Sedating the agitated patient

The agitated patient is something paramedics encounter on what often seems like a daily basis in the field.  There are many causes for agitation, but the one we tend to think of, and certainly in my case what our protocols are written to address, is the patient with agitation secondary to psychostimulant drug use, mental health issues, or most commonly, both.  These patients can be extremely difficult to manage, especially with limited resources.  Whilst I believe that the ability to sedate certain patients for their own and our safety is vital, these situations can be fraught with danger.

There have been some excellent posts in the FOAMed world recently on sedating the agitated patient (in the emergency department)

Brent over at boringem.org has posted two parts in a three part series on agitation in the ED which is a superb summary of the issues surrounding sedation of patients.  Bear in mind that this is a Canadian site, so make sure you are aware of the legal ins and outs in your own area.

Minh posted a some of cases over at the PHARM on cases from the WA coroner on the death of a couple of patients.  Read the one regarding the sedation and subsequent death of an agitated patient in an ED.  This case highlights the need for vigilance in any patient who receives sedation (for any reason).

Kane from LITFL has also posted in the past about behavioural emergencies in the ED

Everything that is true for sedating the agitated patient in the emergency department applies to ambulance practice; possibly more so.  We are often in the position of having to manage (or run away from) these patients on our own until help can arrive.  That help may take some time to arrive and is usually in the form of police and other ambulance crews.
You may need police to restrain these patients before you can safely administer sedation, but remember that police restrain people for different reasons than we do, so how they typically manage a patient may not be the most appropriate way for us to do so.  You are in charge of patient care, so make sure that care is carried out to a high standard under your control.

Some key points.

  • We are sedating these patients because we see a need to do so in order to ensure their safety (and our safety) and to enable them to be assessed and treated.  There are a raft of medicolegal issues that surround sedation and it is not something to be done lightly.  Make sure you are well versed in the legalities for your particular service/area.
  • Rule out medical causes of agitation and treat accordingly.  Behavioural problems don’t tend to come on suddenly, so if there is a clear acute change in behaviour, consider medical causes first and tailor your treatment.
  • If your sole agent is a benzo the patient may need much larger doses than you are used to giving to manage them.  However the line between enough and too much may be a fine one.
  • In any patient you sedate (for any reason) you must be prepared to take full control of the airway and ventilation.  This isn’t some abstract concept in your head, it means having airway gear at hand and expecting the worst to happen.  Close monitoring is essential.  Do not be lulled when the agitation settles – the behavioural crisis may be over, but the airway crisis may be just beginning!  SpO2 is not a reliable tool to tell you about ventilatory status: it is a time machine that tells you what was happening a little while ago and by the time you see it drop things are probably going downhill fast.
  • Any patient who is mechanically restrained for agitation should have chemical restraint as well.  Take great care that mechanical restraint does not impair respirations, especially if the patient has been extremely physically agitated.  These are patients that sometimes die in care or custody possibly either from positional asphyxia or from “excited delirium”.  Death from excited delirium is poorly understood, but it is thought to be a result of hyperthermia, acidosis and rhabdomyolysis.  Impairing respiration further (be it with restraints or drugs) may exacerbate this.  Check out Kane Guthries post over at LITFL for more on this.
  • Finally, don’t forget that these patients are not bad people.  They are sick people.  We are there to help them, not to punish them.  Do your best to treat them with the same care and respect you would any other patient.  This is not always easy when someone is trying to chew your face off, but try to take a deep breath and not be angry.  We need to take twice as much time and care in looking after people we don’t like (or who made us angry) to avoid cognitive bias making us miss things.
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