Agitation and Aggression Management

Agitation Assessment - Spotting the Spark

• Goal: Rapidly identify escalating agitation to prevent aggression & ensure safety.
• Observable Cues (STAMP 📌 - Staring, Tone, Anxiety, Mumbling, Pacing):
  • Verbal: Loud, pressured speech; cursing, threats, irritability.
  • Non-Verbal (Motor): Restlessness, pacing, clenched fists, property damage, intrusive behavior.
  • Non-Verbal (Affect/Autonomic): Anxious, angry, labile affect; staring, frowning; sweating, flushing.
• Key Risk Factors for Aggression:
  • History of violence (strongest predictor!)
  • Substance intoxication/withdrawal
  • Psychosis (esp. paranoid, command hallucinations)
  • Delirium, medical conditions
  • Certain personality disorders (e.g., Antisocial, Borderline)
• Assessment Scales: Broset Violence Checklist (BVC), Overt Aggression Scale (OAS).

⭐ History of past violence is the single best predictor of future aggression.

De-escalation Tactics - Words Not War

• Goal: Calm patient, prevent escalation, ensure safety for all.
• Verbal Techniques:
  • Respect personal space (maintain 1.5-3 meters).
  • Use calm, clear, non-threatening tone.
  • Listen actively; validate feelings (e.g., "I understand you're upset").
  • Offer choices and solutions; empower the patient.
  • Avoid jargon, threats, or challenging behavior.
• Non-Verbal Cues:
  • Open, relaxed posture; hands visible.
  • Maintain intermittent eye contact.
  • Match patient's vocal rhythm (isopraxism) initially, then guide to calmer state.

⭐ SAFE STAMP Mnemonic for De-escalation: Space, Attitude, Friendly, Empathy, Simple, Tone, Agree, Movements, Phrasing. Helps recall key elements for effective verbal de-escalation before resorting to restraints or medication.

Rapid Tranquillisation - Chemical Composure

• Goal: Rapidly calm agitated patient, ensure safety (patient/staff), enable assessment/treatment.
• Route: IM preferred (safety, reliable absorption). IV (quicker onset) if access & cardiorespiratory monitoring.
• Drug Choices (IM Doses):
  • Benzodiazepine (BZD): Lorazepam 2-4 mg (alcohol/sedative withdrawal, unknown cause, stimulant intoxication).
  • First-Generation Antipsychotic (FGA): Haloperidol 5-10 mg (known psychosis; higher EPS risk).
  • Second-Generation Antipsychotic (SGA): Olanzapine 5-10 mg (psychosis/agitation; monitor metabolic effects).
  • Combination: Haloperidol 5 mg + Lorazepam 2 mg (synergistic). 📌 "H&L" combo.
• Monitoring: Vitals (BP, HR, RR, SpO2) q15-30min initially. ECG (QTc for APs like Haloperidol). Assess EPS, akathisia, sedation (e.g., RASS).
• ⚠️ Olanzapine IM & parenteral BZD: Risk of excessive sedation, hypotension, cardiorespiratory depression. Administer ≥1 hour apart.

⭐ Lorazepam IM: preferred for reliable absorption, no active metabolites; good for hepatic impairment.

Special Cases & Restraints - Delicate Duties

• Special Populations:
  • Elderly:
    • ↓ Psychotropic doses (e.g., Haloperidol 0.25-0.5 mg).
    • Lorazepam preferred BZD (short-acting); avoid diazepam.
    • Monitor: EPS, orthostasis, anticholinergic effects.
  • Pregnancy:
    • Prioritize non-pharmacological methods.
    • Haloperidol if antipsychotic essential.
    • Avoid BZDs (1st trimester, near term).
  • Children & Adolescents:
    • De-escalation is key.
    • ↓ Doses (e.g., Risperidone 0.25-0.5 mg).
• Physical Restraints (Last Resort):
  • Indications: Imminent harm to self/others; failure of de-escalation & medication.
  • Procedure:
    • Trained team (≥4-5 persons). Explain to patient.
    • Supine position; ⚠️ avoid prone (asphyxiation risk). One limb per restraint.
    • Monitor vitals, circulation q15-30 min.
    • Document: indication, type, duration, monitoring.
    • Remove ASAP (aim <2-4 hrs).
  • Legal: Adhere to Mental Healthcare Act, 2017.

  ⭐ Restraints are never punitive or for convenience; only to prevent harm if other methods fail.

High‑Yield Points - ⚡ Biggest Takeaways

• De-escalation techniques are the initial and preferred management for agitation.
• Rapid Tranquilization (RT) aims for prompt calmness without excessive sedation, often via IM route.
• Common RT agents include haloperidol, lorazepam, and olanzapine; haloperidol + lorazepam is a widely used combination.
• Monitor for Extrapyramidal Symptoms (EPS) with antipsychotics, especially typicals, and QTc prolongation.
• Lorazepam is often preferred in patients with liver disease or alcohol withdrawal.
• Physical restraints are a last resort, used only when verbal and chemical methods fail, with strict monitoring.
• Always rule out organic causes of agitation like hypoxia, hypoglycemia, or delirium before psychiatric labeling.