Management of the Combative, Intoxicated Patient

Educational Objectives

The goal of this program is to improve the management of and reduce the risks associated with treating patients who are intoxicated or are receiving sedating medications. After hearing and assimilating this program, the clinician will be better able to:

1. Use clinical judgement to determine if a patient has decision-making capacity.
2. State the requirements for using medical restraints in the emergency department, and describe available drug options for chemical restraint.
3. Recognize the legal, ethical, and moral duties of the emergency physician when treating patients who are intoxicated.

Summary

Available literature: important for emergency physicians (EPs) to understand how to manage combative, intoxicated patients, and when patient should determine decision making vs EPs; medical literature lacking (need to rely on legal literature); important to understand management strategies universally agreed upon by lawyers for both plaintiff and defense

Agitated patient: must ask why patient is agitated; not always something easily correctable; trauma patient who may be intoxicated can have complications; must decide if patient or outside parties (eg, family, courts, insurance companies, police) have any part in dictating care; consider potential medical issues — trauma, hypoglycemia, and hypoxia commonly missed in agitated patients (reversible causes for agitation); EP must be comfortable that medical issues not present before proceeding to next steps

Intoxicated trauma patient: agitation may result from intoxication, personal disposition, head injury, or combination of these; if comfortable that no medical issues are contributing to agitation, then proceed with next steps

Responsibility for care and disposition of intoxicated trauma patient: courts are clear that physician decides, not family members; legal power of attorney not applicable to intoxicated state; courts defend and support medical providers who act in good faith (applies even if, at later time, provider proven wrong in decision to hold patient); difficult for plaintiff attorneys to convince judges and juries that medical providers did not act in good faith for patient; may have to keep patient against his/her will, but decision rests with medical provider

How to assess medical decision-making capacity in intoxicated patient: questions to ask — does patient and/or family members understand diagnosis/injury, proposed treatment, alternatives to treatment, consequences and influences on decision; assessment of medical decision to obtain blood alcohol concentration (BAC) or toxicology screen — decision-making capacity is clinical determination, not based on objective criteria; plaintiff attorney can argue against clinical sobriety if BAC obtained and elevated (without BAC, attorneys must base case on provider’s clinical decision making); BAC should not be obtained unless decision already made to keep the patient in emergency department (ED); BAC can be used against provider in legal proceedings; differing effects of alcohol — patient with BAC >400 mg/dL may present with belligerence vs lethargy vs comatose state depending on individual; no standard number exists above which all people are incapacitated, and no number exists below which capacity is preserved; BAC less helpful for ED physicians than for police; determining capacity — use clinical assessment, not BAC or toxicology screen

Health Insurance Portability and Accountability Act of 1996 (HIPAA): provider may receive and give information required and necessary to care for patient; if police ask for information or BAC, determine necessity for care of patient; HIPAA is federal law and trumps any state laws, so use caution when disclosing information

Reporting: mandatory reporting requirements — gunshot wounds; intentional stabbings; animal bites; domestic violence; sexual abuse; elder abuse; nonaccidental trauma; homicidal intent towards readily identifiable party; intent to leave and drive while intoxicated — no legal obligation for medical providers to report intent to leave and drive while intoxicated; however, medical, ethical, and moral obligations should influence that decision

Mental health holds: not valid on intoxicated or substance-impacted individuals; cannot assess mental capacity when patient under influence of a substance; physician must assess whether mental health hold warranted; legally, any physician can place or release mental health hold (local policy may influence this)

Care of intoxicated patients who present voluntarily: Kowalski vs St. Francis hospital — intoxicated patient presented voluntarily, later absconded, and subsequently severely injured while crossing highway; case heard by New York State Supreme Court; decision in June 2013 ruled that hospital, ED staff, and EP had no duty to hold this intoxicated patient because he presented voluntarily; stated that EPs “cannot have a duty to do that which the law forbids”; State Mental Hygiene Law — hospital may retain “person whose mental or physical functioning substantially impaired as result of presence of alcohol”; New York state distinguishes between patient who presents voluntarily vs person brought to ED with personal objection; hospital has no obligation to retain if patient presents voluntarily; ethical decision to hold patient — determine whether patient in imminent danger or mentally incapacitated; whether patient needs to be held against his/her will is clinical decision; when can intoxicated patient refuse care — EP must be comfortable that patient understands risks and benefits; when in doubt, hold patient until it is felt they are safe to leave; preventing unsafe patients from absconding — make it difficult for them to leave (eg, place an intravenous line, remove clothing, restrain if necessary)

Medical and physical restraint: may be required when patient lacks capacity to make decisions; code of federal regulations 482.13 — requirements for restraint for behavioral health issues stringent and difficult to meet in ED; in the ED, restraint for medical issues (ie, medical restraint) occurs; requirements for medical restraint — include assessment by clinician that patient lacks capacity and potential exists for medical issue; document that until patient demonstrates capacity, medical restraint necessary to perform medical assessment; use of restraints — avoid partial restraints (may put patient and staff at risk); patients fully restrained should be closely observed

Excited delirium: American College of Emergency Physicians task force 2009 — early therapeutic intervention in premortem state; “physical restraints should be rapidly supplemented with chemical restraints”; pathophysiology — profound metabolic acidosis; unchecked catecholamine surge; how to interrupt cycle of agitation — when patient escalating, give sedation with benzodiazepines

Chemical restraint: options include benzodiazepines, antipsychotics (droperidol, haloperidol), and dissociatives (ketamine); benzodiazepines — best option for agitation associated with methamphetamines, cocaine, and synthetic marijuana; droperidol — safe and effective; not readily available; haloperidol — alternative to droperidol; can cause QT prolongation; treatment preferred for alcohol intoxication (benzodiazepines may cause respiratory depression); QT prolongation — potential side effect of many antipsychotics; ketamine — effective for agitated delirium or violent patients; intravenous (1-2 mg) or intramuscular (5 mg) administration; intranasal medications for chemical restraint — ketamine, midazolam, or droperidol can be administered intranasally if supplementation needed

Documentation: necessary for legal protection; credibility of EP lost when documentation supporting use of restraints lacking; avoid “angry documentation” (can be used by plaintiff lawyers to undermine provider credibility); macros — credibility lost if false documentation present; macros should be reviewed

Patients under arrest: cannot determine location of care but can determine what care they receive; can refuse treatment if capacity demonstrated

Summary: patients have freedom to make decisions, however medical providers can decide to hold if concern for danger to themselves or others; intoxication with alcohol or drugs raises question of decision-making capacity; determination of whether patient capable of making medical decisions should be clinically based; EPs have duty to patients, staff, and public to maintain safety as best as possible; do what is defendable, and right for everyone involved

Readings

Allely P et al: Alcohol levels in the emergency department: a worrying trend. Emerg Med J. 2006 Sep; 23(9): 707-8; D’Onofrio G et al: The impact of alcohol, tobacco, and other drug use and abuse in the emergency department. Emerg Med Clin North Am. 2006; 24(4):925-67; Gill JR: The syndrome of excited delirium. Forensic Sci Med Pathol. 2014 Jun; 10(2):223-8; Samuel E et al: Excited delirium: Consideration of selected medical and psychiatric issues. Neuropsychiatr Dis Treat. 2009; 5:61-6; Takeuchi A et al: Excited Delirium. West J Emerg Med. 2011 Feb; 12(1):77-83.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Colwell was recorded at High Risk Emergency Medicine Hawaii, held April 9-13, 2017, on Maui, HI, and presented by the University of California, San Francisco, School of Medicine and its Office of Continuing Medical Education. For information about upcoming CME conferences from the University of California, San Francisco, School of Medicine, please visit http://meded.ucsf.edu/cme. The Audio Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

EM350601

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.