Ghid de abordare a pacientului agresiv si violent in urgenta
Ghid de abordare a pacientului agresiv si violent in urgenta
Ghid de abordare a pacientului agresiv si violent in urgenta
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<strong>Ghid</strong> <strong>de</strong> <strong>abordare</strong> a <strong>pacientului</strong> <strong>agre<strong>si</strong>v</strong> <strong>si</strong> <strong>violent</strong><br />
<strong>in</strong> <strong>urgenta</strong><br />
Al<strong>in</strong>a Petrica, Mihai Grecu <br />
277<br />
Introducere<br />
Comportamentul <strong>violent</strong> reprez<strong>in</strong>ta un set <strong>de</strong> actiuni ce utilizeaza forta,<br />
sau care <strong>de</strong>term<strong>in</strong>a lezarea <strong>pacientului</strong> sau a celor d<strong>in</strong> jur. In esenta, comportamentul<br />
<strong>violent</strong> reprez<strong>in</strong>ta raspunsul la o serie <strong>de</strong> circumstante. Raspunsul<br />
<strong>in</strong>dividualizat la aceste circumstante este <strong>in</strong>fluentat <strong>de</strong> o serie <strong>de</strong> factori, <strong>de</strong><br />
exemplu, caracteristicile personalitatii precum <strong>agre<strong>si</strong>v</strong>itatea, impul<strong>si</strong>vitatea,<br />
comportamentul antisocial.<br />
Emotiile, <strong>in</strong> special teama, lipsa <strong>de</strong> putere, supararea, furia, joaca un rol<br />
important <strong>in</strong> <strong>de</strong>clansarea raspunsului <strong>violent</strong>. Agitatia sau hiperactivitatea<br />
p<strong>si</strong>homotorie <strong>si</strong> p<strong>si</strong>hoza (afectarea perceptiei rationale) se pot datora fie<br />
cauzelor medicale, fie p<strong>si</strong>hiatrice. Indiferent <strong>de</strong> cauza, orice comportament<br />
<strong>violent</strong> <strong>in</strong> <strong>de</strong>partamentul <strong>de</strong> <strong>urgenta</strong> reprez<strong>in</strong>ta un comportament nea<strong>de</strong>cvat<br />
<strong>si</strong> trebuie con<strong>si</strong><strong>de</strong>rat o stare patologica ce poate duce la morbiditate <strong>si</strong><br />
mortalitate (1).<br />
Profilul <strong>pacientului</strong> <strong>violent</strong><br />
Intreg personalul <strong>de</strong>partamentelor <strong>de</strong> <strong>urgenta</strong> trebuie sa cunoasca semnele<br />
<strong>si</strong> <strong>si</strong>mptomele ce sugereaza <strong>de</strong>clansarea unui comportament <strong>violent</strong>. Orice<br />
pacient poate <strong>de</strong>veni <strong>violent</strong>, dar pacientii cu afectiuni organice precum<br />
<strong>de</strong>menta, <strong>de</strong>lirium, <strong>in</strong>toxicatii, au o <strong>in</strong>ci<strong>de</strong>nta mai mare a <strong>violent</strong>ei <strong>de</strong>cat cei<br />
cu tulburari functionale precum mania <strong>si</strong> schizofrenia. Istoricul <strong>de</strong> <strong>violent</strong>a,<br />
<strong>in</strong>diferent <strong>de</strong> patologie este cel mai puternic predictor al comportamentului<br />
<strong>violent</strong> <strong>in</strong> <strong>de</strong>partamentul <strong>de</strong> <strong>urgenta</strong>.<br />
UPU – SMURD, Spitalul Cl<strong>in</strong>ic Ju<strong>de</strong>tean <strong>de</strong> Urgenta Timisoara<br />
Autor corespon<strong>de</strong>nt: Dr. Al<strong>in</strong>a Petrica, medic specialist Medic<strong>in</strong>a <strong>de</strong> Urgenta<br />
e-mail: al<strong>in</strong>a_guran@yahoo.com, Bd. I. Bulbuca, nr.10, 300736, Timisoara<br />
Timisoara 2008
Unii pacienti prez<strong>in</strong>ta un comportament <strong>violent</strong> <strong>in</strong> mod curent, iar altii<br />
se manifesta <strong>violent</strong> <strong>in</strong> functie <strong>de</strong> circumstante. Pacientul <strong>violent</strong> <strong>in</strong> mod<br />
curent este <strong>in</strong> general un tanar <strong>in</strong> jur <strong>de</strong> 30 <strong>de</strong> ani care are acces la arme<br />
sau care abuzeaza <strong>de</strong> alcool sau droguri. Acesta este o persoana care <strong>de</strong><br />
obicei are probleme cu autoritatile <strong>si</strong> are multiple arestari pentru agre<strong>si</strong>une<br />
<strong>in</strong> antece<strong>de</strong>nte.<br />
278<br />
Pacientii <strong>de</strong>pre<strong>si</strong>vi, cu comportament suicidar, con<strong>si</strong><strong>de</strong>ra ca nu au nimic <strong>de</strong><br />
pierdut <strong>si</strong> se pot manifesta <strong>violent</strong> fata <strong>de</strong> anturaj. Pacientii p<strong>si</strong>hiatrici par sa<br />
nu manifeste mai multa <strong>violent</strong>a <strong>de</strong>cat restul populatiei, exceptie facand cei<br />
cu schizofrenie paranoida atunci cand trec <strong>de</strong> la paranoia generalizata (“ma<br />
urmaresc”) la o anumita persoana sau grup (“X ma urmareste”)(2).<br />
Semne premonitorii ale comportamentului <strong>violent</strong><br />
1. Pacientul se manifesta <strong>violent</strong> sau amen<strong>in</strong>ta ca va <strong>de</strong>veni <strong>violent</strong>.<br />
2. Personalul <strong>si</strong>mte anxietate sau teama fata <strong>de</strong> pacient.<br />
3. Comportamentul alterneaza <strong>in</strong>tre strigate <strong>si</strong> perioa<strong>de</strong> <strong>de</strong> l<strong>in</strong>iste sau <strong>in</strong>tre<br />
cooperare <strong>si</strong> <strong>agre<strong>si</strong>v</strong>itate.<br />
4. Pacientul i<strong>si</strong> exprima teama <strong>de</strong> a-<strong>si</strong> pier<strong>de</strong> controlul.<br />
5. Pacientul este necooperant, ostil, agitat <strong>si</strong> <strong>in</strong>capabil sa stea l<strong>in</strong>istit.<br />
6. Pacientul se afla <strong>in</strong> stare <strong>de</strong> etilism acut, este <strong>in</strong>toxicat cu alte substante<br />
sau este <strong>in</strong> stare <strong>de</strong> sevraj.<br />
7. Pacientul are istoric <strong>de</strong> <strong>violent</strong>a, este cunoscut politiei sau personalului<br />
d<strong>in</strong> <strong>de</strong>partamentul <strong>de</strong> <strong>urgenta</strong> pentru comportament impul<strong>si</strong>v sau<br />
<strong>violent</strong>.<br />
8. Pacientul are o postura rigida, ten<strong>si</strong>onata <strong>si</strong> este suspicios.<br />
9. Pacientul are tatuaje care-i sugereaza apartenenta la o anumita grupare.<br />
Evitarea <strong>violent</strong>ei<br />
Majoritatea pacientilor <strong>de</strong>v<strong>in</strong> <strong>violent</strong>i <strong>in</strong> timp, <strong>si</strong> nu imediat, ce <strong>in</strong>tra <strong>in</strong><br />
<strong>de</strong>partamentul <strong>de</strong> <strong>urgenta</strong>. Acest aspect permite personalului sa se pregateasca<br />
<strong>si</strong> sa adopte alte meto<strong>de</strong> <strong>de</strong>cat imobilizarea. Intot<strong>de</strong>auna se <strong>in</strong>dica<br />
utilizarea meto<strong>de</strong>i <strong>de</strong> imobilizare cel mai put<strong>in</strong> restrictive pentru pacientii<br />
potential <strong>violent</strong>i. Pacientului trebuie sa i se ofere alternative pentru corectarea<br />
comportamentului nea<strong>de</strong>cvat, astfel <strong>in</strong>cat sa nu fie afectata relatia<br />
medic – pacient <strong>si</strong> nici <strong>de</strong>mnitatea <strong>pacientului</strong> (3).<br />
Meto<strong>de</strong> <strong>de</strong> evitare a <strong>si</strong>tuatiilor ten<strong>si</strong>onate <strong>si</strong> a comportamentului <strong>violent</strong>:<br />
1. Evita contactul vizual cu pacientul.<br />
2. Nu bloca ie<strong>si</strong>rile <strong>si</strong> lasa <strong>de</strong>schisa usa <strong>de</strong> la camera <strong>de</strong> exam<strong>in</strong>are.<br />
Actualitati <strong>in</strong> anestezie, terapie <strong>in</strong>ten<strong>si</strong>va <strong>si</strong> medic<strong>in</strong>a <strong>de</strong> <strong>urgenta</strong>
3. Ment<strong>in</strong>e o distanta apreciabila fata <strong>de</strong> pacientul <strong>violent</strong>, nu ii <strong>in</strong>vada<br />
spatiul.<br />
4. Adopta o postura <strong>si</strong> o atitud<strong>in</strong>e pa<strong>si</strong>va, necombativa <strong>si</strong> permite-i <strong>pacientului</strong><br />
sa spuna ce gan<strong>de</strong>ste.<br />
5. Comporta-te cu pacientul asa cum ai vrea sa se comporte <strong>si</strong> el.<br />
6. Ofera-i <strong>pacientului</strong> ceva <strong>de</strong> baut sau <strong>de</strong> mancare.<br />
7. Evita remarcile provocatoare sau malitioase.<br />
8. Daca pacientul <strong>de</strong>v<strong>in</strong>e <strong>agre<strong>si</strong>v</strong>, spune-i direct ca are un comportament<br />
nea<strong>de</strong>cvat care-i sperie pe cei d<strong>in</strong> jur <strong>si</strong> care nu este permis <strong>in</strong> <strong>de</strong>partamentul<br />
<strong>de</strong> <strong>urgenta</strong>.<br />
9. Nu <strong>in</strong>toarce spatele <strong>pacientului</strong> potential <strong>violent</strong>.<br />
10. Nu subestima niciodata potentialul <strong>violent</strong> al unui pacient.<br />
279<br />
Daca, <strong>in</strong> ciuda masurilor luate, pacientul cont<strong>in</strong>ua sa se manifeste <strong>violent</strong>,<br />
se poate apela la ajutorul familiei sau prietenilor.<br />
Cauzele comportamentului <strong>violent</strong> (4)<br />
1. Organice<br />
Sunt sugerate <strong>de</strong>:<br />
• <strong>de</strong>butul rapid al unui comportament p<strong>si</strong>hotic, agitat sau <strong>violent</strong> la un<br />
pacient fara antece<strong>de</strong>nte <strong>de</strong> boala p<strong>si</strong>hiatrica cu varsta > 40 <strong>de</strong> ani<br />
• prezenta unuia d<strong>in</strong> urmatoarele semne <strong>si</strong> <strong>si</strong>mptome<br />
- confuzie, <strong>de</strong>zorientare<br />
- bradip<strong>si</strong>hie<br />
- <strong>de</strong>ficite cognitive/<strong>in</strong>telectuale<br />
- vorbire neclara<br />
- haluc<strong>in</strong>atii vizuale<br />
- semne vitale anormale<br />
2. P<strong>si</strong>hiatrice<br />
Sunt suspicionate la pacientii cu :<br />
• varsta < 45 <strong>de</strong> ani<br />
• constienti <strong>si</strong> orientati temporo-spatial<br />
• semne vitale normale<br />
• istoric <strong>de</strong> boala p<strong>si</strong>hiatrica<br />
• haluc<strong>in</strong>atii auditive<br />
• gandire logica dar totu<strong>si</strong> bizara<br />
Schizofrenia paranoida este cea mai frecventa cauza <strong>de</strong> <strong>violent</strong>a <strong>in</strong> <strong>de</strong>partamentul<br />
<strong>de</strong> <strong>urgenta</strong>, fi<strong>in</strong>d urmata <strong>de</strong> tulburarile <strong>de</strong> personalitate.<br />
Timisoara 2008
3. Alte cauze<br />
• abuzul <strong>de</strong> alcool sau droguri<br />
• timpul lung <strong>de</strong> asteptare<br />
• <strong>in</strong>tarzierile <strong>in</strong> acordarea a<strong>si</strong>stentei medicale<br />
• complianta mai scazuta a anumitor categorii etnice<br />
• lipsa <strong>de</strong> <strong>in</strong>formare a pacientilor<br />
280<br />
Abordarea pacientilor <strong>violent</strong>i<br />
Cand pacientul <strong>de</strong>v<strong>in</strong>e brusc <strong>violent</strong>:<br />
• anunta serviciul <strong>de</strong> paza<br />
• dim<strong>in</strong>ua contactul vizual cu pacientul<br />
• a<strong>si</strong>gura-te ca tu <strong>si</strong> pacientul aveti acces egal la o usa<br />
• ment<strong>in</strong>e o distanta <strong>de</strong> <strong>si</strong>guranta fata <strong>de</strong> pacient (cel put<strong>in</strong> o lungime <strong>de</strong><br />
brat)<br />
• nu fugi sau nu te lupta <strong>de</strong>cat daca esti <strong>si</strong>gur <strong>de</strong> succes.<br />
Exam<strong>in</strong>area unui pacient potential <strong>violent</strong><br />
• cere personalului <strong>de</strong> paza sa perchizitioneze pacientul <strong>si</strong> sa <strong>in</strong><strong>de</strong>parteze<br />
eventualele arme<br />
• e <strong>in</strong>dicata prezenta personalului <strong>de</strong> paza <strong>in</strong> camera <strong>de</strong> exam<strong>in</strong>are sau <strong>in</strong><br />
fata acesteia<br />
• utilizeaza o camera <strong>de</strong> exam<strong>in</strong>are cu doua u<strong>si</strong><br />
• ment<strong>in</strong>e o distanta fata <strong>de</strong> pacient <strong>de</strong> 4 ori mai mare <strong>de</strong>cat <strong>in</strong> mod normal<br />
• <strong>in</strong><strong>de</strong>parteaza accesoriile personale ce pot fi utilizate ca arme<br />
• niciodata nu te apropia <strong>de</strong> pacient pr<strong>in</strong> spatele lui<br />
Managementul pacientilor <strong>violent</strong>i<br />
1. Managementul verbal<br />
Evitati confruntarea directa, dar impuneti limite. Subl<strong>in</strong>iati consec<strong>in</strong>tele<br />
comportamentului <strong>violent</strong>. Empatizati cu problemele <strong>pacientului</strong> <strong>si</strong> implicati <strong>si</strong><br />
alti membri ai personalului. Subl<strong>in</strong>iati faptul ca tot personalul vrea sa-i ajute.<br />
Fiti atenti la limbajul corpului: bratele <strong>in</strong>crucisate, ma<strong>in</strong>ile la spate, postura<br />
<strong>de</strong> aplecat <strong>in</strong>a<strong>in</strong>te, contactul vizual <strong>in</strong>tens sau prelungit, pot fi percepute<br />
ca amen<strong>in</strong>tatoare sau provocatoare.<br />
Cand vorbiti cu un pacient potential <strong>violent</strong> este important sa ment<strong>in</strong>eti<br />
un ton calm. Incercati sa nu exprimati manie sau ostilitate <strong>si</strong> niciodata nu<br />
m<strong>in</strong>imizati sau neglijati temerile <strong>si</strong> sentimentele pacientilor.<br />
Fiti atenti la schimbarile <strong>de</strong> dispozitie ale <strong>pacientului</strong>, vorbirea <strong>agre<strong>si</strong>v</strong>a<br />
sau cu tonalitate ridicata, cresterea activitatii p<strong>si</strong>homotorii, care pot sem-<br />
Actualitati <strong>in</strong> anestezie, terapie <strong>in</strong>ten<strong>si</strong>va <strong>si</strong> medic<strong>in</strong>a <strong>de</strong> <strong>urgenta</strong>
nifica pier<strong>de</strong>rea controlului <strong>de</strong> catre pacient. Daca perceptia personalului<br />
<strong>in</strong> fata <strong>pacientului</strong> este <strong>de</strong> ne<strong>si</strong>guranta <strong>si</strong> teama, este mai b<strong>in</strong>e sa se evite<br />
<strong>in</strong>teractiunea cu el pana cand sunt luate masuri.<br />
Aceasta <strong>abordare</strong> nu este eficienta la pacientii cu p<strong>si</strong>hoze, <strong>de</strong>lirium, <strong>in</strong>toxicatii<br />
severe sau agitatie secundara episoa<strong>de</strong>lor maniacale (5,6).<br />
2. Imobilizarea fizica<br />
Medicii trebuie sa specifice clar motivele imobilizarii chiar <strong>si</strong> atunci cand<br />
pacientul nu au<strong>de</strong> sau nu <strong>in</strong>telege. Toate <strong>de</strong>ciziile <strong>de</strong> imobilizare trebuie<br />
consemnate <strong>in</strong> scris. Imobilizarea fizica nu trebuie aplicata ca pe<strong>de</strong>apsa sau<br />
d<strong>in</strong> comoditate.<br />
Criterii <strong>de</strong> aplicare a imobilizarii fizice (Asociatia Americana <strong>de</strong> P<strong>si</strong>hiatrie)(7,8):<br />
• pentru a preveni autovatamarea sau vatamarea altor persoane cand au<br />
esuat alte meto<strong>de</strong> <strong>de</strong> control, mai put<strong>in</strong> severe<br />
• pentru a preveni perturbarea activitatii d<strong>in</strong> <strong>de</strong>partamentul <strong>de</strong> <strong>urgenta</strong> <strong>si</strong><br />
distrugerea aparaturii sau mobilierului<br />
• pentru a dim<strong>in</strong>ua stimularea <strong>pacientului</strong><br />
• la cererea <strong>pacientului</strong><br />
281<br />
Modul <strong>de</strong> aplicare a imobilizarii fizice:<br />
• I<strong>de</strong>al, imobilizarea trebuie a<strong>si</strong>gurata <strong>de</strong> 5 persoane, uzand cat mai put<strong>in</strong><br />
<strong>de</strong> forta.<br />
• Daca pacientul este <strong>de</strong> sex fem<strong>in</strong><strong>in</strong>, cel put<strong>in</strong> o femeie trebuie sa participe<br />
la imobilizare.<br />
• Imobilizarea se face <strong>in</strong> patru puncte cu pacientul <strong>in</strong> pozitie culcat sau<br />
<strong>de</strong>cubit lateral.<br />
• Se pot utiliza gulerul cervical <strong>si</strong> curelele suplimentare peste pelvis <strong>si</strong><br />
genunchi. Curelele se leaga <strong>de</strong> asa natura <strong>in</strong>cat sa nu afecteze circulatia<br />
(cca 1 cm <strong>in</strong>tre piele <strong>si</strong> curea).<br />
• Se ridica usor capul <strong>pacientului</strong> pentru a dim<strong>in</strong>ua riscul <strong>de</strong> aspiratie.<br />
• Dupa imobilizare, la fiecare 15 m<strong>in</strong>. trebuie monitorizate perfuzia periferica,<br />
mobilitatea, postura <strong>si</strong> statusul mental. Se evalueaza pacientul<br />
periodic pentru a aprecia oportunitatea cont<strong>in</strong>uarii imobilizarii (7,9).<br />
In fisa <strong>pacientului</strong> trebuie specificate motivul imobilizarii, motivul pentru<br />
care nu s-au putut utiliza alte meto<strong>de</strong> mai put<strong>in</strong> restrictive, medicatia adm<strong>in</strong>istrata,<br />
raspunsul la tratament.<br />
3. Imobilizarea medicamentoasa<br />
Timisoara 2008
Se realizeaza cu opiacee, barbiturice, neuroleptice, benzodiazep<strong>in</strong>e <strong>si</strong>, <strong>in</strong><br />
conditii extreme, blocante neuromusculare (fig. 1). Are acela<strong>si</strong> impact asupra<br />
<strong>pacientului</strong> ca <strong>si</strong> imobilizarea fizica, dar sca<strong>de</strong> riscul aparitiei leziunilor<br />
traumatice <strong>in</strong> urma imobilizarii <strong>si</strong> este <strong>de</strong> preferat (10,11).<br />
Avantajele tratamentului medicamentos:<br />
• controleaza comportamentul <strong>violent</strong> <strong>si</strong> pacientul agitat;<br />
• dim<strong>in</strong>ua nece<strong>si</strong>tatea imobilizarii fizice;<br />
• permite exam<strong>in</strong>area <strong>si</strong> efectuarea <strong>in</strong>vestigatiilor radiologice (12).<br />
282<br />
Dezavantajele tratamentului medicamentos:<br />
• poate <strong>de</strong>term<strong>in</strong>a complicatii precum <strong>de</strong>pre<strong>si</strong>a respiratorie <strong>si</strong> pier<strong>de</strong>rea<br />
reflexului <strong>de</strong> <strong>de</strong>glutitie;<br />
• ocazional, reactii paradoxale <strong>de</strong> accentuare a agitatiei;<br />
• limiteaza exam<strong>in</strong>area neurologica <strong>si</strong> a statusului mental pe durata sedarii<br />
(13).<br />
Concluzii<br />
Managementul <strong>pacientului</strong> agitat <strong>si</strong> <strong>violent</strong> <strong>in</strong>cepe cu <strong>in</strong>cercarea <strong>de</strong> a controla<br />
verbal <strong>si</strong>tuatia. Personalul trebuie sa evite sa se puna <strong>in</strong> pericol <strong>si</strong> sa<strong>si</strong><br />
comunice <strong>in</strong>tot<strong>de</strong>auana preocuparea pentru b<strong>in</strong>ele <strong>pacientului</strong>. Accentul<br />
se pune <strong>in</strong> general pe strategiile verbale. Nu trebuie neglijata po<strong>si</strong>bilitatea<br />
existentei unor afectiuni medicale care sa cauzeze sau sa potenteze comportamentul<br />
<strong>violent</strong>.<br />
Medicatia se utilizeaza cand controlul verbal e <strong>in</strong>complet sau a esuat. Se<br />
pot adm<strong>in</strong>istra: droperidol, haloperidol sau asocieri cu o benzodiazep<strong>in</strong>a.<br />
Acestea se titreaza pana la efectul dorit. Metoda sedarii rapi<strong>de</strong> este <strong>si</strong>gura<br />
<strong>si</strong> eficienta. Uneori poate fi utila asocierea d<strong>in</strong>tre imobilizarea fizica <strong>si</strong> medicatie.<br />
Cand se utilizeaza imobilizarea fizica, este obligatorie consemnarea <strong>in</strong> fisa<br />
<strong>pacientului</strong> a motivelor ce au dus la aceasta <strong>de</strong>cizie.<br />
Actualitati <strong>in</strong> anestezie, terapie <strong>in</strong>ten<strong>si</strong>va <strong>si</strong> medic<strong>in</strong>a <strong>de</strong> <strong>urgenta</strong>
ALGORITM DE MANAGEMENT AL PACIENTULUI VIOLENT (14)<br />
Management verbal<br />
Imobilizare fizica<br />
Ineficiente<br />
Terapie medicamentoasa<br />
orala<br />
Lorazepam 2-4 mg (sedare <strong>in</strong><br />
35-45 m<strong>in</strong>), Olanzap<strong>in</strong>a 10 mg<br />
Terapia orala <strong>in</strong>eficienta, dupa o<br />
ora, reevaluati pacientul <strong>si</strong><br />
repetati Olanzap<strong>in</strong>a 5-10 mg<br />
Pacientul refuza terapia<br />
orala<br />
283<br />
Ineficienta<br />
Lorazepam 1-2 mg im<br />
(sedare <strong>in</strong> 35-40 m<strong>in</strong>)<br />
Haloperidol 5 mg im<br />
(sedare <strong>in</strong> 10 m<strong>in</strong>)<br />
Fara<br />
raspuns<br />
Diazepam 10 mg iv<br />
Haloperidol 5-10 mg iv<br />
Fig. 1. ALGORITM DE MANAGEMENT AL PACIENTULUI VIOLENT (14)<br />
Bibliografie<br />
1. Kennedy MP. Violence <strong>in</strong> emergency <strong>de</strong>partments: un<strong>de</strong>r-reported, unconstra<strong>in</strong>ed. MJA 2005;<br />
183(7):362-5.<br />
2. T<strong>in</strong>t<strong>in</strong>alli J. Emergency Medic<strong>in</strong>e – A Comprehen<strong>si</strong>ve Study Gui<strong>de</strong>, Behavioral Disor<strong>de</strong>rs.<br />
3. Bradshaw Bunney E. The Agitated Patient <strong>in</strong> the Emergency Department.<br />
4. Hill S, Petit J. The <strong>violent</strong> patient. Emerg Med Cl<strong>in</strong> North Am 2000; 18:301-15.<br />
5. Rice MM, Moore GP. Management of the <strong>violent</strong> patient. Therapeutic and legal con<strong>si</strong><strong>de</strong>rations. Emerg<br />
Med Cl<strong>in</strong> North Am 1991; 9:13-30.<br />
6. Hill S. Management of the <strong>violent</strong> patient <strong>in</strong> the Emergency Departament.<br />
7. American Psychiatric Association Task Force on the Psychiatric Uses of Seclu<strong>si</strong>on and Restra<strong>in</strong>t : Seclu<strong>si</strong>on<br />
and Restra<strong>in</strong>t: The Psychiatric Uses. 1985. Wash<strong>in</strong>gton DC: American Psychiatric Association.<br />
8. Annas GJ. The last resort - the use of phy<strong>si</strong>cal restra<strong>in</strong>ts <strong>in</strong> medical emergencies. N Engl J Med 1999;<br />
341(18): 1408-12.<br />
9. Zun LS. A prospective study of the complication rate of use of patient restra<strong>in</strong>t <strong>in</strong> the emergency <strong>de</strong>partment.<br />
J Emerg Med 2003; 24(2):119-24.<br />
10. Allen MH, et al. The Expert Consensus Gui<strong>de</strong>l<strong>in</strong>e Series. Treatment of behavioral emergencies. Postgrad<br />
Med Spec 2001; 1:1-88.<br />
11. Cl<strong>in</strong>ton JE, et al. Haloperidol for sedation of disruptive emergency patients. Ann Emerg Med 1987; 3<br />
(16):319-22.<br />
12. Battaglia J, et al. Haloperidol, lorazepam, or both for psychotic agitation A multicenter, prospective,<br />
double-bl<strong>in</strong>d, emergency <strong>de</strong>partment study. Am J Emerg Med 1997; 4 (15):335-40.<br />
Timisoara 2008
13. Yildiz A, Sachs GS, Turgay A. Pharmacological management of agitation <strong>in</strong> emergency sett<strong>in</strong>gs. Emerg<br />
Med J 2003; 20:339-46.<br />
14. Dartford D, Gravesham D. Short Term Cl<strong>in</strong>ical Gui<strong>de</strong>l<strong>in</strong>es on the Management of Disturbed/Violent<br />
Behaviour of Patients <strong>in</strong> A&E and Emergency Situations (<strong>in</strong>clud<strong>in</strong>g the use of Rapid Tranquilisation).<br />
284<br />
Actualitati <strong>in</strong> anestezie, terapie <strong>in</strong>ten<strong>si</strong>va <strong>si</strong> medic<strong>in</strong>a <strong>de</strong> <strong>urgenta</strong>
Aspecte practice <strong>si</strong> etice priv<strong>in</strong>d terapia<br />
<strong>pacientului</strong> aflat <strong>in</strong> stare term<strong>in</strong>ala<br />
Marian Popescu, Serban Mar<strong>in</strong>escu,<br />
Silvius Negoita, Madal<strong>in</strong>a Dutu <br />
285<br />
Trecerea catre viata eterna a fiecarei fi<strong>in</strong>te umane este un eveniment <strong>in</strong>evitabil<br />
ce nu poate fi <strong>de</strong>cat amanat pentru un timp f<strong>in</strong>it.<br />
De cele mai multe ori atat pacientii cat <strong>si</strong> membrii familiilor acestora (cat<br />
<strong>si</strong> unii colegi d<strong>in</strong> alte specialitati medicale), datorita noilor achizitii tehnice<br />
<strong>si</strong> farmacologice d<strong>in</strong> medic<strong>in</strong>a mo<strong>de</strong>rna, cred ca terapia <strong>in</strong>ten<strong>si</strong>va poate face<br />
“m<strong>in</strong>uni”, <strong>in</strong><strong>si</strong>stand atat pentru admi<strong>si</strong>a pacientilor, dar <strong>si</strong> pentru o terapie<br />
sust<strong>in</strong>uta, <strong>in</strong> cazuri cu mult <strong>de</strong>pa<strong>si</strong>te medical.<br />
Se uita <strong>in</strong> aceste cazuri ca, <strong>de</strong> fapt o importanta covar<strong>si</strong>toare (pentru familie,<br />
societate, costurile d<strong>in</strong> spitale) o are calitatea vietii dupa ce se realizeaza<br />
o recuperare temporara, pasagera.<br />
Moartea fi<strong>in</strong>tei umane trebuie sa fie una <strong>de</strong>mna, <strong>in</strong> pace <strong>si</strong> confort, fara<br />
ch<strong>in</strong>uri <strong>in</strong>utile, atunci cand toate evaluarile realizate <strong>in</strong> d<strong>in</strong>amica arata <strong>in</strong>utilitatea<br />
oricarui act medical, oricat <strong>de</strong> sust<strong>in</strong>ut <strong>si</strong> b<strong>in</strong>e <strong>in</strong>tentionat ar fi.<br />
Peste 20% d<strong>in</strong> <strong>de</strong>cesele <strong>in</strong> serviciile <strong>de</strong> terapie <strong>in</strong>ten<strong>si</strong>va d<strong>in</strong> Statele Unite<br />
surv<strong>in</strong> <strong>in</strong> cursul sau imediat dupa admi<strong>si</strong>e (Irw<strong>in</strong> RS, Rippe JM, 2008). Intre<br />
55-85% d<strong>in</strong> toate <strong>de</strong>cesele d<strong>in</strong> ICU surv<strong>in</strong> dupa <strong>de</strong>cizia <strong>de</strong> a scoate sau a nu<br />
utiliza terapia <strong>de</strong> suport a functiilor vitale. Intr-un studiu realizat <strong>in</strong> unitatile<br />
<strong>de</strong> terapie <strong>in</strong>ten<strong>si</strong>va d<strong>in</strong> Europa se arata ca (<strong>in</strong>ca) 73% d<strong>in</strong> pacientii d<strong>in</strong><br />
ICU sunt admi<strong>si</strong> fara a exista o sansa <strong>de</strong> supravietuire (Irw<strong>in</strong> RS, Rippe JM,<br />
2008).<br />
D<strong>in</strong> pacate, <strong>de</strong>seori pacientii sunt adu<strong>si</strong> <strong>in</strong> stare <strong>de</strong> <strong>in</strong>constienta, fara a<br />
fi <strong>in</strong>sotiti <strong>de</strong> familii, necunoscandu-se dor<strong>in</strong>ta lor expresa priv<strong>in</strong>d ne<strong>in</strong>ceperea<br />
sau <strong>in</strong>itierea unei terapii <strong>de</strong> suport/resuscitare, <strong>de</strong>cizia <strong>de</strong> a limita/a<br />
Spitalul Univer<strong>si</strong>tar <strong>de</strong> Urgenta Elias Bucuresti<br />
Timisoara 2008
286<br />
nu <strong>in</strong>cepe suportul functiilor vitale. Reprez<strong>in</strong>ta procedura pr<strong>in</strong> <strong>in</strong>termediul<br />
careia medicii d<strong>in</strong> ICU, impreuna / cu acordul familiei / <strong>pacientului</strong> (cand<br />
este po<strong>si</strong>bil) se ia <strong>de</strong>cizia <strong>de</strong> a nu se <strong>in</strong>cepe/a se <strong>in</strong>trerupe terapia <strong>de</strong> suport a<br />
functiilor vitale, afectate sever pr<strong>in</strong>tr-o boala cu evolutie irever<strong>si</strong>bila (Thelen<br />
M, 2005).<br />
Discutia priv<strong>in</strong>d luarea unei astfel <strong>de</strong> <strong>de</strong>cizii va fi <strong>in</strong>itiata <strong>in</strong> urmatoarele<br />
<strong>si</strong>tuatii:<br />
• status postressuscitare dupa oprire cardiorespiratorie (fara martori,<br />
cand nu se cunoaste timpul total <strong>de</strong> stop fara flux cerebral , fara resuscitare);<br />
• boli extrem <strong>de</strong> severe cu disfunctii multiple <strong>de</strong> organe, nonrespon<strong>si</strong>ve la<br />
medicatia utilizata;<br />
• coma prelungita pr<strong>in</strong> boli cerebrovasculare irever<strong>si</strong>bile/status vegetativ<br />
per<strong>si</strong>stent, fara sanse <strong>de</strong> recuperare;<br />
• boli cerebrale severe <strong>si</strong> irever<strong>si</strong>bile;<br />
• neoplazii multimetastatice (<strong>in</strong>clu<strong>si</strong>v cerebrale), fara raspuns la terapia<br />
specifica;<br />
• dor<strong>in</strong>ta <strong>pacientului</strong>, sust<strong>in</strong>ut <strong>de</strong> familie, <strong>de</strong> a nu <strong>in</strong>cepe/renunta la o<br />
terapie <strong>de</strong> suport a functiilor vitale.<br />
In aceste <strong>si</strong>tuatii se va actiona <strong>in</strong> conformitate cu pr<strong>in</strong>cipiile morale, unanim<br />
acceptate, anume:<br />
• a actiona <strong>in</strong> <strong>in</strong>teresul <strong>pacientului</strong> (beneficiance);<br />
• a lua <strong>de</strong>cizia care nu-i face rau acestuia (nonmalefience);<br />
• a aloca corect, egal, resursele <strong>de</strong> suport <strong>in</strong>diferent <strong>de</strong> rasa, sex, religie,<br />
apartenenta sociala (justice);<br />
• <strong>de</strong>cizia va fi luata <strong>in</strong> conformitate cu dor<strong>in</strong>ta respectata a <strong>pacientului</strong><br />
<strong>in</strong>format, <strong>de</strong> a refuza sau nu suportul <strong>in</strong>itiat (patient autonomy);<br />
• se vor respecta <strong>de</strong> asemenea: confi<strong>de</strong>ntialitatea actului medical realizat,<br />
pacientul va fi respectat <strong>si</strong> i se vor a<strong>si</strong>gura confortul <strong>si</strong> compa<strong>si</strong>unea<br />
conforma <strong>si</strong>tuatiei date (Irw<strong>in</strong> RS, Rippe JM, 2008).<br />
Se doreste <strong>in</strong> asemenea <strong>si</strong>tuatii renuntarea la termenul <strong>de</strong> “terapie <strong>in</strong>utila”,<br />
<strong>in</strong>locu<strong>in</strong>du-se cu cel <strong>de</strong> terapie care nu este “<strong>in</strong> the best <strong>in</strong>terest of the<br />
patient”.<br />
Decizia <strong>de</strong> a <strong>in</strong>trerupe/ a nu adm<strong>in</strong>istra o anume terapie <strong>de</strong>p<strong>in</strong><strong>de</strong> ca atitud<strong>in</strong>e<br />
<strong>de</strong> la o tara la alta:<br />
• <strong>in</strong> Statele Unite se aplica pr<strong>in</strong>cipiul autonomiei <strong>pacientului</strong>, care-<strong>si</strong> exprima<br />
dor<strong>in</strong>ta cu mult <strong>in</strong>a<strong>in</strong>te <strong>de</strong> a avea o sufer<strong>in</strong>ta severa (“patient<br />
/surrogate directed”);<br />
• <strong>in</strong> tarile d<strong>in</strong> sudul Europei <strong>de</strong>ciziile sunt luate <strong>de</strong> catre medici <strong>in</strong> <strong>in</strong>teresul<br />
<strong>pacientului</strong> (“phi<strong>si</strong>cian directed –mak<strong>in</strong>g <strong>de</strong>ci<strong>si</strong>on for the patient”);<br />
Actualitati <strong>in</strong> anestezie, terapie <strong>in</strong>ten<strong>si</strong>va <strong>si</strong> medic<strong>in</strong>a <strong>de</strong> <strong>urgenta</strong>