Management of the Agitated Emergency Department Patient

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Management of the Agitated Emergency Department
Patient

• Marc L. Martel, MD
• Program Director
• Hennepin County Medical Center
• Assistant Professor
• University of Minnesota

2
Case 1

• 20s yo male presents by EMS and police to the ED
  with AMS. Medics report patient was found
  smashing car windows randomly on a local street.
  The patient is thrashing about on the EMS gurney,
  strapped prone to a backboard, handcuffed,
  screaming profanities, and spitting at providers.
• What is this clinical entity?

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Behavioral Emergencies

• What are they?
• I know it when I see it
• Justice Potter Stewart, 1964
• undifferentiated pt presenting with a
  behavior-related complaint
• No true defined criteria

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Behavioral Emergencies

• First described 1682, Sydenham
• Personal experience
• Negative reactions
• Appearance
• Attitude
• Interactive style
• Chief complaint
• Expectation Reality of encounter
• Recognize you play a role
• Escalate
• Contain

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Behavioral Emergencies

• Acute Undifferentiated Agitation
• Excited Delirium

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Behavioral Emergencies

• Acute Undifferentiated Agitation
• Altered Mental Status
• Positive symptoms
• Multiple etiologies
• Limited EBM

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Behavioral Emergencies

• Excited (Agitated) Delirium
• Acute onset bizarre and violent behavior
• Combativeness
• Hyperactivity
• Super-human strength
• Delusions / hallucinations
• Hyperthermia
• DEATH

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Behavioral EmergenciesEtiologies

• Psychiatric
• Alcohol
• Illicit substances
• Cocaine, PCP, Methamphetamine
• Intracranial pathology
• Genetic predilection?
• Mutated potassium channel