Brazilian guidelines for the management of psychomotor agitation. Part 1. Non-pharmacological approach

Abstract

Objective:To present the essential guidelines for non-pharmacological management of patients with psychomotor agitation in Brazil.Methods:These guidelines were developed based on a systematic review of articles published from 1997 to 2017, retrieved from MEDLINE (PubMed), Cochrane Database of Systematic Review, and SciELO. Other relevant articles identified by searching the reference lists of included studies were also used to develop these guidelines. The search strategy used structured questions formulated using the PICO model, as recommended by the Guidelines Project of the Brazilian Medical Association. Recommendations were summarized according to their level of evidence, which was determined using the Oxford Centre for Evidence-based Medicine system and critical appraisal tools.Results:We initially selected 1,731 abstracts among 5,362 articles. The final sample included 104 articles that fulfilled all the inclusion criteria. The management of agitated patients should always start with the least coercive approach. The initial non-pharmacological measures include a verbal strategy and referral of the patient to the appropriate setting, preferably a facility designed for the care of psychiatric patients with controlled noise, lighting, and safety aspects. Verbal de-escalation techniques have been shown to decrease agitation and reduce the potential for associated violence in the emergency setting. The possibility of underlying medical etiologies must be considered first and foremost. Particular attention should be paid to the patient’s appearance and behavior, physical signs, and mental state. If agitation is severe, rapid tranquilization with medications is recommended. Finally, if verbal measures fail to contain the patient, physical restraint should be performed as the ultimate measure for patient protection, and always be accompanied by rapid tranquilization. Healthcare teams must be thoroughly trained to use these techniques and overcome difficulties if the verbal approach fails. It is important that healthcare professionals be trained in non-pharmacological management of patients with psychomotor agitation as part of the requirements for a degree and graduate degree.Conclusion:The non-pharmacological management of agitated patients should follow the hierarchy of less invasive to more invasive and coercive measures, starting with referral of the patient to an appropriate environment, management by a trained team, use of verbal techniques, performance of physical and mental assessment, use of medications, and, if unavoidable, use of the mechanical restraint.Systematic review registry number:CRD42017054440.

The Impact of Mental Illness Stigma on Psychiatric Emergencies

“…In the emergency room, care must be taken with physical restraint, which should only be used as a last resort to protect the patient in cases of psychomotor agitation (7,61). Before physical restraint is considered, all other techniques should be employed, especially verbal de-escalation.…”

“…Before physical restraint is considered, all other techniques should be employed, especially verbal de-escalation. Physical restriction presents significant risks (7,62). Trauma from coercive techniques, which may seem a little coercive, can cause feelings of fear, humiliation, and helplessness, both for the patient and for the professionals (7,31).…”

“…Physical restriction presents significant risks (7,62). Trauma from coercive techniques, which may seem a little coercive, can cause feelings of fear, humiliation, and helplessness, both for the patient and for the professionals (7,31). Unexpected events can occur, such as orthopedic injury, dehydration, rhabdomyolysis, thrombosis, asphyxia, and even death (7,62).…”

“…Psychiatric emergencies are severe behavioral changes secondary to worsening mental illness. Such situations present a risk to the patient and other people, so they need immediate therapeutic intervention (6,7). Although such emergencies can also be secondary to physical illnesses, what differs them from other emergencies is precisely the presence of severe behavioral changes.…”

“…In most cases, they represent extreme severity in mental illness, they are associated with feelings of fear, anger, prejudice, and even exclusion. Among the most prevalent psychiatric emergencies are suicidal behavior, severe depressive or manic episodes, self-mutilation, severely impaired judgment, severe self-neglect, substance intoxication or abstinence crises, and aggressive agitation (6,7). Adequate management of such situations can reduce patient suffering and prevent the perpetuation of stigma.…”