This section addresses the issue of how to best help a violent and aggressive pt. The procedures surrounding chemical and physical restraint should provide a safe environment for the pt and the staff (HEC Forum 1998;10:244).

Initial physical restraints may include wrist and ankle restraints to a stretcher/bed (J Nurs Adm 1998;28:19). If the pt does not respond to this immobilization, it may be necessary to secure the chest, pelvis, and be sure that the gurney is anchored to the floor. If the pt is spitting or biting, a mask may need to be positioned, and someone should be available at all times to remove the mask, if a patent airway becomes an issue.

Chemical restraints are medications used to modify and subdue a pt’s behavior so that the pt is not a danger to him/herself or staff. This will also allow for a medical evaluation. Some options that are initially dosed via the im route are midazolam 5 mg—this is perhaps the best (Acad Emerg Med 2004;11:744), haloperidol 5 mg, droperidol 2.5-5 mg (Ann EM 1992;21:407), diphenhydramine 25-50 mg, lorazepam 2 mg, olanzapine 2.5-10 mg im (Can J Psychiatry 2003;48:716; Arch Gen Psychiatry 2002;59:441; J Clin Psychopharmacol 2001;21:389; Am J Psych 2001;158:1149), or perphenazine (Trilafon) (Curr Ther Res Clin Exp 1972;14:478). Use with caution
in the elderly and may want to use lower doses—if using for delirium, these medications may change the exam.

Once chemical restraints begin to work, physical restraints can be modified and eventually eliminated. Frequent reassessment and rx of underlying medical issues may help release pts from physical restraints in a timely manner.

Am J Psych 1999;156:1; Geriatrics 1999;54:28, 36, 39; Dement Geriatr Cogn Disord 1999;10:310

Cause: Drugs (Intoxication discussed in next section); intracranial lesion or process, such as encephalitis, meningitis, amyloid or primary neoplasm or metastatic disease; systemic diseases such as infections (syphilis) or autoimmune phenomenons; ethanol or sedative withdrawal; drug abuse—eg, ecstasy (J Psychoactive Drugs 1999;31:167); metabolic, such as hyperammonemia, sodium disorders, hypoglycemia, etc; seizures.

Epidem: High incidence in elderly, with 15% developing this after general surgery; higher rate noted in those with dementia.

Pathophys: Dependent on process, but overall leading to CNS dysfunction (Dement Geriatr Cogn Disord 1999;10:330). Increased serum anticholinergic activity in the elderly (J Gerontol A Biol Sci Med Sci 1999;54:M12) and elevated serotonergic activity in general (Dement Geriatr Cogn Disord 1999;10:339).

Sx: Hallucinations, often visual but also auditory.

Si: Acute onset and fluctuating course; transient global disorder of cognition and attention. Inattention, loss of attention span is most prominent deficit; test by serial 7’s; serial digits up to 7, such as phone numbers; spell “world” backwards; disorganized thinking or altered level of consciousness; may also “sundown”—exacerbated at night (Dement Geriatr Cogn Disord 1999;10:353).

Crs: Variable depending on underlying illnesses and cause. Prognosis/course may be guided by the Delirium Rating Scale (Psychosomatics 1999;40:193), which is a tool applied over time (eg, 24 hr).

Cmplc: Inherent with cause.

Diff Dx: Psychoses are not global; consider total global amnesia in pt who recovers in 1 d.

Lab: Directed by exam and past medical history. Consider metabolic (p221), intoxication (p411, p449), infectious (p185) and CNS (Neurology p249) work-up.