioral disorders
• Increased risk of CVAs in elderly pts with
  dementia related psychosis

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Intubation and Paralysis

• Ultimate control
• Consider in patients with
• Risk of C-spine injury
• Hyperthermia

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Succinylcholine

• In most cases it will be safe
• Hyperkalemia is a risk in the patient with a
  protracted and fulminant course

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Hyperthermia
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Treatment of Hyperthermia

• Mist and fan
• Ice packs to groin and axilla

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Back to the Case

• P 140 BP 150/95 RR 24 SaO2 98 T 39.5 C
• Agitated
• Pupils 7 mm, reactive
• Diaphoretic

• What toxidrome is this?

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Sympathomimetic Toxidrome

• Hyperdynamic vitals
• Agitated mental status
• Dilated pupils
• Diaphoresis

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What are the causes of death in cocaine
intoxication?
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Cocaine related deaths

• Seizures
• CVA
• MI
• Aortic dissection
• Dysrhythmias
• HYPERTHERMIA
• How does cocaine cause hyperthermia?

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How does cocaine cause hyperthermia?

• Psychomotor agitation --gt increased heat
  production
• Vasoconstriction--gtdecreased heat dissipation
• A direct central effect
• A metabolic effect

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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.

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My approach

• Midazolam 2.5 - 5.0 mg IV q3-5min
• Endpoints
• Control of patient
• Control of hyperthermia
• Ativan 2 mg IV

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That should be the worst of it

• Review differential diagnosis
• Look for complications

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Causes of agitation

• Personality disorders
• Borderline, antisocial
• Ethanol enhanced personality disorders
• Medical causes of delirium
• Psychiatric causes of pyschosis and agitation
• Dementia
• Drug intoxication

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History

• Collateral history from police, paramedics,
  friends or family
• Medical and psych history, alcohol and drug
  usage, medications
• Previous medical records

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Physical

• Toxidromes
• Signs of infection
• Meningismus, cellulitis, pneumonia, etc
• Trauma
• Thyroid disease

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Labs

• CBC, electrolytes, renal function, CK, EKG, urine
  dip
• When indicated
• LFTs, Ca, Mg, Phos, TSH, T4,
• CXR,
• LP,
• head CT

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Back to the case

• A Foley catheter is inserted and tea colored
  urine comes out.
• How do we explain this finding.

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Rhabdomyolysis

• How can we confirm the diagnosis?

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Rhabdomyolysis

• Urine
• Urine dipstick
• Urine for myoglobin

• Blood
• Myoglobin
• Creatine Kinase

Treatment?
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Rhabdomyolysis

• Treatment
• Hydration and electrolyte management
• ? Alkalinization
• ? Mannitol

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Rhabdomyolysis

• 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 gt 6
• Monitor serial CK
• If still rising look for a compartment syndrome

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Re-assessments

• Drain the bladder
• Look and treat for causes of pain
• Re-assess need for restraints and document
  progress

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Summary of Approach

• Control
• Life threats
• Differential Diagnosis
• Complications

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Summary of Drug Therapy

• Drug induced benzodiazepines
• Drug withdrawal benzodiazepines
• Psychiatric antipsychotic
• Dementia antipsychotic
• Unknown benzodiazepines

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Tox TriviaName 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.

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Uma Thurman overdoses on what drug and how do
they revive her?
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Heroin Adrenaline
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