Agitated Patients Research Articles

Effects of cariprazine on reducing symptoms of irritability, hostility, and agitation in patients with manic or mixed episodes of bipolar I disorder

BackgroundHostility, irritability, and agitation are common in patients with bipolar I disorder. Post hoc analyses evaluated the effect of cariprazine on these symptoms in patients with bipolar I mania. MethodsData were pooled from three randomized, double-blind, placebo-controlled phase 3 cariprazine trials in adults with bipolar I manic/mixed episodes (NCT00488618, NCT01058096, NCT01058668); pooled cariprazine doses (3–12 mg/d) were analyzed. Patients were categorized into hostility/irritability and agitation subgroups by baseline scores: Young Mania Rating Scale (YMRS) irritability and disruptive-aggressive behavior items score ≥ 2; Positive and Negative Syndrome Scale (PANSS) hostility item ≥ 2; PANSS–Excited Component (PANSS-EC) total score ≥ 14 and score ≥ 4 on ≥ 1 individual item. Changes from baseline to week 3 in hostility/irritability- and agitation-related outcomes were evaluated. Adjustments were made for the presence of other manic symptoms, sedation, and akathisia. ResultsMost patients met subgroup inclusion criteria (YMRS hostility = 930; PANSS hostility = 841, PANSS-EC agitation = 486). In the YMRS subgroup, least squares mean differences in change from baseline were statistically significant for cariprazine versus placebo on YMRS hostility/irritability-related items (irritability [−0.93], disruptive-aggressive behavior [−0.79], combined [−1.75]; P ≤ 0.001 each), YMRS total score (−5.92, P ≤ 0.0001), and all individual YMRS items (−0.25 to −0.93, P ≤ 0.0001); differences remained significant after adjustment for other manic symptoms, sedation, and akathisia. Differences in PANSS hostility and PANSS-EC subgroups were significant for cariprazine versus placebo (P ≤ 0.001). LimitationsPost hoc analysis. ConclusionCariprazine demonstrated specific antihostility/irritability and anti-agitation effects in patients with manic/mixed episodes of bipolar I disorder and baseline hostility, irritability, or agitation.

The effects of combined acupuncture anesthesia and serratus anterior plane block with ropivacaine on postoperative analgesia in patients undergoing chest surgery

Objective To investigate the effects of combined acupuncture anesthesia and ropivacaine on postoperative analgesia and neuro-related factors in patients undergoing chest surgery. Methods The analgesic drug dosage, postoperative PCIA pressing times, VAS scores at rest and during activity at 6 h (T1), 12 h (T2), 18 h (T3), and 24 h (T4) postoperatively. Results The analgesic drug dosage and postoperative PCIA pressing times were lower in the observation group than in the control group (p < 0.05). The VAS scores at T1–T4 postoperatively were lower in the observation group than in the control group (p < 0.05). The SAS scores at T1–T4 postoperatively were lower in the observation group than in the control group (p < 0.05). The levels of IL-6 and IL-10 on postoperative day 1 were higher than those on preoperative day 1 in both groups, with a smaller change in the observation group (p < 0.05). The levels of S100β protein on postoperative day 1 were higher than those on preoperative day 1 in both groups, while the BDNF levels were lower, with a smaller change in the observation group (p < 0.05). There was no significant difference in the incidence of adverse reactions between the control group (11.36%) and the observation group (15.56%) (p > 0.05). Conclusion Combined acupuncture anesthesia and ropivacaine can effectively improve postoperative analgesia and agitation in patients undergoing chest surgery, reduce the dosage of analgesic drugs, regulate the levels of inflammatory factors and neurotrophic factors in patients, and do not increase the risk of adverse reactions related to patients.

Fewer emergency department alarms is associated with reduced use of medications for acute agitation

Background and objectivesPatient monitoring systems provide critical information but often produce loud, frequent alarms that worsen patient agitation and stress. This may increase the use of physical and chemical restraints with implications for patient morbidity and autonomy. This study analyzes how augmenting alarm thresholds affects the proportion of alarm-free time and the frequency of medications administered to treat acute agitation. MethodsOur emergency department's patient monitoring system was modified on June 28, 2022 to increase the tachycardia alarm threshold from 130 to 150 and to remove alarm sounds for several arrhythmias, including bigeminy and premature ventricular beats. A pre-post study was performed lasting 55 days before and 55 days after this intervention. The primary outcome was change in number of daily patient alarms. The secondary outcomes were alarm-free time per day and median number of antipsychotic and benzodiazepine medications administered per day. The safety outcome was the median number of patients transferred daily to the resuscitation area. We used quantile regression to compare outcomes between the pre- and post-intervention period and linear regression to correlate alarm-free time with the number of sedating medications administered. ResultsBetween the pre- and post-intervention period, the median number of alarms per day decreased from 1332 to 845 (−37%). This was primarily driven by reduced low-priority arrhythmia alarms from 262 to 21 (−92%), while the median daily census was unchanged (33 vs 32). Median hours per day free from alarms increased from 1.0 to 2.4 (difference 1.4, 95% CI 0.8–2.1). The median number of sedating medications administered per day decreased from 14 to 10 (difference − 4, 95% CI −1 to −7) while the number of escalations in level of care to our resuscitation care area did not change significantly. Multivariable linear regression showed a 60-min increase of alarm-free time per day was associated with 0.8 (95% CI 0.1–1.4) fewer administrations of sedating medication while an additional patient on the behavioral health census was associated with 0.5 (95% CI 0.0–1.1) more administrations of sedating medication. ConclusionA reasonable change in alarm parameter settings may increase the time patients and healthcare workers spend in the emergency department without alarm noise, which in this study was associated with fewer doses of sedating medications administered.

Pharmacological Treatment for Terminal Agitation, Delirium and Anxiety in Frail Older Patients.

Psychological distress symptoms in the last days of life often contribute to the overall symptom burden in frail older patients. Good symptom management practices are crucial to ensure high-quality end-of-life care in an aging population, though the best pharmacological approach to treat these psychological symptoms has yet to be established. To identify current evidence-based and practice-based knowledge of pharmacological interventions for the treatment of agitation, delirium, and anxiety during the last days of life in frail older patients. A systematic, mixed methods review was performed through MEDLINE via PubMed and EMBASE from inception until February 2022 and updated through March 2023. National and international guideline databases and grey literature were searched for additional studies and guidelines. Four quantitative studies, two non-randomized and two descriptive, were identified. No randomized controlled trials met inclusion criteria. No qualitative studies were withheld. The three consensus-based protocols that were found through citation searching and screening of grey literature did not meet the standards for inclusion. Haloperidol is recommended in consensus-based guidelines for delirium and is widely used, but high-quality evidence about its efficacy is missing. Better control of agitation or refractory delirium might be achieved with the addition of a benzodiazepine. There is no evidence available about the treatment of anxiety in the last days of life in frail older patients. This mixed methods review demonstrates the lack of good quality evidence that is needed to help clinicians with pharmacological treatment decisions when confronted with psychological symptoms in the last days of life in frail older patients. Population aging will only emphasize the need for further research in this specific population.

A Review of Recent Advances in the Management of Alzheimer's Disease.

Alzheimer's disease (AD) is the most common neurodegenerative condition and a form of dementia encountered in medical practice. Despite many proposed and attempted treatments, this disease remains a major puzzle in the public health systems worldwide. The initial part of this article provides an overview and illustration of the primary mechanisms responsible for neuronal damage in AD. Subsequently, it offers a critical evaluation of the most noteworthy studies on pharmacological therapy for AD and outlines recent advancements and novel approaches to managing this condition. Main properties, categorization, Food and Drug Administration (FDA) status, mechanisms of action, benefits, and common side effects of the classical and the most recently proposed pharmacological treatments for AD are described. The conventional pharmacological agents revised comprise cholinesterase inhibitors, monoclonal antibodies, and other therapies, such as memantine, valproic acid, and rosiglitazone. The innovative reviewed pharmacological agents comprise the monoclonal antibodies: donanemab, gantenerumab, solanezumab, bapineuzumab, crenezumab, and semorinemab. Nutritional supplements such as alpha-tocopherol (vitamin E) and caprylidene are also revised. Tau and amyloid-targeting treatments include methylthioninium moiety (MT), leuco-methylthioninium bis (LMTM), an oxidized form of MT, and tramiprosate, which inhibits the beta-amyloid (Aβ) monomer aggregation into toxic oligomers. Antidiabetic and anti-neuroinflammation drugs recently proposed for AD treatment are discussed. The antidiabetic drugs include NE3107, an anti-inflammatory and insulin sensitizer, and the diabetes mainstream drug metformin. The anti-neuroinflammatory AD therapies include the use of sodium oligomannate (GV-971), infusions with intravenous immunoglobulin aiming to decrease plasma levels of the constituents of Aβ plaques, and masitinib, a tyrosine kinase inhibitor that impacts mast and microglia cells. Additional anti-inflammatory agents being currently tested in phase-2 clinical trials, such as atomoxetine (selective norepinephrine reuptake inhibitor), losartan (angiotensin 2 receptor agonist), genistein (anti-inflammatory isoflavone neuroprotective agent), trans-resveratrol (polyphenol antioxidant plant estrogen), and benfotiamine (synthetic thiamine precursor), were reviewed. Lastly, drugs targeting Alzheimer's-associated symptoms, such as brexpiprazole (serotonin dopamine activity modulator) and suvorexant (orexin receptor antagonist), respectively, used for agitation and insomnia in AD patients, are reviewed.As experimental investigations and clinical research progress, there is a possibility that a combination of newly tested medications and traditional ones may emerge as a promising treatment option for AD in the future.

Brain structural alterations associated with impulsiveness in male violent patients with schizophrenia

BackgroundViolence in schizophrenia (SCZ) is a phenomenon associated with neurobiological factors. However, the neural mechanisms of violence in patients with SCZ are not yet sufficiently understood. Thus, this study aimed to explore the structural changes associated with the high risk of violence and its association with impulsiveness in patients with SCZ to reveal the possible neurobiological basis.MethodThe voxel-based morphometry approach and whole-brain analyses were used to measure the alteration of gray matter volume (GMV) for 45 schizophrenia patients with violence (VSC), 45 schizophrenia patients without violence (NSC), and 53 healthy controls (HC). Correlation analyses were used to examine the association of impulsiveness and brain regions associated with violence.ResultsThe results demonstrated reduced GMV in the right insula within the VSC group compared with the NSC group, and decreased GMV in the right temporal pole and left orbital part of superior frontal gyrus only in the VSC group compared to the HC group. Spearman correlation analyses further revealed a positive correlation between impulsiveness and GMV of the left superior temporal gyrus, bilateral insula and left medial orbital part of the superior frontal gyrus in the VSC group.ConclusionOur findings have provided further evidence for structural alterations in patients with SCZ who had engaged in severe violence, as well as the relationship between the specific brain alterations and impulsiveness. This work provides neural biomarkers and improves our insight into the neural underpinnings of violence in patients with SCZ.

Use of actigraphy for monitoring agitation and rest-activity cycles in patients with acute traumatic brain injury in the ICU

ABSTRACT Background In traumatic brain injury patients (TBI) admitted to the intensive care unit (ICU), agitation can lead to accidental removal of catheters, devices as well as self-extubation and falls. Actigraphy could be a potential tool to continuously monitor agitation. The objectives of this study were to assess the feasibility of monitoring agitation with actigraphs and to compare activity levels in agitated and non-agitated critically ill TBI patients. Methods Actigraphs were placed on patients’ wrists; 24-hour monitoring was continued until ICU discharge or limitation of therapeutic efforts. Feasibility was assessed by actigraphy recording duration and missing activity count per day. Results Data from 25 patients were analyzed. The mean number of completed day of actigraphy per patient was 6.5 ± 5.1. The mean missing activity count was 20.3 minutes (±81.7) per day. The mean level of activity measured by raw actigraphy counts per minute over 24 hours was higher in participants with agitation than without agitation. Conclusions This study supports the feasibility of actigraphy use in TBI patients in the ICU. In the acute phase of TBI, agitated patients have higher levels of activity, confirming the potential of actigraphy to monitor agitation.

Dexmedetomidine as an Emerging Treatment of Agitation in Psychiatric Patients: A Narrative Review

Acute agitation occurs in a variety of medical and psychiatric conditions and is the clinical presentation in a significant percentage of urgent psychiatric episodes, requiring prompt and effective intervention. Traditionally, agitation was managed in psychiatric wards using physical restraint. With the advent of tranquilizing neuroleptics, such as chlorpromazine, the pharmacological management of these conditions became possible. Acute agitation, although a potential result of most psychiatric disorders, is often associated with psychotic conditions, mood disorders and neurodegenerative disorders. The authors propose to explore dexmedetomidine as a therapeutic option in states of acute agitation in psychiatric patients in which traditional drugs are not effective. The authors based the work on a non-systematic review of the literature. Keywords used included: dexmedetomidine, acute agitation, rapid tranquilisation, restraint, sedation, psychiatric population and psychiatric disorders. Recently, a significant step forward in methods of treating acute agitation has been achieved through the use of dexmedetomidine in psychiatric patients. It is a selective α2‐receptor agonist being approved for short‐term sedation with the benefit of not having excessive sedation, thus allowing a concomitant psychotherapeutic approach. This proves to be a promising treatment option for those with acute agitation. The amount of studies available on its usefulness in psychiatric mental illness are still scarce. The interventional recommendations in the literature for agitation were developed based on research data, theoretical considerations and clinical experience, however, studies that provide definitive data are needed. It is imperative that the investigation of episodes of acute agitation and their restraint evolve, in order to protect these patients from the consequences of this behaviour and its treatment. Exploring the potential of dexmedetomidine as a tool in the mental health professional’s kit is well deserved as there are few alternatives that reassure the highly agitated patient without excessive sedation.

Screening and Intervention to Prevent Violence Against Health Professionals from Hospitalized Patients: A Pilot Study

Health care providers, particularly nursing staff, are at risk of physical or emotional abuse from patients. This abuse has been associated with increased use of physical and pharmacological restraints on patients, poor patient outcomes, high staff turnover, and reduced job satisfaction. In this study, a multidisciplinary team at Tufts Medical Center implemented the Brøset Violence Checklist (BVC), a screening tool administered by nurses to identify patients displaying agitated behavior. Patients who scored high on the BVC received a psychiatry consultation, followed by assessments and recommendations. This tool was implemented in an inpatient medical setting in conjunction with a one-hour de-escalation training led by nursing and Public Safety. The intervention design was executed through a series of three distinct Plan-Do-Study-Act cycles. This study measured the number of BVCs completed and their scores, the number of psychiatric consults placed, the number of calls to Public Safety, the number of staff assaults, nursing restraint use, and staff satisfaction. During the study period, restraint use decreased 17.6% from baseline mean and calls to Public Safety decreased 60.0% from baseline mean. In the staff survey, nursing staff reported feeling safer at work and feeling better equipped to care for agitated patients. The BVC is an effective, low-cost tool to proactively identify patients displaying agitated or aggressive behavior. Simple algorithms for next steps in interventions and training help to mitigate risk and increase feelings of safety among staff. Regular psychiatric rounding and the identification of champions were key components in a successful implementation.

Awareness of standard precautions, circumstances of occurrence and management of occupational exposures to body fluids among healthcare workers in a regional level referral hospital (Bertoua, Cameroon)

BackgroundHealthcare workers (HCW) are exposed to infectious agents within biological materials including blood, tissues, other body fluids and on medical supplies, contaminated surfaces within the care delivery environment. Trends in occupational injuries are influenced by the level of awareness and observance of standard precautions (SP) among HCWs. This study aimed to assess the level of awareness of SP, exposure to body fluids, reporting pattern and management among HCWs in a Referral Hospital.MethodsThe present hospital-based cross-sectional study was carried out from 1st November 2020 to 31st May 2021. The exhaustive sampling method was used and a total of 120 consenting HCWs were invited to participate. A self-administered questionnaire addressed questions related to knowledge, experience, circumstances of exposure, reporting, management of occupational exposure to body fluids, hepatitis B vaccination status. Data were analyzed using R Statistic version 4.3.1. A p-value < 0.05 was considered significant.ResultsOut of the 120 participating HCWs, 104 (86.7%) reported at least one accidental exposure to body fluids over the last year. Men (aOR = 4.19; p = 0.277) and HCWs aged 35 and over (aOR = 4.11; p = 0.114) were more at risk for AEB even though the difference was not statistically significant. Nurses/midwives (aOR = 65.9; p-value = 0.0005) and cleaners (aOR = 14.7; p-value = 0.0438) faced the highest risk of exposure. Lack of knowledge (79%) and patient agitation (49%) were the most reported reasons for exposure. Half of the participants (53%) reported that they used a personal protective equipment during care. Face mask (59.2%) and gowns (30.8%) were the most commonly used PPE. Most HCWs (62%) did not report AEB. Half of the affected HCWs (50.8%) received a course of post-exposure antiretroviral therapy. Few HCWs (4.2%) were fully immunized against Hepatitis B.ConclusionsMost HCWs reported an accidental exposure to body fluids over the last year. Midwives and nurses were disproportionally affected socio-professional groups. Two-thirds of the AEB were undeclared. Only half of the participants reported using PPE systematically. Hepatitis B vaccination coverage was low. There is need to strengthen the observance of standard precautions, including preventive vaccination and the systematic reporting and management of AEB.

Risperidone Induced DRESS Syndrome: A case report

IntroductionDRESS (Drug Reaction with Eoshinophilia and Systemic Symptoms) syndrome, also called DIHS (Drug-Induced Hypersensitivity Syndrome) is a rare drug-induced systemic hypersensitivity reaction that can be potentially life-threatening (Choudhary et al. J Clin Aesthet Dermatol 2013; 6 -7). Risperidone is an antipsychotic drug with significant antagonist activity at the 5-HT2 and the D2 receptors. It has been reported that risperidone may be effective in controlling agitation, delusion, hallucination, and withdrawal behavior in geriatric patients (Yunusa &amp; El Helou. Front Pharmacol 2020;11:596).Objectives The aim of this study is to demonstrate the case of developed DRESS syndrome following the use of risperidone.Methods The 81-year-old female patient was admitted to the Dermatology Clinic due to skin rash, high fever and leukocytosis following the use of risperidone. The patient was consulted to Psychiatry.Results In her history it was determined that risperidone 0.5 mg/d was started to the patient with depression due to agitative symptom. On the 4th day of treatment, targeoid lesions, starting from the back and spreading first to the trunk and then to the extremities, were observed. Further laboratory examinations revealed that the fever was measured at 39.5 C°, liver enzymes were elevated (ALT= 119 IU/ lt, AST= 124 IU /lt), and significant leukocytosis (WBC =12.000) was present along with the lesions. The patient was planned to be hospitalized to Dermatology Clinic on the 5th day and risperidone was stopped. The patient’s agitation increased and following the risperidone discontinuation thereupon the lesions tended to fade and desquamation began. After the treatment of the DRESS syndrome, aripiprazole was given to the patient for agitative symptom. The level of agitation symptoms decreased, and the patient tolerated aripiprazole well without any observed side effects.Image:ConclusionsWhen initiating medication for the elderly population to address agitation, considering such rare side effects can prevent the patient from being hospitalized due to DRESS syndrome. To the best of our knowledge, this is the first case report associated with DRESS syndrome and risperidone treatment thus, it is necessary to be very careful when starting psychotropic medication for elderly patients.Disclosure of InterestNone Declared

Pathophysiology and Management of Amphetamine-Related Psychiatric Disorders

IntroductionAmphetamines may induce symptoms of psychosis very similar to those of acute schizophrenia spectrum psychosis. This has been an argument for using amphetamine-induced psychosis as a model for primary psychotic disorders. To distinguish the two types of psychosis on the basis of acute symptoms is difficult. However, acute psychosis induced by amphetamines seems to have a faster recovery and appears to resolve more completely compared to schizophrenic psychosis.ObjectivesThe objectives of this e-poster is to identify the pathophysiology of amphetamine-related psychiatric disorders and outline the available treatment and management options for amphetamine-related psychiatric disorders.MethodsA bibliopgraphical review was performed using PubMed platform. All relevant articles were found using the keywords: psychotic episode, amphetamines, pathophysiology and menagement.Results Amphetamines inhibit monoamine (dopamine, norepinephrine, epinephrine, serotonin) reuptake, leading to increased monoamine concentrations in the neuronal synapse. Amphetamines can also lead to increased monoamines in the cytosol by interactions with vesicular monoamine transporter 2. Dopamine and norepinephrine release in the nucleus accumbens results in a feeling of euphoria and a reward feedback loop, which may result in addiction. Studies also suggest increased dopaminergic pathways lead to glutamate excesses in the cerebral cortex, altering the function of cortical GABAergic neurons. This damage leads to dysregulation of glutamate in the cerebral cortex, a precursor to psychosis. Prior psychiatric studies have found that GABAergic cortical dysfunction seems to relate to schizophrenia. Generally, acutely agitated psychotic patients are treated with intravenous benzodiazepines (lorazepam, diazepam, or midazolam) as first-line agents. However, if a second-line agent is needed, antipsychotic medicines like risperidone, haloperidol, ziprasidone, and olanzapine have been successful in managing amphetamine-associated psychosis. Lipophilic beta-blockers, such as metoprolol and labetalol, have also been used successfully to resolve agitation and hyperadrenergic vital signs.ConclusionsCompared to schizophrenic psychosis, amphetamine-induced acute psychosis induced appears to demonstrate a more rapid recovery. It also seems to resolve with substance abstinence; however, this recovery may be incomplete.Disclosure of InterestNone Declared

Sleep Disturbance During Post-Traumatic Amnesia and Early Recovery After Traumatic Brain Injury.

After moderate to severe traumatic brain injury (TBI), sleep disturbance commonly emerges during the confused post-traumatic amnesia (PTA) recovery stage. However, the evaluation of early sleep disturbance during PTA, its recovery trajectory, and influencing factors is limited. This study aimed to evaluate sleep outcomes in patients experiencing PTA using ambulatory gold-standard polysomnography (PSG) overnight and salivary endogenous melatonin (a hormone that influences the sleep-wake cycle) assessment at two time-points. The relationships between PSG-derived sleep-wake parameters and PTA symptoms (i.e., agitation and cognitive disturbance) were also evaluated. In a patient subset, PSG was repeated after PTA had resolved to assess the trajectory of sleep disturbance. Participants with PTA were recruited from Epworth HealthCare's inpatient TBI Rehabilitation Unit. Trained nurses administered overnight PSG at the patient bedside using the Compumedics Somté portable PSG device (Compumedics, Ltd., Australia). Two weeks after PTA had resolved, PSG was repeated. On a separate evening, two saliva specimens were collected (at 24:00 and 06:00) for melatonin testing. Results of routine daily hospital measures (i.e., Agitated Behavior Scale and Westmead PTA Scale) were also collected. Twenty-nine patients were monitored with PSG (mean: 41.6 days post-TBI; standard deviation [SD]: 28.3). Patients' mean sleep duration was reduced (5.6 h, SD: 1.2), and was fragmented with frequent awakenings (mean: 27.7, SD: 15.0). Deep, slow-wave restorative sleep was reduced, or completely absent (37.9% of patients). The use of PSG did not appear to exacerbate patient agitation or cognitive disturbance. Mean melatonin levels at both time-points were commonly outside of normal reference ranges. After PTA resolved, patients (n = 11) displayed significantly longer mean sleep time (5.3 h [PTA]; 6.5 h [out of PTA], difference between means: 1.2, p = 0.005). However, disturbances to other sleep-wake parameters (e.g., increased awakenings, wake time, and sleep latency) persisted after PTA resolved. This is the first study to evaluate sleep disturbance in a cohort of patients as they progressed through the early TBI recovery phases. There is a clear need for tailored assessment of sleep disturbance during PTA, which currently does not form part of routine hospital assessment, to suggest new treatment paradigms, enhance patient recovery, and reduce its long-term impacts.

Needs and Problems of the Caregivers of Psychiatric Patients With Violent Behaviours.

Violent behaviour exhibited by psychiatric patients is a major problem faced by their family members. Agitated violent patients constitute a part of all emergency psychiatry treatment, and family members carry out most of the care for the mentally ill. Caring for the mentally ill is a burden for the caregivers, and they face difficulties and problems that affect their health and well-being. This study aimed to assess the needs and problems of the caregivers of psychiatric patients with violent behaviour. This study was conducted at Mary LottLyles Hospital, Andhra Pradesh, India. Fifty caregivers of patients with violent behaviour were assessed concerning their needs and problems, which were explored using an open-ended questionnaire, and responses were documented and voice-recorded. Qualitative and quantitative analyses were done. Caregivers of psychiatric patients exhibiting violent behaviour face pressing needs and formidable challenges. They urgently require prompt treatment, detailed explanations from healthcare professionalsand hope for their loved ones' full recovery. However, they grapple with managing the unpredictable and aggressive behaviour of patients, transportation difficultiesand the pervasive stigma of mental illness. Economic crises further exacerbate their struggles, making it challenging to access necessary care and support for their relatives. Despite the challenges encountered in handling violent behaviour, caregivers consistently ensured that patients received emergency treatment and ongoing care. They stressed the importance of healthcare professionals understanding their needs and those of the patients. These results highlight the necessity of addressing the comprehensive requirements of both patients and caregivers when dealing with violent behaviour in psychiatric settings.

Advancing Emergency Medical Services’ (EMS) Response Capability for Behavioral Health Emergencies: Los Angeles County’s Performance Improvement Initiative

Introduction Behavioral health emergencies (BHEs) are a common patient encounter for emergency medical services (EMS) clinicians and other first responders, in particular law enforcement (LE) officers. It is critical for EMS clinicians to have management strategies for BHEs, yet relatively little information exists on best practices. In 2016, the Los Angeles County EMS Agency’s Commission initiated a comprehensive evaluation of the 9-1-1 response for BHEs and developed a plan for improving the quality of care and safety for patients and first responders. Methods A Behavioral Health Initiative Committee was assembled with broad representation from EMS, LE, health agencies, and the public. Committee objectives included: 1) produce a process map of the BHE response from the time of a 9-1-1 call to patient arrival at transport destination, 2) identify and describe the different agencies that respond, 3) describe the critical decision points in the EMS and LE field responses, 4) acquire data that quantitatively and/or qualitatively describe the services available, and 5) recommend interventions for system performance improvement. Results The committee generated comprehensive process maps for the prehospital response to BHEs, articulated principles for evaluation, and described key observations of the current system including: 9-1-1 dispatch criteria are variable and often defaults to a LE response, the LE response inadvertently criminalizes BHEs, EMS field treatment protocols for BHEs (and especially agitated patients) are limited, substance use disorder treatment lacks integration, destination options differ by transporting agency, and receiving facilities’ capabilities to address BHEs are variable. Recommendations for performance improvement interventions and initial implementation steps included: standardize dispatch protocols, shift away from a LE primary response, augment EMS treatment protocols for BHEs and the management of agitation, develop alternate destination for EMS transport. Conclusion This paper describes a comprehensive performance improvement initiative in LAC-EMSA’s 9-1-1 response to BHEs. The initiative included a thorough current state analysis, followed by future state mapping and the implementation of interventions to reduce LE as the primary responder when an EMS response is often warranted, and to improve EMS protocols and access to resources for BHEs.

Macroglossia Revealing a Neuroleptic Malignant Syndrome: a Clinical Images

Neuroleptic malignant syndrome is a rare and potentially fatal side effect that can occur in response to treatment with antipsychotic drugs. It is characterized by four main symptoms: Impaired mental function, fever, muscle rigidity and autonomic dysfunction. We report the case of a 20-year-old patient, followed for psychosis, in whom a new therapeutic line was adapted 3 days ago: Largactil (chlorpromazine) and Haldol (Haloperidol), who presented to the maxillofacial emergency department with tongue laceration. Clinical examination revealed in an agitated, uncooperative tachycardic and apyretic patient, revealed a generalized muscular spasm associated with trismus attacks, causing tongue injuries due to the installed macroglossia.

Ventilator-assisted preoxygenation in an aeromedical retrieval setting.

Ventilator-assisted preoxygenation (VAPOX) is a method of preoxygenation and apnoeic ventilation which has been tried in hospital setting. We aimed to describe VAPOX during intubation of critically unwell patients in aeromedical retrieval setting. Retrospective observational study of VAPOX performed at LifeFlight Retrieval Medicine (LRM) between January 2018 and December 2022 across Queensland, Australia. Demographic and clinical data were recorded. Descriptive statistics and paired Student's t-tests were used to evaluate the efficacy of VAPOX on oxygen saturation (SpO2). VAPOX was used in 40 patients. Diagnoses included pneumonia (n = 11), COPD (n = 6) and neurological (n = 7). Patients were intubated in hospital (n = 36), in helicopter (n = 2) and ambulance (n = 2). Median VAPOX settings were: positive end-expiratory pressure 6 (IQR 5-9), pressure support 10 (IQR 10-14) and back up respiratory rate 14 (IQR 11-18). Twelve agitated patients underwent delayed sequence induction with ketamine. There was a statistically significant increase in SpO2 after application of VAPOX (P < 0.001), followed by a slight decrease after intubation (P = 0.006). Mean SpO2 were significantly improved after intubation compared with on arrival of LRM (P = 0.016). Hypotension was present prior to VAPOX (n = 13), during VAPOX (n = 2) and post-intubation (n = 15). Two patients had cardiac arrest. Three patients were started on VAPOX but subsequently failed. There were no significant oxygen depletion or aspiration events. VAPOX can be considered for pre-intubation optimisation in the retrieval environment. The incidence of post-intubation critical hypoxia was low, and hypotension was high. Pre-intubation respiratory physiology can be optimised by delivering variable pressure supported minute ventilation, achieving a low incidence of critical hypoxia.

Wrist-worn actigraphy in agitated late-stage dementia patients: A feasibility study on digital inclusion.

Wrist-worn actigraphy can be an objective tool to assess sleep and other behavioral and psychological symptoms in dementia (BPSD). We investigated the feasibility of using wearable actigraphy in agitated late-stage dementia patients. Agitated, late-stage Alzheimer's dementia care home residents in Greater London area (n=29; 14 females, mean age±SD: 80.8±8.2; 93.1% White) were recruited to wear an actigraphy watch for 4weeks. Wearing time was extracted to evaluate compliance, and factors influencing compliance were explored. A high watch-acceptance (96.6%) and compliance rate (88.0%) was noted. Non-compliance was not associated with age or BPSD symptomatology. However, participants with "better" cognitive function (R=0.42, p=0.022) and during nightshift (F1.240, 33.475=8.075, p=0.005) were less compliant. Female participants were also marginally less compliant (F1, 26=3.790, p=0.062). Wrist-worn actigraphy appears acceptable and feasible in late-stage agitated dementia patients. Accommodating the needs of both the patients and their carers may further improve compliance.

Assesment of Dangerousness in Psychiatry: What are They in the Field?

We are confronted with violence daily, through the media and social networks. This scourge brings into play the presence of several factors favouring the potential for dangerousness in some people compared to others. The distinction between criminal dangerousness and psychiatric dangerousness is essential for care. Psychiatry is often confronted with emergencies, the examination of a violent patient, assigning him the heavy task of deciding on the potential danger (for himself and others) of this patient, and the risk of recidivism. What about on the ground?

De-escalation of the Agitated Pediatric Patient: A Standardized Patient Case for Pediatric Residents.

Over the past 5 years, pediatric mental health emergencies requiring emergency safety evaluations and inpatient boarding of pediatric patients requiring psychiatric admission have increased. Pediatric trainees must learn to effectively and safely de-escalate a patient with agitated or aggressive behavior, as mental health patients take up a larger proportion of their patient population. This standardized patient case addresses gaps in knowledge and skills to ameliorate the care of children and adolescents with behavioral crises in the hospital. Resident learners were presented with a teenage patient admitted to the hospital and awaiting inpatient psychiatric placement for suicidal ideation who became acutely agitated with aggressive behaviors. Learners were expected to attempt to verbally de-escalate the patient and select an appropriate pharmacologic agent for decreasing agitation in the patient. A standardized debrief was conducted with the assistance of child and adolescent mental health experts. Twenty-two learners participated in this activity. Residents' confidence in their management skills of the acutely agitated pediatric patient significantly increased after completion of the activity. Seventy-three percent of learners felt confident or very confident in their de-escalation skills at the end of the case, and 86% agreed that the case improved their confidence in managing acute agitation scenarios on the inpatient wards. This case led to overall increased self-efficacy in caring for the acutely agitated pediatric patient. Future iterations may include multidisciplinary learners of various skill levels and evaluating changes in patient-centered outcomes, such as restraint use, after implementation of the case.