Background
Methods
Results
Protocol 1: Identification and evaluation of psychomotor agitation
Type | Signs and Symptoms |
---|---|
Changes in behaviour | • Combative attitude • Inappropriate behaviour without clear purpose • Hyperreactivity to stimuli • Inability to remain quiet, seated or calm • Exaggerated gesticulation • Facial tension and angry expression • Defiant and/or prolonged visual contact • Raised tone of voice, silence or refusal to communicate • Altered emotional state with appearance of anxiety, irritability or hostility • Verbal and/or physical aggression against self or others or objects |
Cognitive changes | • Fluctuations in the levels of consciousness • Temporo-spatial disorientations • Tendency to frustration • Difficulty in anticipating consequences • Delusional ideas and/or hallucinations |
Change in physical parameters | • Fever • Tachycardia • Tachypnoea • Sweating • Tremor • Neurological signs such as difficulty walking |
Establishing a differential diagnosis
Protocol 2: Interventions during an episode of psychomotor agitation
Environmental modifications
Verbal de-escalation
• Talk with the patient in a gentle, relaxed, assured tone | |
• Answer calmly, maintaining a firm attitude | |
• Offer food, beverages and blankets | |
• Be flexible in the dialogue | |
• Reserve your own judgement regarding what the patient should or should not do | |
• Do not seek confrontation of ideas or reasons, only simple partnerships that calm and reinforce the patient | |
• Use simple language and short sentences, repeating as many times as necessary | |
• Be honest and accurate | |
• Clearly communicate that the patient is expected to maintain self-control and that the staff can help him/her achieve this | |
• Redirect the conversation when disruptive questions are asked | |
• Paraphrase what the patient says | |
• Reassure the patient that you have understood him/her well | |
• Use open-ended questions | |
• Establish limits whilst at the same time offering the patient acceptable and realistic opportunities to improve their symptoms | |
• When faced with imminent violence: • Warn the patient that violence is not acceptable • Propose a resolution to any problem through dialogue • Offer pharmacological treatment • Inform them that you will rely on physical restraint if necessary | |
• Consider a mild/moderate show of force in the form of an increased number of medical staff and even security guards ready to act if necessary |
Pharmacological treatment
Route of administration | Agent | Dose | Cause of agitation |
---|---|---|---|
Antipsychotics | |||
Inhaled | Loxapine | 9.1 mg | Psychotic syndrome (schizophrenia, bipolar disorder) |
Oral | Olanzapine | 5–10 mg | Undifferentiated agitation Medical illness (cognitive deterioration and confusion syndrome) Substance intoxication/abstinence Psychiatric illness (schizophrenia, bipolar disorder, mental retardation and autism spectrum disorder) |
Risperidone | 1–3 mg | ||
Asenapine | 5–10 mg | ||
Aripiprazole | 15–30 mg | ||
Quetiapine | 50–100 mg | ||
Ziprasidone | 20–40 mg | ||
Haloperidol | 5 mg | ||
Intramuscular | Haloperidol | 5–15 mg | |
Olanazapine | 5–10 mg | ||
Ziprasidone | 10 mg | ||
Aripiprazole | 9.75 mg | ||
Levomepromazine | 25 mg | ||
Benzodiazepines | |||
Oral | Diazepam | 5–10 mg | Abstinence from alcohol and/or BZD Psychiatric illness (anxiety disorder, affective disorder, personality and adjustment disorder) |
Clonazepam | 1–2 mg | ||
Lorazepam | 1 mg | ||
Intramuscular | Midazolam | 5 mg | |
Diazepam | 5–10 mg |
Seclusion and physical restraint
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Patient admitted voluntarily and with consent for immobilisation: restraint is voluntary or requested by the patient in the event of failure of other measures. Despite this, since they are deprived of liberty, this must be communicated to the local authorities.
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Patient admitted voluntarily but without consent for immobilisation: physical restraint is applied against their will and, although under voluntary admission, it would then be considered involuntary and the local authorities must be informed.
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Patient with involuntary admission: physical restraint is applied against their will in an involuntary admission, where the local authorities have been already awarded of this admission.