Combative or Confused patients

1. Does the patient have altered mental status or is he/she upset over something?
2. If there is any question of physical injury, call security (0). No matter how many years of commando training you have, it is not your responsibility to restrain patients in a safe manner. Also, patients generally tend to calm down when they are confronted by overwhelming numbers of people who are responsive to their needs or anxieties.
3. Try to do as much of an altered mental status workup as you can. If you suspect an underlying reason for the agitation (pain, sundowning, hypoxia, medication), then obviously treat the underlying reason. 

Management

Non-pharmacologic

• Accompaniment (sitter, family members at the bedside or via phone)
• Minimize restraint but if you 
• If you feel restraints are needed, you need to put order under non-violent restraint specifying the type of restraint and the reason for initiating. They must be renewed every 24 hours. Generally, try to initiate the least restrictive type of restraint. Posey vests prevent patients from leaving the bed but leave the arms and legs free. Four-point cloth restraints limit the movement of arms and legs. They are more restrictive than Poseys but may be necessary if a patient is pulling out lines, etc.

Pharmacologic

• Haldol 0.5mg - 1mg BID PO or IM can also used as needed q4hr
• Quetiapine 12.5mg-25mg once at night 
• Olanzapine 5mg-10mg IM, may repeat based on response 2 hrs after the initial dose and 4hrs after second dose. Max 30mg/day
• Benzo (avoid in elderly): 0.5-1mg q4hr