Page 35 - JSOM Fall 2024

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a joint guideline on managing suicide risk in general. Other enable a more thorough medical and psychiatric evaluation to
published empirical reports on managing suicidal ideations in be conducted. In certain cases of severe agitation, restraints
deployed environments were incorporated into this guideline. may have to be used before medications.
Based on one of the reports, a vast majority of patients (96%)
who endorsed suicidal ideation within the past month did not Verbal de-escalation is defined as a set of environmental con-
get medically evacuated. 7 siderations and verbal techniques to allow the patient to calm
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themselves down. Specific techniques of verbal de-escalation
are described in Box 3. 11
Assessment and Treatment Guideline
Assessment of CSRs BOX 3 Summary of Verbal De-Escalation Techniques 11
Combat stress reaction is defined as normal but significant • Two-arm lengths of space
changes in psychological and physiological functioning due to • Give patient choices
9
gratuitous exposure to combat or operational stress. The most • Provider hands visible
common manifestations are exhaustion, inability to perform • Believe the patient
normal tasks, insomnia in the absence of acute combat en- • One provider talks to patient
• Agree with patient on something
gagement, inability to focus (in more severe cases loss of sense • Use short sentences
of reality), extreme anger (expressed verbally or physically), • Set limits/voice consequences
loss of positive emotions, recklessness, conduct problems, and • Ask patient their wants
increased medical complaints, which in previous conflicts have • Debrief with staff after
manifested as functional neurological symptoms. 9
The medication recommendations for the treatment of agita-
Treatment of CSRs
Currently, PIES is the recommended treatment for CSRs and is tion from unknown causes, nonpsychotic psychiatric illness
defined as rudimentary psychotherapy that is proximal (pro- (e.g., CSR), psychosis, substance-induced psychosis, mania,
12,16,17
vided by medical personnel who are as embedded as possible and delirium are listed in Table 1. Oral administration
to the stress casualty), immediate (as soon as the stress reac- of medications is preferred when patients are cooperative.
tion has been identified and not delay treatment to the next Intramuscular or intranasal administration is preferred if the
level of care), delivered with expectancy (expectation of full patient is uncooperative or combative. The use of ketamine
recovery of the temporary symptoms, including a return to full to treat agitation has been recently evaluated and is under-
duty), and carried out through the use of simple interventions going further testing for severe nonpsychotic agitation. Com-
such as the use of the 5 Rs (see Box 1). For treatment of severe, pared with antipsychotics and benzodiazepines, ketamine has
17,18
acute CSRs such as freezing behavior, the 6-step bystander in- a shorter time to sedation.
vention termed ICOVER (see Box 2) is recommended. 16
Restraints are any physical or material method that prevents
a patient from moving part or parts of their body. Restraints
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BOX 1 5 Rs Mnemonic for CSR Treatment 8
should be used immediately if a patient is currently or in im-
• Reassure that CSRs are normal minent danger of hurting themselves or others. This method
• Rest
• Replenish (fluids, food, sleep, hygiene, thermal comfort) should be used along with medication for agitation and should
• Restore confidence by continuing to engage in meaningful work be used only when verbal de-escalation and/or pharmacolog-
• Return to duty/reunite with unit ical methods are ineffective. To properly restrain a patient,
a minimum of five staff members and/or security personnel
BOX 2 ICOVER Mnemonic for Acute CSRs with Freezing Features 16 should assist. Patients are to be restrained in the supine (belly
up) position to prevent asphyxiation and with arms at an an-
I = Identify stress casualty gle lower than 90° to the torso. Four team members should
C = Connect via physical touch and asking for eye contact
O = Offer reassurance to affected member that they are not alone be assigned to each of the four limbs, with a remaining team
V = Verify by asking questions about patient’s unit and commander’s member leading the intervention and placing the physical re-
name straint on the patient.
E = Establish what is occurring and what is next
R = Request action to the affected member
Assessment of Psychosis and Mania
Psychosis is defined as delusions, hallucinations, illogical
Agitation Assessment thinking, verbalizations, or bizarre behaviors by a patient. De-
Agitation is defined as acute disruptive or destructive behavior lusions are implausible beliefs, which are often paranoid in na-
on the part of the patient that has the potential to harm self, ture. Hallucinations are patient reports of implausible voices,
others, or valuable property. Determining the cause of agita- visions, or other inclinations. Psychosis should be differenti-
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tion is paramount to providing the correct treatment. Causes ated from delirium, which is a medically induced loss of mem-
of agitation include delirium, head injury, intoxication, with- ory, concentration, and reality testing (e.g., severe infections
drawal, psychosis and mania, or another psychiatric condition. or head injuries may cause an altered mental state). Psychotic
Collateral sources, the patient’s chief complaint, and visual behavior should be distinguished from severe insomnia and
signs of agitation assist in determining the cause of agitation. 10 should be considered as an etiology based on collateral reports
of team members, if available.
Agitation Treatment
Treat agitation with the least invasive treatment: verbal de- Mania is a severe psychiatric state lasting at least 7 days. It
escalation, then medication, and finally restraints, if other is characterized by a lack of ability to sleep, excessive goal-
interventions are ineffective. The goal of treating agitation is directed behaviors, boundless energy, rapid speech, grandiose
to calm the patient without overly sedating them. This will ideas, and, at times, psychosis.
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Tactical Psychiatric Care | 33