Topic: paramedic
Pages: 3, Double spaced
Sources: 10
Order type: Essay
Subject: Medicine and Health
Style: Harvard
Language: English (U.K.)
Introduction
Agitation is a common behavioural emergency encountered by paramedics in pre-hospital, emergency, and intensive care settings. It presents serious challenge including risk for harm to people in contact with the patient. Agitation is a condition usually marked by an unpleasant emotional state, extreme arousal, aggravated anxiety, restlessness, violence, or verbal and physical aggressiveness (Cumming, et al., 2015). It can be caused by drug and substance abuse, mental illness, physical conditions, such as trauma, or distressing social events (Richmond, et al., 2012). This guideline provides a systematic approach of assessing and managing an agitated patient to paramedics regardless of their skills, levels, and setting of practice.
Important Considerations to Paramedics
Firstly, regardless of the underlying cause, the paramedics should consider agitation as an acute emergency situation that needs immediate intervention. This is to manage the symptoms and alleviate potential harm and risks in time (Sato, et al., 2013). Secondly, paramedics should know that safety is paramount at all time when handling agitated patient. The paramedic should ensure the safety of staff, the patient, and others.
Thirdly paramedics should always aim to assist the agitated patients to recognise and manage their emotions and distress. This is to maintain and regain complete control of their behaviour (Bruno, et al., 2014). Fourthly, paramedics should avoid the use of chemical and physical restrain as much as possible. This has been found to reduce rate of further agitation among patients (Banno, et al., 2014). Lastly, paramedics are to avoid coercive interventions, which may escalate agitation.
Guideline for Management of Agitated Patient
Figure 1: Guideline for paramedical management of patient with agitation (Nordstrom et al., 2012)
Extra Considerations
Quick rapid assessment and categorisation is to help the paramedic in determining severity of agitation and identify appropriate intervention (Nordstrom, et al., 2012). The paramedic is to perform a quick assessment and categorise the severity of the agitation of the patient into class I, II, III, or IV. The classes I-IV are derived from Behavioural Activity Rating Scale (BARS) (Schumacher, et al., 2010). A study conducted by Swift, et al. (2002) revealed that BARS is psychometrically effective, efficient, and reliable measuring behavioural activities among the acutely agitated patient.
Verbal de-escalation should focus on verbal engagement, establishment of collaborative relationship, and verbal de-escalation of the patient (Richmond, et al., 2012). Verbal de-escalation has been proven to enhance patients’ understanding of the situations and conditions causing their agitation, and promote a positive relationship with the healthcare worker (Livingston, et al., 2014; Richmond, et al., 2012). It also limits the chances of requiring physical and chemical restraints, which may escalate agitation and has adverse side effects, such as airway compromise and over-sedation (Livingston, et al., 2014).
Lastly, physical or chemical restrain are applied to violent patients who cause, or highly prone to cause, harm and destruction of property (Wilson, et al., 2012). Lorazepam and midazolam are recommended because of rapid sedation, which provide time for management of other conditions contributing to agitation (Sato, et al., 2013; Wilson, et al., 2012). Antipsychotics, olanzapine and thiopentine, are recommended for long term sedation because of few side effects, such as respiratory distress, hypotension, and withdrawal symptoms (Raskind & Wang, 2014). They work by binding to GABAA receptors neuronal depolarisation, which causing decreased neural activity and cause consequent sedation (Wilson, et al., 2012).
References
Banno, K., Nakaaki, S., Sato, J., Torii, K., Narumoto, J., Miyata, J., Hirono, N., et al. 2014. Neural basis of three dimensions of agitated behaviours in patients with Alzheimer disease, Neurosychiatric Disease and treatment, 10: pp. 339-348.
Cumming, J., Mintzer, J., Brodaty, H., Sano, M., Banerjee, S., Devanand, D, Gauthier, S. et al. 2015. Agitation in cognitive disorders: International Psychogeriatric Association provisional consensus clinical and research definition. International Psychogeriatrics, 27(1): pp. 7-17.
Livingston, G., Kelly, L., Lewis-Holmes, E., Baio, G., Morris, S., Patel, N., Omar, R., Katona, C., & Cooper, C. 2014. Non-pharmacological interventions for agitation in dementia: systematic review of randomized controlled trials. The British Journal of Psychiatry, 205: pp. 436-442.
Nordstrom, K., Zun, L., Wilson, M., Stiebel, V., & Ng, A. 2012. Medical evaluation and triage of the agitated patient: Consensus statement of the American Association for emergency psychiatry project BETA Medical Evaluation Workgroup. Western Journal of Emergency Medicine, 13(1): pp. 3-10.
Raskind, M. & Wang, L. 2014. Antipsychotic drugs for psychosis and agitation in dementia: efficacy, safety, and a possible noradrenergic mechanism of actions. International Psychogeriatric, 26(6): pp. 879-883.
Richmond, J., Berlin, J., Fishkind, A., Hollman, G., Zeller, S., Wilson, M., Rifai, M., & Ng, A. 2012. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West Journal of Emergency Medicine, 13(1): pp. 17-25.
Sato, J., Nakaaki, S., Tori, K., Oka, M., Negi, A., Tatsumi, H., Narumoto, J., et al., 2013. Behavior management approach for agitated behavior in Japanese patients with dementia: a pilot study. Neuropsychiatric Disease and Treatment, 9: pp. 9-14.
Schumacher, J., Gleason, S., Holloman, G., & McLeod, T. 2010. Using a Single-item Rating Scale as a Psychiatric Behavioral Management Triage Tool in the Emergency Department. Emergency Nursing, 36(5): pp. 434-438.
Swift, R., Harrigan, E., Cappelleri, J., Kramer, D., & Chandler, L. 2002. Validation of the behavioural activity rating scale (BARS): a novel measure of activity in agitated patients. Journal of Psychiatric Research, 36(2): pp. 87-95.
Wilson, M., Pepper, D., Currier, G., Holloman, G., & Feifel, D. 2012. The psychopharmacology of Agitation: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup. Western Journal of Emergency Medicine, 13(1): pp. 1-11.
