The Journal of Family Practice

Nordestgaard, B.G., J Am Coll Cardiol 70(13):1637, September 26, 2017

This Danish author reviews the impact of a fasting versus nonfasting state on lipid profile testing. He addresses the pros and cons of fasting or nonfasting lipid profiles, the impact on individual lipid parameters, and the implications for diagnosing and treating cardiovascular disease (CVD). Testing lipid profiles in the nonfasting state is increasingly common, in part because it is simpler, given that (typically) 16 hours per day are nonfasting. In addition, a nonfasting lipid profile is more accurate for measuring total atherogenic lipoproteins in plasma because it includes those of hepatic origin in the fasting state and those of intestinal origin in the nonfasting state. Maximum mean differences in lipid parameters measured in nonfasting versus fasting patients are +26mg/dL for triglycerides, -8mg/dL for total cholesterol, -8mg/dL for LDL cholesterol, +8mg/dL for remnant cholesterol, and -8mg/dL for non-HDL cholesterol. The reductions in total, LDL and non-HDL cholesterol are mainly due to fluid intake and not food consumption. A nonfasting condition has no appreciable effect on HDL cholesterol, lipoprotein(a), or apolipoproteins A1 and B. Nonfasting lipid profiles have equal predictive ability for CVD and should not affect treatment decisions (e.g., statin use) for most patients. Testing of nonfasting samples is simpler for all parties (patients, clinicians and laboratories), safer for patients who cannot fast, increases efficiency, and saves money. International guidelines since 2009 are increasingly recommending nonfasting lipid profiles. The author notes that testing of fasting lipid profiles continues largely because “we have always done it this way.” He recommends that nonfasting blood samples be routinely tested, except in selected patients who require fasting samples. 55 references ([email protected] – no reprints)

Nordestgaard, B.G., J Am Coll Cardiol 70(13):1637, September 26, 2017

This Danish author reviews the impact of a fasting versus nonfasting state on lipid profile testing. He addresses the pros and cons of fasting or nonfasting lipid profiles, the impact on individual lipid parameters, and the implications for diagnosing and treating cardiovascular disease (CVD). Testing lipid profiles in the nonfasting state is increasingly common, in part because it is simpler, given that (typically) 16 hours per day are nonfasting. In addition, a nonfasting lipid profile is more accurate for measuring total atherogenic lipoproteins in plasma because it includes those of hepatic origin in the fasting state and those of intestinal origin in the nonfasting state. Maximum mean differences in lipid parameters measured in nonfasting versus fasting patients are +26mg/dL for triglycerides, -8mg/dL for total cholesterol, -8mg/dL for LDL cholesterol, +8mg/dL for remnant cholesterol, and -8mg/dL for non-HDL cholesterol. The reductions in total, LDL and non-HDL cholesterol are mainly due to fluid intake and not food consumption. A nonfasting condition has no appreciable effect on HDL cholesterol, lipoprotein(a), or apolipoproteins A1 and B. Nonfasting lipid profiles have equal predictive ability for CVD and should not affect treatment decisions (e.g., statin use) for most patients. Testing of nonfasting samples is simpler for all parties (patients, clinicians and laboratories), safer for patients who cannot fast, increases efficiency, and saves money. International guidelines since 2009 are increasingly recommending nonfasting lipid profiles. The author notes that testing of fasting lipid profiles continues largely because “we have always done it this way.” He recommends that nonfasting blood samples be routinely tested, except in selected patients who require fasting samples. 55 references ([email protected] – no reprints)

Nordestgaard, B.G., J Am Coll Cardiol 70(13):1637, September 26, 2017

This Danish author reviews the impact of a fasting versus nonfasting state on lipid profile testing. He addresses the pros and cons of fasting or nonfasting lipid profiles, the impact on individual lipid parameters, and the implications for diagnosing and treating cardiovascular disease (CVD). Testing lipid profiles in the nonfasting state is increasingly common, in part because it is simpler, given that (typically) 16 hours per day are nonfasting. In addition, a nonfasting lipid profile is more accurate for measuring total atherogenic lipoproteins in plasma because it includes those of hepatic origin in the fasting state and those of intestinal origin in the nonfasting state. Maximum mean differences in lipid parameters measured in nonfasting versus fasting patients are +26mg/dL for triglycerides, -8mg/dL for total cholesterol, -8mg/dL for LDL cholesterol, +8mg/dL for remnant cholesterol, and -8mg/dL for non-HDL cholesterol. The reductions in total, LDL and non-HDL cholesterol are mainly due to fluid intake and not food consumption. A nonfasting condition has no appreciable effect on HDL cholesterol, lipoprotein(a), or apolipoproteins A1 and B. Nonfasting lipid profiles have equal predictive ability for CVD and should not affect treatment decisions (e.g., statin use) for most patients. Testing of nonfasting samples is simpler for all parties (patients, clinicians and laboratories), safer for patients who cannot fast, increases efficiency, and saves money. International guidelines since 2009 are increasingly recommending nonfasting lipid profiles. The author notes that testing of fasting lipid profiles continues largely because “we have always done it this way.” He recommends that nonfasting blood samples be routinely tested, except in selected patients who require fasting samples. 55 references ([email protected] – no reprints)

The physician suspected that this was a benign blue nevus because it had a regular border and was uniformly dark in color. He also recognized that melanoma is very rare at age 19. That said, it is hard to ignore a changing mole that is so black in color.

The patient wanted it removed, so a 5-mm punch biopsy was performed. (See the Watch and Learn video on punch biopsy.)

When the punch core was removed, the physician noted that the pigment was visible in the deep dermis (as expected with a blue nevus). A single suture was placed, and the patient was scheduled for follow-up in one week. The pathology report came back as a blue nevus, which is completely benign.

While many blue nevi actually appear blue because of the Tyndall effect causing the dark melanin in the deep dermis to create a blue coloration, some will appear black (as was seen in this case). On the follow-up visit, the suture was removed and the incision was healing well. The patient was reassured that this was a benign mole and was happy with the cosmetic result.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M, Usatine R. Benign nevi. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:945-952.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The physician suspected that this was a benign blue nevus because it had a regular border and was uniformly dark in color. He also recognized that melanoma is very rare at age 19. That said, it is hard to ignore a changing mole that is so black in color.

The patient wanted it removed, so a 5-mm punch biopsy was performed. (See the Watch and Learn video on punch biopsy.)

When the punch core was removed, the physician noted that the pigment was visible in the deep dermis (as expected with a blue nevus). A single suture was placed, and the patient was scheduled for follow-up in one week. The pathology report came back as a blue nevus, which is completely benign.

While many blue nevi actually appear blue because of the Tyndall effect causing the dark melanin in the deep dermis to create a blue coloration, some will appear black (as was seen in this case). On the follow-up visit, the suture was removed and the incision was healing well. The patient was reassured that this was a benign mole and was happy with the cosmetic result.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M, Usatine R. Benign nevi. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:945-952.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The physician suspected that this was a benign blue nevus because it had a regular border and was uniformly dark in color. He also recognized that melanoma is very rare at age 19. That said, it is hard to ignore a changing mole that is so black in color.

The patient wanted it removed, so a 5-mm punch biopsy was performed. (See the Watch and Learn video on punch biopsy.)

When the punch core was removed, the physician noted that the pigment was visible in the deep dermis (as expected with a blue nevus). A single suture was placed, and the patient was scheduled for follow-up in one week. The pathology report came back as a blue nevus, which is completely benign.

While many blue nevi actually appear blue because of the Tyndall effect causing the dark melanin in the deep dermis to create a blue coloration, some will appear black (as was seen in this case). On the follow-up visit, the suture was removed and the incision was healing well. The patient was reassured that this was a benign mole and was happy with the cosmetic result.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M, Usatine R. Benign nevi. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:945-952.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

Pinkerton, J. V., et al, Menopause 24(10):1099, October 2017

The authors, writing for the North American Menopause Society (NAMS), protest the recent guideline recommendations regarding postmenopausal hormone therapy (HT) from the US Preventive Services Task Force (USPSTF). The USPSTF draft guidance gives HT (both combined regimens and estrogen alone) a D recommendation for preventing chronic disease because of harms outweighing benefits. The NAMS panel contends that the USPSTF opinion does not distinguish between approved and unapproved indications for HT. They note that the conclusions are based on the Women’s Health Initiative (WHI) trial, from which certain patient populations who may benefit (bothersome hot flashes, high osteoporosis risk, genitourinary symptoms) were omitted. The WHI tested a single dose of a single formulation in women having an average age of 63 who were 13 years past menopause. According to NAMS, the USPSTF should acknowledge that HT relieves vasomotor symptoms, helps prevent bone loss and fracture, and may improve quality of life in women younger than 60 years who take HT within ten years of menopause. Women younger than 60 years who have had a hysterectomy benefit from early estrogen monotherapy, having a lower incidence of breast cancer, cardiovascular disease and mortality. Further, the panel feels that the USPSTF should state that the findings of harm were based on higher-dose formulations, and that the results may not apply to lower doses, different and newer formulations (e.g., natural progesterone, bazedoxifene), and different dosing routes (e.g., transdermal administration). NAMS agrees that HT does not prevent heart disease, but indicates that its use (and insurance coverage) should not be precluded for women with early menopause, bothersome hot flashes, genitourinary symptoms and/or a high risk of fracture. 12 references

Pinkerton, J. V., et al, Menopause 24(10):1099, October 2017

The authors, writing for the North American Menopause Society (NAMS), protest the recent guideline recommendations regarding postmenopausal hormone therapy (HT) from the US Preventive Services Task Force (USPSTF). The USPSTF draft guidance gives HT (both combined regimens and estrogen alone) a D recommendation for preventing chronic disease because of harms outweighing benefits. The NAMS panel contends that the USPSTF opinion does not distinguish between approved and unapproved indications for HT. They note that the conclusions are based on the Women’s Health Initiative (WHI) trial, from which certain patient populations who may benefit (bothersome hot flashes, high osteoporosis risk, genitourinary symptoms) were omitted. The WHI tested a single dose of a single formulation in women having an average age of 63 who were 13 years past menopause. According to NAMS, the USPSTF should acknowledge that HT relieves vasomotor symptoms, helps prevent bone loss and fracture, and may improve quality of life in women younger than 60 years who take HT within ten years of menopause. Women younger than 60 years who have had a hysterectomy benefit from early estrogen monotherapy, having a lower incidence of breast cancer, cardiovascular disease and mortality. Further, the panel feels that the USPSTF should state that the findings of harm were based on higher-dose formulations, and that the results may not apply to lower doses, different and newer formulations (e.g., natural progesterone, bazedoxifene), and different dosing routes (e.g., transdermal administration). NAMS agrees that HT does not prevent heart disease, but indicates that its use (and insurance coverage) should not be precluded for women with early menopause, bothersome hot flashes, genitourinary symptoms and/or a high risk of fracture. 12 references

Pinkerton, J. V., et al, Menopause 24(10):1099, October 2017

The authors, writing for the North American Menopause Society (NAMS), protest the recent guideline recommendations regarding postmenopausal hormone therapy (HT) from the US Preventive Services Task Force (USPSTF). The USPSTF draft guidance gives HT (both combined regimens and estrogen alone) a D recommendation for preventing chronic disease because of harms outweighing benefits. The NAMS panel contends that the USPSTF opinion does not distinguish between approved and unapproved indications for HT. They note that the conclusions are based on the Women’s Health Initiative (WHI) trial, from which certain patient populations who may benefit (bothersome hot flashes, high osteoporosis risk, genitourinary symptoms) were omitted. The WHI tested a single dose of a single formulation in women having an average age of 63 who were 13 years past menopause. According to NAMS, the USPSTF should acknowledge that HT relieves vasomotor symptoms, helps prevent bone loss and fracture, and may improve quality of life in women younger than 60 years who take HT within ten years of menopause. Women younger than 60 years who have had a hysterectomy benefit from early estrogen monotherapy, having a lower incidence of breast cancer, cardiovascular disease and mortality. Further, the panel feels that the USPSTF should state that the findings of harm were based on higher-dose formulations, and that the results may not apply to lower doses, different and newer formulations (e.g., natural progesterone, bazedoxifene), and different dosing routes (e.g., transdermal administration). NAMS agrees that HT does not prevent heart disease, but indicates that its use (and insurance coverage) should not be precluded for women with early menopause, bothersome hot flashes, genitourinary symptoms and/or a high risk of fracture. 12 references

CASE A 40-year-old man came to our office slightly agitated. He had an acute illness that was minor in nature. However, he was not interested in answering my questions or undergoing a physical exam. The more I tried to proceed with the visit, the more agitated he became—pacing the room, muttering, avoiding eye contact. I was uncomfortable and knew that the situation could quickly escalate if it was not brought under control.

What steps would you take if this were your patient?

The scene described above occurred several years ago, but more recently, one of the institutions in my (TIM) area was affected by a shooter in the workplace. The apprehension felt by all of us who were on the periphery paled in comparison to what was experienced by those at the scene. The outcome was horrific. Communicating with those directly involved during, and immediately after, the event was heart-wrenching. The trauma that they continue to relive is unimaginable, and some are not yet able to return to work.

Situations involving agitated patients are not uncommon in health care settings, although ones that escalate to the level of a shooting are. And no matter where on the spectrum an incident involving an agitated patient falls, it can leave those involved with various levels of physical, emotional, and psychological harm. It can also leave everyone asking themselves: “How can I better prepare for such occurrences?”

This article offers some answers by providing tips and guidelines for handling agitated and/or violent patients in various settings.

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Defining the problem, assessing its severity

Between 2011 and 2013, workplace assaults ranged from 23,540 and 25,630 annually, with 70% to 74% occurring in health care and social service settings.^1,2

Agitation is defined as a state that may include inattention, disinhibition, emotional lability, impulsivity, motor restlessness, and aggression.^3,4 Violence in a clinical setting may be seen as an extreme expression of agitation sufficient enough to cause harm to an individual or damage to an object.^5,6

The causes of agitation can be grouped into categories: those due to a general medical condition, those due to a psychiatric condition, and those due to drug intoxication and/or withdrawal.⁷ We have chosen to add a fourth category—iatrogenic (see TABLE 1^3,4,7-9). They are not distinct categories, as there is sometimes overlap among areas.

Determining the level of agitation. Various scales and approaches can help determine the level of agitation in a patient (eg, the Agitated Behavior Scale [ABS; FIGURE];⁵ the Behavioral Activity Rating Scale [BARS]¹⁰) and the risk for violence (eg, the ABC violence risk assessment, TABLE 2⁸).

Scales like the ABS should be employed as soon as a patient shows signs of agitation sufficient to warrant intervention. The idea is for the family physician (FP) to be familiar enough with the tool to be able to mentally check it off, fill it out when time permits, and keep it in the patient’s chart. The first version of the form serves as a baseline so that if care is handed off to another provider, that provider can monitor whether signs and symptoms are improving or worsening.

Setting often drives the solution

Much of the evidence-based research on managing patient agitation and violence stems from inpatient psychiatric and emergency department (ED) settings. To make other health care providers aware of the experience gained in those settings, the American Association for Emergency Psychiatry created Project BETA (Best Practices in Evaluation and Treatment of Agitation). This project is designed to help promote consistency across health care settings and specialties in the way clinicians respond to agitated patients and to emphasize for all health care providers the availability of more than just pharmacologic approaches.⁷

De-escalating the situation. General tenets of de-escalation apply across practice settings. Among them:

• Stay calm. Avoid aggressive postures and prolonged eye contact.
• Be nonconfrontational. Acknowledge the patient’s frustration/perceptions and ask open-ended questions.
• Assess available resources such as clinical team members, family members, and silent alarms.
• Manage the situation and the patient’s underlying issues/diagnoses. This includes mobilizing other patients to avoid collateral damage and exploring solutions with the patient.

For more on de-escalation tools, see (TABLE 3^4,6,9,11).

Your setting matters. It’s worth noting that the settings in which clinicians practice greatly influence the resources available to de-escalate a situation and ensure the safety of the patient and others.⁷ The review that follows provides some issues—and tips—that are unique to different practice settings.

Ambulatory settings

Sim and colleagues⁹ noted that aggressive behavior in the general practice setting may stem not only from factors related to the patient’s own physical or psychological discomfort, but from patients feeling that they are being treated unfairly, whether it be because of wait times, uncomfortable waiting conditions, or something else. A number of international studies have shown high rates of abuse toward FPs.^9,12 Of 831 primary care physicians surveyed in a German study, close to three-quarters indicated that within the last year, they had experienced aggression (ranging from verbal abuse and threats to physical violence and property damage) from a patient.¹² This statistic increased to 91% when it included the length of their career.

Between 2011 and 2013, 7 out of 10 workplace assaults occurred in health care and social service settings.

Bell¹³ suggests that physicians be aware that transference and countertransference issues are often at play when dealing with hostile or potentially violent patients. Suggestions to prevent aggression include some practice-level approaches (eg, providing waiting room distractions, making patients aware of potential delays), as well as being aware of nonverbal cues suggesting increased agitation (eg, clenched fists, crossed arms, chin thrusts, finger pointing).⁹

Group practice

An FP who practices with other health care providers and clinical staff has a built-in team that can assist with de-escalation. When meeting with a patient who has a history of violence or agitation in an exam room or office, try to ensure that you can get to an exit quickly if necessary. Also, alert staff to any concerns, and have a system for at least one staff member to check in periodically during the visit.

It is also helpful to develop an evacuation plan and create a “panic room” or “safe zone” for emergencies.^14,15 Such a space may be nothing more than an area or room for staff to gather. It should have access to the police or other emergency services via a land and/or cell phone line.

Solo practice

If you practice alone, institute safeguards whereby a colleague (at a different practice, building, or location) can be alerted if concerns arise. In addition, consider the following precautions: locking the door when alone after hours, screening potential patients, having a way to call for help (keep the number for the local police station and ED readily available), prohibiting potential weapons (as some states allow them to be carried), and learning some form of self-defense.¹⁵

Ensure that agitated patients are not positioned between you and the exit so that you can quickly escape if necessary.

Resources exist that offer guidelines for developing policies and procedures, checklists, and sample incident forms (eg, the International Association for Healthcare Security and Safety; iahss.org). Other organizations that can help with the development of a preparedness plan include the Occupational Safety and Health Administration (https://www.osha.gov/SLTC/workplaceviolence/evaluation.html), the Department of Homeland Security (https://www.dhs.gov/sites/default/files/publications/ISC%20Violence%20in%20%20the%20Federal%20Workplace%20Guide%20April%202013.pdf), and The Joint Commission (https://www.jointcommission.org/workplace_violence.aspx).

In long-term care settings, such as nursing homes, and shorter-term care settings, such as rehabilitation facilities, agitation may stem from causes related to a head injury or dementia or from living in an unfamiliar environment. Assessment can be accomplished using a formal scale (eg, the ABS), as well as by identifying potential underlying health-related factors that can lead to agitation, such as pain, an infection, bowel and bladder issues, seizures, wounds, endocrine anomalies, cardiac or pulmonary problems, gastrointestinal dysfunction, and metabolic abnormalities.³

Modify the environment. For this population, a primary approach involves modifying the environment to decrease the likelihood of agitation. This may involve decreasing noise or light or ensuring adequate levels of stimulation. Preventing disorientation can be addressed through verbal and visual reminders of the date, schedule, etc. If a particular situation or activity is identified as a source of agitation, attempts at modifications are called for.³

For patients with dementia, the American Psychiatric Association recommends using the lowest effective dose of an antipsychotic in conjunction with environmental and behavioral measures.¹⁶ A benzodiazepine (lorazepam, oxazepam) may be used for infrequent agitation. Trazodone or a selective serotonin reuptake inhibitor are alternatives for those without psychosis or who are intolerant to antipsychotics.¹⁶

For individuals in a rehabilitation setting, agitation can impede participation in therapy and has been associated with poorer functioning at the time of discharge.³ Agitation can also be disruptive and lead to distress for family members and caregivers, as well as for fellow patients. And because this environment has a greater likelihood of visitors unrelated to the patient being exposed to the aberrant behavior, it is especially important to have established policies and procedures for de-escalation in place.

Home care

More and more FPs and residents are conducting home visits. That’s because the Accreditation Council for Graduate Medical Education Program Requirements for Graduate Medical Education in Family Medicine now include integrating a patient’s care across settings—including the home.¹⁷ Those who do provide home care may find themselves in circumstances similar to those of domestic disputes.

The German study mentioned earlier of more than 800 primary care physicians found that while the vast majority of physicians felt safe in their offices, 66% of female doctors and 34% of male doctors did not feel safe making home visits.¹²

Know the neighborhood. There’s no doubt that working in the home health sector makes one vulnerable. More than 61% of home care workers report workplace violence annually.^18,19 An action plan, as well as established policies and procedures, are essential when making home visits. Prior to the visit, be aware of the community and the location of the nearest police department and hospital.

Unwin and Tatum²⁰ suggest not wearing a white coat or carrying a doctor’s bag so as not to stand out as a physician in neighborhoods where personal safety is an issue. Make sure that your cell phone is fully charged and that there is a GPS mechanism activated that allows others to locate you.²¹ Note the available exits in a patient’s home, and position yourself near them, if possible. Have someone call or text you at predetermined times so that the absence of a response from you will alert someone to send help.

In such situations, it is imperative to remain calm and to use the same verbal de-escalation techniques (TABLE 3^4,6,9,11) that would be used in any other health care setting. It is prudent to set expectations for the patient and family members prior to the home visit regarding the tools and services that will be provided in the home setting and the limitations in terms of scope of practice.

Emergency department

The ED is one of the most common settings for patient agitation and violence within the health care continuum.²² Providers must quickly determine the cause of the agitation while de-escalating the situation and ensuring that they do not miss a pertinent medical finding related to a time-sensitive issue, such as an intracerebral bleed or poisoning.⁷ In addition, the ED is usually heavily populated, providing an opportunity for tremendous collateral human damage should the violence escalate or weapons be deployed. The upside is that many EDs are now staffed with security personnel and, depending on the community, police officers may be on the premises or in the vicinity.²²

Avoid wearing a white coat or carrying a doctor's bag when doing a home visit so as not to stand out as a physician in neighborhoods where personal safety is an issue.

Etiologies for agitation in the ED can range from ingestion of unknown or unidentified substances to psychiatric or medical conditions. Knowledge of etiology is necessary prior to initiation of treatment.⁴

As in other settings, the safety of the patient and others present is of utmost importance. Key recommendations for managing agitated patients in the ED include: ⁴

1. Have an established plan for the management of agitated patients.
2. Identify signs of agitation early, and complete an agitation rating scale.
3. Attempt verbal de-escalation before using medication whenever possible.
4. Employ a “show of concern” rather than “a show of force” in response to escalating agitation/violence. Doing so can strengthen the perception that interventions are coming from a place of caring.
5. Use physical restraint as a last resort. When used, it should be with the intention of protecting the patient and those present, rather than as punishment.

Inpatient units

Unlike the ED, patients on units generally have a working diagnosis, and the provider has some background information with which to work, such as laboratory test results and radiology reports, facilitating more expedient and accurate situational assessment. However, the recommendations for assessment and early identification, as described for the ED, still apply.

If a provider finds him- or herself in an escalating situation, the call bells located in the rooms are of use. An alternative is to call out for help from someone in the hallway. One needs to be aware of the current policies and procedures for de-escalation, as some facilities have a specific “code” that is called for such occasions.¹⁹

Postop delirium is a common cause of agitation in the inpatient setting. Ng and colleagues¹¹ recommend a cognitive assessment before surgery to establish a baseline in order to determine the risk for delirium after surgery. Additionally, the FP must remain aware of preexisting conditions that may surface during a hospital stay, such as dehydration or unrecognized alcohol or medication withdrawal.

A "show of concern" rather than a "show of force" can strengthen the perception that interventions are coming from a place of caring.

Medication choice should be based on the type of delirium. Hyperactive delirium (restlessness, emotional lability, hallucinations) and mixed delirium (a combination of signs of hyperactive and hypoactive dementia) both hold the potential for agitation and even violence. The approach to hyperactive delirium includes consideration of an antipsychotic medication, although the efficacy of antipsychotics is considered controversial. In the case of mixed delirium, behavioral and environmental modifications are useful (eg, reducing noise and early ambulation).¹¹

No medications are registered with the US Food and Drug Administration for the management of delirium, and it is suggested that antipsychotics be considered only when other, less invasive, strategies have been attempted.²³

Regardless of the setting in which FPs work, witnessing or being directly involved in a traumatic event puts one at risk for symptoms—or a full diagnosis—of posttraumatic stress disorder (PTSD), acute stress disorder, or anxiety or mood disorders.^24,25 Although findings vary, studies have found that as many as 12% of ED personnel meet the criteria for PTSD^26,27 and 12% to 15% report having been threatened physically.^28,29 More than half of physicians in another study had witnessed a physical attack.³⁰

Physicians and other health care personnel who have experienced a traumatic incident, or offered help to another during an incident, may attempt to cope through avoidance, cutting down on work hours, leaving the work setting in which the event took place, or leaving the profession altogether.^29,31,32

There is a paucity of methodologically sound research with regard to prevention and treatment of PTSD symptoms in this population.²⁴ According to a 2002 Cochrane review, the effectiveness of individual, single-session debriefing does not have solid research support,³³ and there are concerns about potential harms due to reliving the traumatic event when sessions are led by poorly trained debriefing staff.^34-36

Critical incident stress debriefing (CISD), however, holds promise in terms of facilitating a return to pretrauma functioning based on studies of first responders.^34,35 This may be because CISD follows a specific protocol and that group sessions may capitalize on the social support/camaraderie within a group that has undergone a traumatic event.^34,35 It is important that those providing debriefing and support be well-trained.³⁵

Debriefing, however, is not always sufficient, and those who appear to be affected on an ongoing basis may require individual treatment for PTSD symptoms. Evidence-based treatments for PTSD, such as trauma-focused psychotherapy and/or pharmacotherapy, may be considered³⁷ (TABLE 4^24,34,38).

Ongoing support in the workplace. The Cleveland Clinic has developed a “Code Lavender” to combat stress in the workplace. Like a Code Blue for medical emergencies, a Code Lavender is called when a health care worker is in need of emotional or spiritual support.³⁸ A provider who initiates the call is met by a team of holistic nurses within 30 minutes. The team provides Reiki and massage, healthy snacks and water, and lavender arm bands to remind the individual to relax for the rest of the day. Further opportunities for spiritual support, mindfulness training, counseling, and yoga may also be made available.

CASE  Sensing that the situation with my patient might escalate, I lowered my voice, relaxed my shoulders, leaned casually against the desk, and asked him to tell me how I could best help him. As he spoke, I offered him a seat (by gesturing to the chair). I did this for 2 reasons: to move him away from blocking my exit from the room, and to put him at a lower level than me so that he was entirely in my view. I didn’t interrupt him as he spoke. I just nodded or tilted my head to show I was listening. In my mind, I played out the various scenarios that could ensue.

Like a Code Blue for medical emergencies, a Code Lavender is called when a health care worker is in need of emotional or spiritual support.

Fortunately, I was able to get him to relax enough for an assessment, which involved a more relevant history and the exam, which he agreed to once an aide had come into the room. He did not exhibit the concerning signs of flushed skin, dilated pupils, shallow rapid respirations, or perspiration. He did have a comorbid behavioral health issue, which we were able to address. His earlier behavioral indicators of agitation were controlled with verbal and physical cues on my part. Our conversation didn't reveal an intent to harm himself or others. In this case, physical restraints were not required. Throughout the encounter the door was left open, and the patient was reminded that we were there to help.

Once he left, I made the relevant notes in the chart regarding his agitated state at the start of the visit and his final state at the end of the visit so as to assist any other providers. We (TIM, MG) also held a quick debrief after the encounter with the office staff and decided that we needed to create a policy and protocol regarding how to handle such situations in the future.

CORRESPONDENCE
Tochi Iroku-Malize, MD, MPH, MBA, Family Medicine Department, Southside Hospital, 301 East Main Street, Bay Shore, NY 11706; [email protected].

CASE A 40-year-old man came to our office slightly agitated. He had an acute illness that was minor in nature. However, he was not interested in answering my questions or undergoing a physical exam. The more I tried to proceed with the visit, the more agitated he became—pacing the room, muttering, avoiding eye contact. I was uncomfortable and knew that the situation could quickly escalate if it was not brought under control.

What steps would you take if this were your patient?

The scene described above occurred several years ago, but more recently, one of the institutions in my (TIM) area was affected by a shooter in the workplace. The apprehension felt by all of us who were on the periphery paled in comparison to what was experienced by those at the scene. The outcome was horrific. Communicating with those directly involved during, and immediately after, the event was heart-wrenching. The trauma that they continue to relive is unimaginable, and some are not yet able to return to work.

Situations involving agitated patients are not uncommon in health care settings, although ones that escalate to the level of a shooting are. And no matter where on the spectrum an incident involving an agitated patient falls, it can leave those involved with various levels of physical, emotional, and psychological harm. It can also leave everyone asking themselves: “How can I better prepare for such occurrences?”

This article offers some answers by providing tips and guidelines for handling agitated and/or violent patients in various settings.

[polldaddy:9948472]

Defining the problem, assessing its severity

Between 2011 and 2013, workplace assaults ranged from 23,540 and 25,630 annually, with 70% to 74% occurring in health care and social service settings.^1,2

Agitation is defined as a state that may include inattention, disinhibition, emotional lability, impulsivity, motor restlessness, and aggression.^3,4 Violence in a clinical setting may be seen as an extreme expression of agitation sufficient enough to cause harm to an individual or damage to an object.^5,6

The causes of agitation can be grouped into categories: those due to a general medical condition, those due to a psychiatric condition, and those due to drug intoxication and/or withdrawal.⁷ We have chosen to add a fourth category—iatrogenic (see TABLE 1^3,4,7-9). They are not distinct categories, as there is sometimes overlap among areas.

Determining the level of agitation. Various scales and approaches can help determine the level of agitation in a patient (eg, the Agitated Behavior Scale [ABS; FIGURE];⁵ the Behavioral Activity Rating Scale [BARS]¹⁰) and the risk for violence (eg, the ABC violence risk assessment, TABLE 2⁸).

Scales like the ABS should be employed as soon as a patient shows signs of agitation sufficient to warrant intervention. The idea is for the family physician (FP) to be familiar enough with the tool to be able to mentally check it off, fill it out when time permits, and keep it in the patient’s chart. The first version of the form serves as a baseline so that if care is handed off to another provider, that provider can monitor whether signs and symptoms are improving or worsening.

Setting often drives the solution

Much of the evidence-based research on managing patient agitation and violence stems from inpatient psychiatric and emergency department (ED) settings. To make other health care providers aware of the experience gained in those settings, the American Association for Emergency Psychiatry created Project BETA (Best Practices in Evaluation and Treatment of Agitation). This project is designed to help promote consistency across health care settings and specialties in the way clinicians respond to agitated patients and to emphasize for all health care providers the availability of more than just pharmacologic approaches.⁷

De-escalating the situation. General tenets of de-escalation apply across practice settings. Among them:

• Stay calm. Avoid aggressive postures and prolonged eye contact.
• Be nonconfrontational. Acknowledge the patient’s frustration/perceptions and ask open-ended questions.
• Assess available resources such as clinical team members, family members, and silent alarms.
• Manage the situation and the patient’s underlying issues/diagnoses. This includes mobilizing other patients to avoid collateral damage and exploring solutions with the patient.

For more on de-escalation tools, see (TABLE 3^4,6,9,11).

Your setting matters. It’s worth noting that the settings in which clinicians practice greatly influence the resources available to de-escalate a situation and ensure the safety of the patient and others.⁷ The review that follows provides some issues—and tips—that are unique to different practice settings.

Ambulatory settings

Sim and colleagues⁹ noted that aggressive behavior in the general practice setting may stem not only from factors related to the patient’s own physical or psychological discomfort, but from patients feeling that they are being treated unfairly, whether it be because of wait times, uncomfortable waiting conditions, or something else. A number of international studies have shown high rates of abuse toward FPs.^9,12 Of 831 primary care physicians surveyed in a German study, close to three-quarters indicated that within the last year, they had experienced aggression (ranging from verbal abuse and threats to physical violence and property damage) from a patient.¹² This statistic increased to 91% when it included the length of their career.

Between 2011 and 2013, 7 out of 10 workplace assaults occurred in health care and social service settings.

Bell¹³ suggests that physicians be aware that transference and countertransference issues are often at play when dealing with hostile or potentially violent patients. Suggestions to prevent aggression include some practice-level approaches (eg, providing waiting room distractions, making patients aware of potential delays), as well as being aware of nonverbal cues suggesting increased agitation (eg, clenched fists, crossed arms, chin thrusts, finger pointing).⁹

Group practice

An FP who practices with other health care providers and clinical staff has a built-in team that can assist with de-escalation. When meeting with a patient who has a history of violence or agitation in an exam room or office, try to ensure that you can get to an exit quickly if necessary. Also, alert staff to any concerns, and have a system for at least one staff member to check in periodically during the visit.

It is also helpful to develop an evacuation plan and create a “panic room” or “safe zone” for emergencies.^14,15 Such a space may be nothing more than an area or room for staff to gather. It should have access to the police or other emergency services via a land and/or cell phone line.

Solo practice

If you practice alone, institute safeguards whereby a colleague (at a different practice, building, or location) can be alerted if concerns arise. In addition, consider the following precautions: locking the door when alone after hours, screening potential patients, having a way to call for help (keep the number for the local police station and ED readily available), prohibiting potential weapons (as some states allow them to be carried), and learning some form of self-defense.¹⁵

Ensure that agitated patients are not positioned between you and the exit so that you can quickly escape if necessary.

Resources exist that offer guidelines for developing policies and procedures, checklists, and sample incident forms (eg, the International Association for Healthcare Security and Safety; iahss.org). Other organizations that can help with the development of a preparedness plan include the Occupational Safety and Health Administration (https://www.osha.gov/SLTC/workplaceviolence/evaluation.html), the Department of Homeland Security (https://www.dhs.gov/sites/default/files/publications/ISC%20Violence%20in%20%20the%20Federal%20Workplace%20Guide%20April%202013.pdf), and The Joint Commission (https://www.jointcommission.org/workplace_violence.aspx).

In long-term care settings, such as nursing homes, and shorter-term care settings, such as rehabilitation facilities, agitation may stem from causes related to a head injury or dementia or from living in an unfamiliar environment. Assessment can be accomplished using a formal scale (eg, the ABS), as well as by identifying potential underlying health-related factors that can lead to agitation, such as pain, an infection, bowel and bladder issues, seizures, wounds, endocrine anomalies, cardiac or pulmonary problems, gastrointestinal dysfunction, and metabolic abnormalities.³

Modify the environment. For this population, a primary approach involves modifying the environment to decrease the likelihood of agitation. This may involve decreasing noise or light or ensuring adequate levels of stimulation. Preventing disorientation can be addressed through verbal and visual reminders of the date, schedule, etc. If a particular situation or activity is identified as a source of agitation, attempts at modifications are called for.³

For patients with dementia, the American Psychiatric Association recommends using the lowest effective dose of an antipsychotic in conjunction with environmental and behavioral measures.¹⁶ A benzodiazepine (lorazepam, oxazepam) may be used for infrequent agitation. Trazodone or a selective serotonin reuptake inhibitor are alternatives for those without psychosis or who are intolerant to antipsychotics.¹⁶

For individuals in a rehabilitation setting, agitation can impede participation in therapy and has been associated with poorer functioning at the time of discharge.³ Agitation can also be disruptive and lead to distress for family members and caregivers, as well as for fellow patients. And because this environment has a greater likelihood of visitors unrelated to the patient being exposed to the aberrant behavior, it is especially important to have established policies and procedures for de-escalation in place.

Home care

More and more FPs and residents are conducting home visits. That’s because the Accreditation Council for Graduate Medical Education Program Requirements for Graduate Medical Education in Family Medicine now include integrating a patient’s care across settings—including the home.¹⁷ Those who do provide home care may find themselves in circumstances similar to those of domestic disputes.

The German study mentioned earlier of more than 800 primary care physicians found that while the vast majority of physicians felt safe in their offices, 66% of female doctors and 34% of male doctors did not feel safe making home visits.¹²

Know the neighborhood. There’s no doubt that working in the home health sector makes one vulnerable. More than 61% of home care workers report workplace violence annually.^18,19 An action plan, as well as established policies and procedures, are essential when making home visits. Prior to the visit, be aware of the community and the location of the nearest police department and hospital.

Unwin and Tatum²⁰ suggest not wearing a white coat or carrying a doctor’s bag so as not to stand out as a physician in neighborhoods where personal safety is an issue. Make sure that your cell phone is fully charged and that there is a GPS mechanism activated that allows others to locate you.²¹ Note the available exits in a patient’s home, and position yourself near them, if possible. Have someone call or text you at predetermined times so that the absence of a response from you will alert someone to send help.

In such situations, it is imperative to remain calm and to use the same verbal de-escalation techniques (TABLE 3^4,6,9,11) that would be used in any other health care setting. It is prudent to set expectations for the patient and family members prior to the home visit regarding the tools and services that will be provided in the home setting and the limitations in terms of scope of practice.

Emergency department

The ED is one of the most common settings for patient agitation and violence within the health care continuum.²² Providers must quickly determine the cause of the agitation while de-escalating the situation and ensuring that they do not miss a pertinent medical finding related to a time-sensitive issue, such as an intracerebral bleed or poisoning.⁷ In addition, the ED is usually heavily populated, providing an opportunity for tremendous collateral human damage should the violence escalate or weapons be deployed. The upside is that many EDs are now staffed with security personnel and, depending on the community, police officers may be on the premises or in the vicinity.²²

Avoid wearing a white coat or carrying a doctor's bag when doing a home visit so as not to stand out as a physician in neighborhoods where personal safety is an issue.

Etiologies for agitation in the ED can range from ingestion of unknown or unidentified substances to psychiatric or medical conditions. Knowledge of etiology is necessary prior to initiation of treatment.⁴

As in other settings, the safety of the patient and others present is of utmost importance. Key recommendations for managing agitated patients in the ED include: ⁴

1. Have an established plan for the management of agitated patients.
2. Identify signs of agitation early, and complete an agitation rating scale.
3. Attempt verbal de-escalation before using medication whenever possible.
4. Employ a “show of concern” rather than “a show of force” in response to escalating agitation/violence. Doing so can strengthen the perception that interventions are coming from a place of caring.
5. Use physical restraint as a last resort. When used, it should be with the intention of protecting the patient and those present, rather than as punishment.

Inpatient units

Unlike the ED, patients on units generally have a working diagnosis, and the provider has some background information with which to work, such as laboratory test results and radiology reports, facilitating more expedient and accurate situational assessment. However, the recommendations for assessment and early identification, as described for the ED, still apply.

If a provider finds him- or herself in an escalating situation, the call bells located in the rooms are of use. An alternative is to call out for help from someone in the hallway. One needs to be aware of the current policies and procedures for de-escalation, as some facilities have a specific “code” that is called for such occasions.¹⁹

Postop delirium is a common cause of agitation in the inpatient setting. Ng and colleagues¹¹ recommend a cognitive assessment before surgery to establish a baseline in order to determine the risk for delirium after surgery. Additionally, the FP must remain aware of preexisting conditions that may surface during a hospital stay, such as dehydration or unrecognized alcohol or medication withdrawal.

A "show of concern" rather than a "show of force" can strengthen the perception that interventions are coming from a place of caring.

Medication choice should be based on the type of delirium. Hyperactive delirium (restlessness, emotional lability, hallucinations) and mixed delirium (a combination of signs of hyperactive and hypoactive dementia) both hold the potential for agitation and even violence. The approach to hyperactive delirium includes consideration of an antipsychotic medication, although the efficacy of antipsychotics is considered controversial. In the case of mixed delirium, behavioral and environmental modifications are useful (eg, reducing noise and early ambulation).¹¹

No medications are registered with the US Food and Drug Administration for the management of delirium, and it is suggested that antipsychotics be considered only when other, less invasive, strategies have been attempted.²³

Regardless of the setting in which FPs work, witnessing or being directly involved in a traumatic event puts one at risk for symptoms—or a full diagnosis—of posttraumatic stress disorder (PTSD), acute stress disorder, or anxiety or mood disorders.^24,25 Although findings vary, studies have found that as many as 12% of ED personnel meet the criteria for PTSD^26,27 and 12% to 15% report having been threatened physically.^28,29 More than half of physicians in another study had witnessed a physical attack.³⁰

Physicians and other health care personnel who have experienced a traumatic incident, or offered help to another during an incident, may attempt to cope through avoidance, cutting down on work hours, leaving the work setting in which the event took place, or leaving the profession altogether.^29,31,32

There is a paucity of methodologically sound research with regard to prevention and treatment of PTSD symptoms in this population.²⁴ According to a 2002 Cochrane review, the effectiveness of individual, single-session debriefing does not have solid research support,³³ and there are concerns about potential harms due to reliving the traumatic event when sessions are led by poorly trained debriefing staff.^34-36

Critical incident stress debriefing (CISD), however, holds promise in terms of facilitating a return to pretrauma functioning based on studies of first responders.^34,35 This may be because CISD follows a specific protocol and that group sessions may capitalize on the social support/camaraderie within a group that has undergone a traumatic event.^34,35 It is important that those providing debriefing and support be well-trained.³⁵

Debriefing, however, is not always sufficient, and those who appear to be affected on an ongoing basis may require individual treatment for PTSD symptoms. Evidence-based treatments for PTSD, such as trauma-focused psychotherapy and/or pharmacotherapy, may be considered³⁷ (TABLE 4^24,34,38).

Ongoing support in the workplace. The Cleveland Clinic has developed a “Code Lavender” to combat stress in the workplace. Like a Code Blue for medical emergencies, a Code Lavender is called when a health care worker is in need of emotional or spiritual support.³⁸ A provider who initiates the call is met by a team of holistic nurses within 30 minutes. The team provides Reiki and massage, healthy snacks and water, and lavender arm bands to remind the individual to relax for the rest of the day. Further opportunities for spiritual support, mindfulness training, counseling, and yoga may also be made available.

CASE  Sensing that the situation with my patient might escalate, I lowered my voice, relaxed my shoulders, leaned casually against the desk, and asked him to tell me how I could best help him. As he spoke, I offered him a seat (by gesturing to the chair). I did this for 2 reasons: to move him away from blocking my exit from the room, and to put him at a lower level than me so that he was entirely in my view. I didn’t interrupt him as he spoke. I just nodded or tilted my head to show I was listening. In my mind, I played out the various scenarios that could ensue.

Like a Code Blue for medical emergencies, a Code Lavender is called when a health care worker is in need of emotional or spiritual support.

Fortunately, I was able to get him to relax enough for an assessment, which involved a more relevant history and the exam, which he agreed to once an aide had come into the room. He did not exhibit the concerning signs of flushed skin, dilated pupils, shallow rapid respirations, or perspiration. He did have a comorbid behavioral health issue, which we were able to address. His earlier behavioral indicators of agitation were controlled with verbal and physical cues on my part. Our conversation didn't reveal an intent to harm himself or others. In this case, physical restraints were not required. Throughout the encounter the door was left open, and the patient was reminded that we were there to help.

Once he left, I made the relevant notes in the chart regarding his agitated state at the start of the visit and his final state at the end of the visit so as to assist any other providers. We (TIM, MG) also held a quick debrief after the encounter with the office staff and decided that we needed to create a policy and protocol regarding how to handle such situations in the future.

CORRESPONDENCE
Tochi Iroku-Malize, MD, MPH, MBA, Family Medicine Department, Southside Hospital, 301 East Main Street, Bay Shore, NY 11706; [email protected].

CASE A 40-year-old man came to our office slightly agitated. He had an acute illness that was minor in nature. However, he was not interested in answering my questions or undergoing a physical exam. The more I tried to proceed with the visit, the more agitated he became—pacing the room, muttering, avoiding eye contact. I was uncomfortable and knew that the situation could quickly escalate if it was not brought under control.

What steps would you take if this were your patient?

The scene described above occurred several years ago, but more recently, one of the institutions in my (TIM) area was affected by a shooter in the workplace. The apprehension felt by all of us who were on the periphery paled in comparison to what was experienced by those at the scene. The outcome was horrific. Communicating with those directly involved during, and immediately after, the event was heart-wrenching. The trauma that they continue to relive is unimaginable, and some are not yet able to return to work.

Situations involving agitated patients are not uncommon in health care settings, although ones that escalate to the level of a shooting are. And no matter where on the spectrum an incident involving an agitated patient falls, it can leave those involved with various levels of physical, emotional, and psychological harm. It can also leave everyone asking themselves: “How can I better prepare for such occurrences?”

This article offers some answers by providing tips and guidelines for handling agitated and/or violent patients in various settings.

[polldaddy:9948472]

Defining the problem, assessing its severity

Between 2011 and 2013, workplace assaults ranged from 23,540 and 25,630 annually, with 70% to 74% occurring in health care and social service settings.^1,2

Agitation is defined as a state that may include inattention, disinhibition, emotional lability, impulsivity, motor restlessness, and aggression.^3,4 Violence in a clinical setting may be seen as an extreme expression of agitation sufficient enough to cause harm to an individual or damage to an object.^5,6

The causes of agitation can be grouped into categories: those due to a general medical condition, those due to a psychiatric condition, and those due to drug intoxication and/or withdrawal.⁷ We have chosen to add a fourth category—iatrogenic (see TABLE 1^3,4,7-9). They are not distinct categories, as there is sometimes overlap among areas.

Determining the level of agitation. Various scales and approaches can help determine the level of agitation in a patient (eg, the Agitated Behavior Scale [ABS; FIGURE];⁵ the Behavioral Activity Rating Scale [BARS]¹⁰) and the risk for violence (eg, the ABC violence risk assessment, TABLE 2⁸).

Scales like the ABS should be employed as soon as a patient shows signs of agitation sufficient to warrant intervention. The idea is for the family physician (FP) to be familiar enough with the tool to be able to mentally check it off, fill it out when time permits, and keep it in the patient’s chart. The first version of the form serves as a baseline so that if care is handed off to another provider, that provider can monitor whether signs and symptoms are improving or worsening.

Setting often drives the solution

Much of the evidence-based research on managing patient agitation and violence stems from inpatient psychiatric and emergency department (ED) settings. To make other health care providers aware of the experience gained in those settings, the American Association for Emergency Psychiatry created Project BETA (Best Practices in Evaluation and Treatment of Agitation). This project is designed to help promote consistency across health care settings and specialties in the way clinicians respond to agitated patients and to emphasize for all health care providers the availability of more than just pharmacologic approaches.⁷

De-escalating the situation. General tenets of de-escalation apply across practice settings. Among them:

• Stay calm. Avoid aggressive postures and prolonged eye contact.
• Be nonconfrontational. Acknowledge the patient’s frustration/perceptions and ask open-ended questions.
• Assess available resources such as clinical team members, family members, and silent alarms.
• Manage the situation and the patient’s underlying issues/diagnoses. This includes mobilizing other patients to avoid collateral damage and exploring solutions with the patient.

For more on de-escalation tools, see (TABLE 3^4,6,9,11).

Your setting matters. It’s worth noting that the settings in which clinicians practice greatly influence the resources available to de-escalate a situation and ensure the safety of the patient and others.⁷ The review that follows provides some issues—and tips—that are unique to different practice settings.

Ambulatory settings

Sim and colleagues⁹ noted that aggressive behavior in the general practice setting may stem not only from factors related to the patient’s own physical or psychological discomfort, but from patients feeling that they are being treated unfairly, whether it be because of wait times, uncomfortable waiting conditions, or something else. A number of international studies have shown high rates of abuse toward FPs.^9,12 Of 831 primary care physicians surveyed in a German study, close to three-quarters indicated that within the last year, they had experienced aggression (ranging from verbal abuse and threats to physical violence and property damage) from a patient.¹² This statistic increased to 91% when it included the length of their career.

Between 2011 and 2013, 7 out of 10 workplace assaults occurred in health care and social service settings.

Bell¹³ suggests that physicians be aware that transference and countertransference issues are often at play when dealing with hostile or potentially violent patients. Suggestions to prevent aggression include some practice-level approaches (eg, providing waiting room distractions, making patients aware of potential delays), as well as being aware of nonverbal cues suggesting increased agitation (eg, clenched fists, crossed arms, chin thrusts, finger pointing).⁹

Group practice

An FP who practices with other health care providers and clinical staff has a built-in team that can assist with de-escalation. When meeting with a patient who has a history of violence or agitation in an exam room or office, try to ensure that you can get to an exit quickly if necessary. Also, alert staff to any concerns, and have a system for at least one staff member to check in periodically during the visit.

It is also helpful to develop an evacuation plan and create a “panic room” or “safe zone” for emergencies.^14,15 Such a space may be nothing more than an area or room for staff to gather. It should have access to the police or other emergency services via a land and/or cell phone line.

Solo practice

If you practice alone, institute safeguards whereby a colleague (at a different practice, building, or location) can be alerted if concerns arise. In addition, consider the following precautions: locking the door when alone after hours, screening potential patients, having a way to call for help (keep the number for the local police station and ED readily available), prohibiting potential weapons (as some states allow them to be carried), and learning some form of self-defense.¹⁵

Ensure that agitated patients are not positioned between you and the exit so that you can quickly escape if necessary.

Resources exist that offer guidelines for developing policies and procedures, checklists, and sample incident forms (eg, the International Association for Healthcare Security and Safety; iahss.org). Other organizations that can help with the development of a preparedness plan include the Occupational Safety and Health Administration (https://www.osha.gov/SLTC/workplaceviolence/evaluation.html), the Department of Homeland Security (https://www.dhs.gov/sites/default/files/publications/ISC%20Violence%20in%20%20the%20Federal%20Workplace%20Guide%20April%202013.pdf), and The Joint Commission (https://www.jointcommission.org/workplace_violence.aspx).

In long-term care settings, such as nursing homes, and shorter-term care settings, such as rehabilitation facilities, agitation may stem from causes related to a head injury or dementia or from living in an unfamiliar environment. Assessment can be accomplished using a formal scale (eg, the ABS), as well as by identifying potential underlying health-related factors that can lead to agitation, such as pain, an infection, bowel and bladder issues, seizures, wounds, endocrine anomalies, cardiac or pulmonary problems, gastrointestinal dysfunction, and metabolic abnormalities.³

Modify the environment. For this population, a primary approach involves modifying the environment to decrease the likelihood of agitation. This may involve decreasing noise or light or ensuring adequate levels of stimulation. Preventing disorientation can be addressed through verbal and visual reminders of the date, schedule, etc. If a particular situation or activity is identified as a source of agitation, attempts at modifications are called for.³

For patients with dementia, the American Psychiatric Association recommends using the lowest effective dose of an antipsychotic in conjunction with environmental and behavioral measures.¹⁶ A benzodiazepine (lorazepam, oxazepam) may be used for infrequent agitation. Trazodone or a selective serotonin reuptake inhibitor are alternatives for those without psychosis or who are intolerant to antipsychotics.¹⁶

For individuals in a rehabilitation setting, agitation can impede participation in therapy and has been associated with poorer functioning at the time of discharge.³ Agitation can also be disruptive and lead to distress for family members and caregivers, as well as for fellow patients. And because this environment has a greater likelihood of visitors unrelated to the patient being exposed to the aberrant behavior, it is especially important to have established policies and procedures for de-escalation in place.

Home care

More and more FPs and residents are conducting home visits. That’s because the Accreditation Council for Graduate Medical Education Program Requirements for Graduate Medical Education in Family Medicine now include integrating a patient’s care across settings—including the home.¹⁷ Those who do provide home care may find themselves in circumstances similar to those of domestic disputes.

The German study mentioned earlier of more than 800 primary care physicians found that while the vast majority of physicians felt safe in their offices, 66% of female doctors and 34% of male doctors did not feel safe making home visits.¹²

Know the neighborhood. There’s no doubt that working in the home health sector makes one vulnerable. More than 61% of home care workers report workplace violence annually.^18,19 An action plan, as well as established policies and procedures, are essential when making home visits. Prior to the visit, be aware of the community and the location of the nearest police department and hospital.

Unwin and Tatum²⁰ suggest not wearing a white coat or carrying a doctor’s bag so as not to stand out as a physician in neighborhoods where personal safety is an issue. Make sure that your cell phone is fully charged and that there is a GPS mechanism activated that allows others to locate you.²¹ Note the available exits in a patient’s home, and position yourself near them, if possible. Have someone call or text you at predetermined times so that the absence of a response from you will alert someone to send help.

In such situations, it is imperative to remain calm and to use the same verbal de-escalation techniques (TABLE 3^4,6,9,11) that would be used in any other health care setting. It is prudent to set expectations for the patient and family members prior to the home visit regarding the tools and services that will be provided in the home setting and the limitations in terms of scope of practice.

Emergency department

The ED is one of the most common settings for patient agitation and violence within the health care continuum.²² Providers must quickly determine the cause of the agitation while de-escalating the situation and ensuring that they do not miss a pertinent medical finding related to a time-sensitive issue, such as an intracerebral bleed or poisoning.⁷ In addition, the ED is usually heavily populated, providing an opportunity for tremendous collateral human damage should the violence escalate or weapons be deployed. The upside is that many EDs are now staffed with security personnel and, depending on the community, police officers may be on the premises or in the vicinity.²²

Avoid wearing a white coat or carrying a doctor's bag when doing a home visit so as not to stand out as a physician in neighborhoods where personal safety is an issue.

Etiologies for agitation in the ED can range from ingestion of unknown or unidentified substances to psychiatric or medical conditions. Knowledge of etiology is necessary prior to initiation of treatment.⁴

As in other settings, the safety of the patient and others present is of utmost importance. Key recommendations for managing agitated patients in the ED include: ⁴

1. Have an established plan for the management of agitated patients.
2. Identify signs of agitation early, and complete an agitation rating scale.
3. Attempt verbal de-escalation before using medication whenever possible.
4. Employ a “show of concern” rather than “a show of force” in response to escalating agitation/violence. Doing so can strengthen the perception that interventions are coming from a place of caring.
5. Use physical restraint as a last resort. When used, it should be with the intention of protecting the patient and those present, rather than as punishment.

Inpatient units

Unlike the ED, patients on units generally have a working diagnosis, and the provider has some background information with which to work, such as laboratory test results and radiology reports, facilitating more expedient and accurate situational assessment. However, the recommendations for assessment and early identification, as described for the ED, still apply.

If a provider finds him- or herself in an escalating situation, the call bells located in the rooms are of use. An alternative is to call out for help from someone in the hallway. One needs to be aware of the current policies and procedures for de-escalation, as some facilities have a specific “code” that is called for such occasions.¹⁹

Postop delirium is a common cause of agitation in the inpatient setting. Ng and colleagues¹¹ recommend a cognitive assessment before surgery to establish a baseline in order to determine the risk for delirium after surgery. Additionally, the FP must remain aware of preexisting conditions that may surface during a hospital stay, such as dehydration or unrecognized alcohol or medication withdrawal.

A "show of concern" rather than a "show of force" can strengthen the perception that interventions are coming from a place of caring.

Medication choice should be based on the type of delirium. Hyperactive delirium (restlessness, emotional lability, hallucinations) and mixed delirium (a combination of signs of hyperactive and hypoactive dementia) both hold the potential for agitation and even violence. The approach to hyperactive delirium includes consideration of an antipsychotic medication, although the efficacy of antipsychotics is considered controversial. In the case of mixed delirium, behavioral and environmental modifications are useful (eg, reducing noise and early ambulation).¹¹

No medications are registered with the US Food and Drug Administration for the management of delirium, and it is suggested that antipsychotics be considered only when other, less invasive, strategies have been attempted.²³

Regardless of the setting in which FPs work, witnessing or being directly involved in a traumatic event puts one at risk for symptoms—or a full diagnosis—of posttraumatic stress disorder (PTSD), acute stress disorder, or anxiety or mood disorders.^24,25 Although findings vary, studies have found that as many as 12% of ED personnel meet the criteria for PTSD^26,27 and 12% to 15% report having been threatened physically.^28,29 More than half of physicians in another study had witnessed a physical attack.³⁰

Physicians and other health care personnel who have experienced a traumatic incident, or offered help to another during an incident, may attempt to cope through avoidance, cutting down on work hours, leaving the work setting in which the event took place, or leaving the profession altogether.^29,31,32

There is a paucity of methodologically sound research with regard to prevention and treatment of PTSD symptoms in this population.²⁴ According to a 2002 Cochrane review, the effectiveness of individual, single-session debriefing does not have solid research support,³³ and there are concerns about potential harms due to reliving the traumatic event when sessions are led by poorly trained debriefing staff.^34-36

Critical incident stress debriefing (CISD), however, holds promise in terms of facilitating a return to pretrauma functioning based on studies of first responders.^34,35 This may be because CISD follows a specific protocol and that group sessions may capitalize on the social support/camaraderie within a group that has undergone a traumatic event.^34,35 It is important that those providing debriefing and support be well-trained.³⁵

Debriefing, however, is not always sufficient, and those who appear to be affected on an ongoing basis may require individual treatment for PTSD symptoms. Evidence-based treatments for PTSD, such as trauma-focused psychotherapy and/or pharmacotherapy, may be considered³⁷ (TABLE 4^24,34,38).

Ongoing support in the workplace. The Cleveland Clinic has developed a “Code Lavender” to combat stress in the workplace. Like a Code Blue for medical emergencies, a Code Lavender is called when a health care worker is in need of emotional or spiritual support.³⁸ A provider who initiates the call is met by a team of holistic nurses within 30 minutes. The team provides Reiki and massage, healthy snacks and water, and lavender arm bands to remind the individual to relax for the rest of the day. Further opportunities for spiritual support, mindfulness training, counseling, and yoga may also be made available.

CASE  Sensing that the situation with my patient might escalate, I lowered my voice, relaxed my shoulders, leaned casually against the desk, and asked him to tell me how I could best help him. As he spoke, I offered him a seat (by gesturing to the chair). I did this for 2 reasons: to move him away from blocking my exit from the room, and to put him at a lower level than me so that he was entirely in my view. I didn’t interrupt him as he spoke. I just nodded or tilted my head to show I was listening. In my mind, I played out the various scenarios that could ensue.

Like a Code Blue for medical emergencies, a Code Lavender is called when a health care worker is in need of emotional or spiritual support.

Fortunately, I was able to get him to relax enough for an assessment, which involved a more relevant history and the exam, which he agreed to once an aide had come into the room. He did not exhibit the concerning signs of flushed skin, dilated pupils, shallow rapid respirations, or perspiration. He did have a comorbid behavioral health issue, which we were able to address. His earlier behavioral indicators of agitation were controlled with verbal and physical cues on my part. Our conversation didn't reveal an intent to harm himself or others. In this case, physical restraints were not required. Throughout the encounter the door was left open, and the patient was reminded that we were there to help.

Once he left, I made the relevant notes in the chart regarding his agitated state at the start of the visit and his final state at the end of the visit so as to assist any other providers. We (TIM, MG) also held a quick debrief after the encounter with the office staff and decided that we needed to create a policy and protocol regarding how to handle such situations in the future.

CORRESPONDENCE
Tochi Iroku-Malize, MD, MPH, MBA, Family Medicine Department, Southside Hospital, 301 East Main Street, Bay Shore, NY 11706; [email protected].

A 39-year-old woman presented to the emergency department for evaluation of diffuse redness, itching, and tenderness of her skin. The patient said the eruption began 4 months earlier as localized plaques on her scalp, elbows, and beneath both breasts. Over the course of a few days, the redness became more diffuse, affecting most of her body. She also noticed swelling and skin desquamation on her lower extremities.

The patient had visited multiple urgent care clinics and underwent several courses of prednisone with initial improvement of symptoms, but experienced recurrence shortly after finishing the tapers.

On physical examination, more than 95% of the patient’s skin was bright red and tender to the touch, with associated exfoliation (FIGURES 1A-1B). Her lower extremities had pitting edema with superficial erosions that were weeping serous fluid. She was afebrile and normotensive, but had shaking chills and was tachycardic, with a heart rate of 115 bpm. There was no nail pitting, pustules, or lymphadenopathy. Lab tests revealed a low albumin level of 2.2 g/dL (normal: 3.5-5.5 g/dL), an elevated white blood cell count of 14,700 cells/mcL (normal: 4500-11,000 cells/mcL), and normocytic anemia (low hemoglobin of 8.7 g/dL; normal: 12-15.5 g/dL). The patient was admitted.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

Based on the patient’s clinical presentation, we diagnosed severe erythroderma secondary to psoriasis. A punch biopsy was performed, and pathology demonstrated subacute spongiotic dermatitis with superficial neutrophilic infiltrates, consistent with psoriasis.

Erythroderma is widespread reddening of the skin associated with desquamation, typically involving more than 90% of the body’s surface area.¹ In most instances, erythroderma is a clinical presentation of an existing dermatosis. The most common causative conditions include primary skin disorders (such as psoriasis or atopic dermatitis), idiopathic erythroderma, and drug eruptions. Less common causes include cutaneous T-cell lymphoma, pityriasis rubra pilaris, and contact dermatitis.¹

Erythroderma is usually a clinical presentation of an existing dermatosis, such as psoriasis or atopic dermatitis.

It’s unclear why some skin diseases progress to erythroderma; the pathogenesis is complicated and involves keratinocytes and lymphocytes interacting with adhesion molecules and cytokines. Erythroderma can arise at any age and occurs in all races, but is more common in males and older adults, with a mean age of 42 to 61 years.² The annual incidence of erythroderma is estimated to be one per 100,000 adults.³

A complete picture of the patient is essential to making the diagnosis

Diagnosis can be difficult and hinges on historical and physical exam findings, as well as lab evaluations and skin biopsies. The history should focus on current and former medications, while the physical exam should hone in on clinical manifestations of existing dermatoses. The most common extracutaneous finding is generalized lymphadenopathy, which if prominent, may warrant lymph node biopsy, with studies for evaluation of underlying lymphoma.

Tachycardia develops in 40% of patients, secondary to increased blood flow to the skin and fluid loss, with risk of high-output cardiac failure.² Patients often have chills because their skin is not able to regulate their body temperature normally.⁴

The lab evaluation should include a complete blood count with differential and a comprehensive metabolic panel, as well as blood, skin, and urine cultures if infection is suspected as an inciting factor. Typical findings include mild anemia, leukocytosis, eosinophilia, and an elevated erythrocyte sedimentation rate.⁵ In addition, patients with chronic erythroderma commonly have low albumin.⁶ Unfortunately, lab studies don’t always reveal the underlying cause of the erythroderma.

Biopsies are commonly performed. However, the underlying etiology is often not clearly reflected in the result. Histology is typically nonspecific; findings frequently include hyperkeratosis, acanthosis, spongiosis, and perivascular inflammatory infiltrate. Additionally, the prominence of histologic features may vary depending on the stage of disease and the severity of inflammation. More specific findings may become evident later in the disease as the erythroderma clears, so repeated skin biopsies over time may be needed for diagnosis.⁷

Consider these conditions, which can lead to erythroderma

First and foremost, it is important to get a thorough history, particularly about prior skin conditions and symptoms that may indicate the presence of undiagnosed skin conditions.

Psoriasis is one of the most common causes of erythroderma. A history of pre-existing psoriasis is very helpful, but when this is not present, a biopsy can help confirm a clinical suspicion for psoriasis. It also helps to look for clues of psoriasis like nail changes or a history of plaques over the elbows and knees.

Atopic dermatitis is another common cause of erythroderma, and the history might include scaling and erythematous patches or plaques involving flexural surfaces before erythroderma occurs. Patients may have a history of atopic dermatitis from childhood and/or a history of other atopic conditions such as asthma and allergic rhinitis.

Drug eruptions occur following the administration of a new medication and can mimic a myriad of dermatoses.

Cutaneous T-cell lymphoma can lead to erythroderma and be differentiated with skin biopsy; pathology may show atypical lymphocytes, and Pautrier’s microabscesses may be seen.⁸

Pityriasis rubra pilaris is a relatively rare condition that presents with red-orange scaling patches and thickened yellowish palms and soles.⁹

Tx targets underlying etiology and associated complications

When treating a patient with erythroderma, it’s important to prevent hypothermia and secondary infections. If symptoms are severe, hospitalization should be considered. Nutrition should be assessed, and any fluid or electrolyte imbalances should be corrected.

Hospitalization should be considered to prevent hypothermia and secondary infections, as well as to assess nutrition and correct any fluid or electrolyte imbalances.

Oral antihistamines are commonly administered to suppress associated pruritus. Topical treatment usually consists of corticosteroids under occlusion with bland emollients. Depending upon the underlying disease, the following systemic medications may be started: methotrexate 7.5 to 15 mg once/week; acitretin 10 to 25 mg/d; or cyclosporine 2.5 to 5  mg/kg/d; in addition to topical treatment.⁴

Our patient. Pathology for our patient was indicative of psoriasis. She was started on a regimen of cyclosporine 4 to 5 mg/kg/d, diphenhydramine 25 to 50 mg as needed for itching, triamcinolone 0.1% ointment under wet wraps to her trunk and extremities, and hydrocortisone 2.5% ointment to be applied to her face daily. She was released after 5 days in the hospital. At outpatient follow-up one week later, her erythroderma was resolving. One month later, her erythroderma was resolved (FIGURE 2), although she did have psoriatic plaques on her lower legs.

CORRESPONDENCE
Richard P. Usatine, MD, University of Texas Health San Antonio, 7703 Floyd Curl Dr., San Antonio, TX 78229; [email protected].

A 39-year-old woman presented to the emergency department for evaluation of diffuse redness, itching, and tenderness of her skin. The patient said the eruption began 4 months earlier as localized plaques on her scalp, elbows, and beneath both breasts. Over the course of a few days, the redness became more diffuse, affecting most of her body. She also noticed swelling and skin desquamation on her lower extremities.

The patient had visited multiple urgent care clinics and underwent several courses of prednisone with initial improvement of symptoms, but experienced recurrence shortly after finishing the tapers.

On physical examination, more than 95% of the patient’s skin was bright red and tender to the touch, with associated exfoliation (FIGURES 1A-1B). Her lower extremities had pitting edema with superficial erosions that were weeping serous fluid. She was afebrile and normotensive, but had shaking chills and was tachycardic, with a heart rate of 115 bpm. There was no nail pitting, pustules, or lymphadenopathy. Lab tests revealed a low albumin level of 2.2 g/dL (normal: 3.5-5.5 g/dL), an elevated white blood cell count of 14,700 cells/mcL (normal: 4500-11,000 cells/mcL), and normocytic anemia (low hemoglobin of 8.7 g/dL; normal: 12-15.5 g/dL). The patient was admitted.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

Based on the patient’s clinical presentation, we diagnosed severe erythroderma secondary to psoriasis. A punch biopsy was performed, and pathology demonstrated subacute spongiotic dermatitis with superficial neutrophilic infiltrates, consistent with psoriasis.

Erythroderma is widespread reddening of the skin associated with desquamation, typically involving more than 90% of the body’s surface area.¹ In most instances, erythroderma is a clinical presentation of an existing dermatosis. The most common causative conditions include primary skin disorders (such as psoriasis or atopic dermatitis), idiopathic erythroderma, and drug eruptions. Less common causes include cutaneous T-cell lymphoma, pityriasis rubra pilaris, and contact dermatitis.¹

Erythroderma is usually a clinical presentation of an existing dermatosis, such as psoriasis or atopic dermatitis.

It’s unclear why some skin diseases progress to erythroderma; the pathogenesis is complicated and involves keratinocytes and lymphocytes interacting with adhesion molecules and cytokines. Erythroderma can arise at any age and occurs in all races, but is more common in males and older adults, with a mean age of 42 to 61 years.² The annual incidence of erythroderma is estimated to be one per 100,000 adults.³

A complete picture of the patient is essential to making the diagnosis

Diagnosis can be difficult and hinges on historical and physical exam findings, as well as lab evaluations and skin biopsies. The history should focus on current and former medications, while the physical exam should hone in on clinical manifestations of existing dermatoses. The most common extracutaneous finding is generalized lymphadenopathy, which if prominent, may warrant lymph node biopsy, with studies for evaluation of underlying lymphoma.

Tachycardia develops in 40% of patients, secondary to increased blood flow to the skin and fluid loss, with risk of high-output cardiac failure.² Patients often have chills because their skin is not able to regulate their body temperature normally.⁴

The lab evaluation should include a complete blood count with differential and a comprehensive metabolic panel, as well as blood, skin, and urine cultures if infection is suspected as an inciting factor. Typical findings include mild anemia, leukocytosis, eosinophilia, and an elevated erythrocyte sedimentation rate.⁵ In addition, patients with chronic erythroderma commonly have low albumin.⁶ Unfortunately, lab studies don’t always reveal the underlying cause of the erythroderma.

Biopsies are commonly performed. However, the underlying etiology is often not clearly reflected in the result. Histology is typically nonspecific; findings frequently include hyperkeratosis, acanthosis, spongiosis, and perivascular inflammatory infiltrate. Additionally, the prominence of histologic features may vary depending on the stage of disease and the severity of inflammation. More specific findings may become evident later in the disease as the erythroderma clears, so repeated skin biopsies over time may be needed for diagnosis.⁷

Consider these conditions, which can lead to erythroderma

First and foremost, it is important to get a thorough history, particularly about prior skin conditions and symptoms that may indicate the presence of undiagnosed skin conditions.

Psoriasis is one of the most common causes of erythroderma. A history of pre-existing psoriasis is very helpful, but when this is not present, a biopsy can help confirm a clinical suspicion for psoriasis. It also helps to look for clues of psoriasis like nail changes or a history of plaques over the elbows and knees.

Atopic dermatitis is another common cause of erythroderma, and the history might include scaling and erythematous patches or plaques involving flexural surfaces before erythroderma occurs. Patients may have a history of atopic dermatitis from childhood and/or a history of other atopic conditions such as asthma and allergic rhinitis.

Drug eruptions occur following the administration of a new medication and can mimic a myriad of dermatoses.

Cutaneous T-cell lymphoma can lead to erythroderma and be differentiated with skin biopsy; pathology may show atypical lymphocytes, and Pautrier’s microabscesses may be seen.⁸

Pityriasis rubra pilaris is a relatively rare condition that presents with red-orange scaling patches and thickened yellowish palms and soles.⁹

Tx targets underlying etiology and associated complications

When treating a patient with erythroderma, it’s important to prevent hypothermia and secondary infections. If symptoms are severe, hospitalization should be considered. Nutrition should be assessed, and any fluid or electrolyte imbalances should be corrected.

Hospitalization should be considered to prevent hypothermia and secondary infections, as well as to assess nutrition and correct any fluid or electrolyte imbalances.

Oral antihistamines are commonly administered to suppress associated pruritus. Topical treatment usually consists of corticosteroids under occlusion with bland emollients. Depending upon the underlying disease, the following systemic medications may be started: methotrexate 7.5 to 15 mg once/week; acitretin 10 to 25 mg/d; or cyclosporine 2.5 to 5  mg/kg/d; in addition to topical treatment.⁴

Our patient. Pathology for our patient was indicative of psoriasis. She was started on a regimen of cyclosporine 4 to 5 mg/kg/d, diphenhydramine 25 to 50 mg as needed for itching, triamcinolone 0.1% ointment under wet wraps to her trunk and extremities, and hydrocortisone 2.5% ointment to be applied to her face daily. She was released after 5 days in the hospital. At outpatient follow-up one week later, her erythroderma was resolving. One month later, her erythroderma was resolved (FIGURE 2), although she did have psoriatic plaques on her lower legs.

CORRESPONDENCE
Richard P. Usatine, MD, University of Texas Health San Antonio, 7703 Floyd Curl Dr., San Antonio, TX 78229; [email protected].

A 39-year-old woman presented to the emergency department for evaluation of diffuse redness, itching, and tenderness of her skin. The patient said the eruption began 4 months earlier as localized plaques on her scalp, elbows, and beneath both breasts. Over the course of a few days, the redness became more diffuse, affecting most of her body. She also noticed swelling and skin desquamation on her lower extremities.

The patient had visited multiple urgent care clinics and underwent several courses of prednisone with initial improvement of symptoms, but experienced recurrence shortly after finishing the tapers.

On physical examination, more than 95% of the patient’s skin was bright red and tender to the touch, with associated exfoliation (FIGURES 1A-1B). Her lower extremities had pitting edema with superficial erosions that were weeping serous fluid. She was afebrile and normotensive, but had shaking chills and was tachycardic, with a heart rate of 115 bpm. There was no nail pitting, pustules, or lymphadenopathy. Lab tests revealed a low albumin level of 2.2 g/dL (normal: 3.5-5.5 g/dL), an elevated white blood cell count of 14,700 cells/mcL (normal: 4500-11,000 cells/mcL), and normocytic anemia (low hemoglobin of 8.7 g/dL; normal: 12-15.5 g/dL). The patient was admitted.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

Based on the patient’s clinical presentation, we diagnosed severe erythroderma secondary to psoriasis. A punch biopsy was performed, and pathology demonstrated subacute spongiotic dermatitis with superficial neutrophilic infiltrates, consistent with psoriasis.

Erythroderma is widespread reddening of the skin associated with desquamation, typically involving more than 90% of the body’s surface area.¹ In most instances, erythroderma is a clinical presentation of an existing dermatosis. The most common causative conditions include primary skin disorders (such as psoriasis or atopic dermatitis), idiopathic erythroderma, and drug eruptions. Less common causes include cutaneous T-cell lymphoma, pityriasis rubra pilaris, and contact dermatitis.¹

Erythroderma is usually a clinical presentation of an existing dermatosis, such as psoriasis or atopic dermatitis.

It’s unclear why some skin diseases progress to erythroderma; the pathogenesis is complicated and involves keratinocytes and lymphocytes interacting with adhesion molecules and cytokines. Erythroderma can arise at any age and occurs in all races, but is more common in males and older adults, with a mean age of 42 to 61 years.² The annual incidence of erythroderma is estimated to be one per 100,000 adults.³

A complete picture of the patient is essential to making the diagnosis

Diagnosis can be difficult and hinges on historical and physical exam findings, as well as lab evaluations and skin biopsies. The history should focus on current and former medications, while the physical exam should hone in on clinical manifestations of existing dermatoses. The most common extracutaneous finding is generalized lymphadenopathy, which if prominent, may warrant lymph node biopsy, with studies for evaluation of underlying lymphoma.

Tachycardia develops in 40% of patients, secondary to increased blood flow to the skin and fluid loss, with risk of high-output cardiac failure.² Patients often have chills because their skin is not able to regulate their body temperature normally.⁴

The lab evaluation should include a complete blood count with differential and a comprehensive metabolic panel, as well as blood, skin, and urine cultures if infection is suspected as an inciting factor. Typical findings include mild anemia, leukocytosis, eosinophilia, and an elevated erythrocyte sedimentation rate.⁵ In addition, patients with chronic erythroderma commonly have low albumin.⁶ Unfortunately, lab studies don’t always reveal the underlying cause of the erythroderma.

Biopsies are commonly performed. However, the underlying etiology is often not clearly reflected in the result. Histology is typically nonspecific; findings frequently include hyperkeratosis, acanthosis, spongiosis, and perivascular inflammatory infiltrate. Additionally, the prominence of histologic features may vary depending on the stage of disease and the severity of inflammation. More specific findings may become evident later in the disease as the erythroderma clears, so repeated skin biopsies over time may be needed for diagnosis.⁷

Consider these conditions, which can lead to erythroderma

First and foremost, it is important to get a thorough history, particularly about prior skin conditions and symptoms that may indicate the presence of undiagnosed skin conditions.

Psoriasis is one of the most common causes of erythroderma. A history of pre-existing psoriasis is very helpful, but when this is not present, a biopsy can help confirm a clinical suspicion for psoriasis. It also helps to look for clues of psoriasis like nail changes or a history of plaques over the elbows and knees.

Atopic dermatitis is another common cause of erythroderma, and the history might include scaling and erythematous patches or plaques involving flexural surfaces before erythroderma occurs. Patients may have a history of atopic dermatitis from childhood and/or a history of other atopic conditions such as asthma and allergic rhinitis.

Drug eruptions occur following the administration of a new medication and can mimic a myriad of dermatoses.

Cutaneous T-cell lymphoma can lead to erythroderma and be differentiated with skin biopsy; pathology may show atypical lymphocytes, and Pautrier’s microabscesses may be seen.⁸

Pityriasis rubra pilaris is a relatively rare condition that presents with red-orange scaling patches and thickened yellowish palms and soles.⁹

Tx targets underlying etiology and associated complications

When treating a patient with erythroderma, it’s important to prevent hypothermia and secondary infections. If symptoms are severe, hospitalization should be considered. Nutrition should be assessed, and any fluid or electrolyte imbalances should be corrected.

Hospitalization should be considered to prevent hypothermia and secondary infections, as well as to assess nutrition and correct any fluid or electrolyte imbalances.

Oral antihistamines are commonly administered to suppress associated pruritus. Topical treatment usually consists of corticosteroids under occlusion with bland emollients. Depending upon the underlying disease, the following systemic medications may be started: methotrexate 7.5 to 15 mg once/week; acitretin 10 to 25 mg/d; or cyclosporine 2.5 to 5  mg/kg/d; in addition to topical treatment.⁴

Our patient. Pathology for our patient was indicative of psoriasis. She was started on a regimen of cyclosporine 4 to 5 mg/kg/d, diphenhydramine 25 to 50 mg as needed for itching, triamcinolone 0.1% ointment under wet wraps to her trunk and extremities, and hydrocortisone 2.5% ointment to be applied to her face daily. She was released after 5 days in the hospital. At outpatient follow-up one week later, her erythroderma was resolving. One month later, her erythroderma was resolved (FIGURE 2), although she did have psoriatic plaques on her lower legs.

CORRESPONDENCE
Richard P. Usatine, MD, University of Texas Health San Antonio, 7703 Floyd Curl Dr., San Antonio, TX 78229; [email protected].

“Good morning, Mr. Harris. What can I do for you today?”

“Dr. Hickner, I need an MRI of my right knee. I hurt it last week, and I need to find out if I tore something.”

We all know that too many patients request—and often get—costly (and unnecessary) magnetic resonance imaging (MRI) and computed tomography (CT) scans of their joints and backs. That’s why such imaging is targeted in the Choosing Wisely campaign, which aims to eliminate needless testing.¹

But how can we confidently tell Mr. Harris that he doesn’t need an MRI or CT scan? One approach is to explain that imaging is generally reserved for those considering surgery, as it serves to inform the surgeon of the exact procedure needed. Another approach is to be skilled in physical exam techniques that increase our confidence in the clinical diagnosis.

Applying this to acute knee injuries. In this issue of JFP, Koster and colleagues explain that the Lachman test (and possibly the newer lever sign test) are maneuvers that have a high probability of ruling out complete anterior cruciate ligament (ACL) tears when performed properly. The Lachman test, for example, has a 96% sensitivity for complete ACL ruptures.² (The anterior drawer test has too low a sensitivity to rule out ACL injuries, and the pivot shift test is a bit too challenging to be performed reliably.)

A thorough physical exam and selective plain x-rays are all that is needed for the initial evaluation of most knee injuries.

This is important information because early surgery for ACL tears leads to better outcomes for athletes, and a reliable physical exam to rule out an ACL tear reduces the need for imaging. Moreover, other than fractures near the knee, no other knee injuries require early surgery. So a thorough physical exam and selective plain x-rays are all that is needed for the initial evaluation of most knee injuries.

The same is true for back and shoulder injuries, where acute imaging with MRI or CT is rarely called for. A thorough and accurate physical examination is usually sufficient, supplemented with plain X-rays on a selective basis.

Going one step further, consider taking a look at the JAMA series called, “The Rational Clinical Examination,” which has been compiled into a single publication by the same name.³ It is an excellent guide to the sensitivity, specificity, and positive and negative likelihood ratios of a host of clinical findings and tests. It can help to greatly improve clinical skills and reduce unnecessary testing.

“Good morning, Mr. Harris. What can I do for you today?”

“Dr. Hickner, I need an MRI of my right knee. I hurt it last week, and I need to find out if I tore something.”

We all know that too many patients request—and often get—costly (and unnecessary) magnetic resonance imaging (MRI) and computed tomography (CT) scans of their joints and backs. That’s why such imaging is targeted in the Choosing Wisely campaign, which aims to eliminate needless testing.¹

But how can we confidently tell Mr. Harris that he doesn’t need an MRI or CT scan? One approach is to explain that imaging is generally reserved for those considering surgery, as it serves to inform the surgeon of the exact procedure needed. Another approach is to be skilled in physical exam techniques that increase our confidence in the clinical diagnosis.

Applying this to acute knee injuries. In this issue of JFP, Koster and colleagues explain that the Lachman test (and possibly the newer lever sign test) are maneuvers that have a high probability of ruling out complete anterior cruciate ligament (ACL) tears when performed properly. The Lachman test, for example, has a 96% sensitivity for complete ACL ruptures.² (The anterior drawer test has too low a sensitivity to rule out ACL injuries, and the pivot shift test is a bit too challenging to be performed reliably.)

A thorough physical exam and selective plain x-rays are all that is needed for the initial evaluation of most knee injuries.

This is important information because early surgery for ACL tears leads to better outcomes for athletes, and a reliable physical exam to rule out an ACL tear reduces the need for imaging. Moreover, other than fractures near the knee, no other knee injuries require early surgery. So a thorough physical exam and selective plain x-rays are all that is needed for the initial evaluation of most knee injuries.

The same is true for back and shoulder injuries, where acute imaging with MRI or CT is rarely called for. A thorough and accurate physical examination is usually sufficient, supplemented with plain X-rays on a selective basis.

Going one step further, consider taking a look at the JAMA series called, “The Rational Clinical Examination,” which has been compiled into a single publication by the same name.³ It is an excellent guide to the sensitivity, specificity, and positive and negative likelihood ratios of a host of clinical findings and tests. It can help to greatly improve clinical skills and reduce unnecessary testing.

“Good morning, Mr. Harris. What can I do for you today?”

“Dr. Hickner, I need an MRI of my right knee. I hurt it last week, and I need to find out if I tore something.”

We all know that too many patients request—and often get—costly (and unnecessary) magnetic resonance imaging (MRI) and computed tomography (CT) scans of their joints and backs. That’s why such imaging is targeted in the Choosing Wisely campaign, which aims to eliminate needless testing.¹

But how can we confidently tell Mr. Harris that he doesn’t need an MRI or CT scan? One approach is to explain that imaging is generally reserved for those considering surgery, as it serves to inform the surgeon of the exact procedure needed. Another approach is to be skilled in physical exam techniques that increase our confidence in the clinical diagnosis.

Applying this to acute knee injuries. In this issue of JFP, Koster and colleagues explain that the Lachman test (and possibly the newer lever sign test) are maneuvers that have a high probability of ruling out complete anterior cruciate ligament (ACL) tears when performed properly. The Lachman test, for example, has a 96% sensitivity for complete ACL ruptures.² (The anterior drawer test has too low a sensitivity to rule out ACL injuries, and the pivot shift test is a bit too challenging to be performed reliably.)

A thorough physical exam and selective plain x-rays are all that is needed for the initial evaluation of most knee injuries.

This is important information because early surgery for ACL tears leads to better outcomes for athletes, and a reliable physical exam to rule out an ACL tear reduces the need for imaging. Moreover, other than fractures near the knee, no other knee injuries require early surgery. So a thorough physical exam and selective plain x-rays are all that is needed for the initial evaluation of most knee injuries.

The same is true for back and shoulder injuries, where acute imaging with MRI or CT is rarely called for. A thorough and accurate physical examination is usually sufficient, supplemented with plain X-rays on a selective basis.

Going one step further, consider taking a look at the JAMA series called, “The Rational Clinical Examination,” which has been compiled into a single publication by the same name.³ It is an excellent guide to the sensitivity, specificity, and positive and negative likelihood ratios of a host of clinical findings and tests. It can help to greatly improve clinical skills and reduce unnecessary testing.

THE CASE

A 12-year-old girl presented to my office (JH) with bilateral wrist pain. She had fallen on both wrists palmar-flexed and then, while trying to get up, landed on both wrists dorsi-flexed. The patient did not hear any “pops,” but felt immediate pain when her wrists hyperextended. Hand, wrist, and forearm x-rays were negative bilaterally for fractures. She was placed in bilateral thumb spica splints.

At follow-up one week later, the patient reported 6/10 pain in her left wrist and 7/10 pain in her right wrist. The pain increased to 10/10 bilaterally with movement and was not relieved by icing or nonsteroidal anti-inflammatory drugs. On physical exam, there was bilateral swelling of the wrists without ecchymosis or erythema. The patient had limited passive and active range of motion, especially during wrist extension. She also had tenderness to palpation over the anatomical snuff box, extending proximally to the distal radius bilaterally. She had no tenderness over the ulna or metacarpals, no loss of sensation in any area nerves, and she was neurovascularly intact bilaterally.

Based on the mechanism of injury, undetected fracture or full thickness ligament tear were both possible. Because of this, and because magnetic resonance imaging (MRI) entails no radiation exposure, MRI was chosen for additional imaging of both wrists.

THE DIAGNOSIS

The MRI revealed bilateral, nondisplaced, extra-articular fractures extending through the scaphoid waist, with surrounding bone marrow edema. In the right wrist, the patient also had a low-grade partial tear of the membranous portion of the scapholunate interosseous ligament (SLIL) at the scaphoid attachment (FIGURE 1). In the left wrist, she also had a low-grade sprain of the SLIL without tear (FIGURE 2).

DISCUSSION

Carpal fractures account for 6% of all fractures.¹ Scaphoid fractures are the most common carpal bone fracture among all age groups, but account for only 0.4% of all pediatric fractures.^1-3 They’re commonly missed on x-rays because they are usually nondisplaced and hidden by other structures superimposed on the image.^1,2,4 Undetected, scaphoid fractures can cause prolonged interruption to the bone’s architecture, leading to avascular necrosis of the proximal portion of the scaphoid bone.^5,6

Bilateral scaphoid fractures are extremely rare and account for less than 1% of all scaphoid fractures.⁷ Very few of these cases have been published in the literature, and those that have been published have talked about the fractures being secondary to chronic stress fractures and as being treated with internal fixation (regardless of whether the fractures were nondisplaced or if the ligaments were intact).^6-9

Our patient was placed in bilateral fiberglass short-arm thumb spica casts. We tried conservative treatment measures first because she had help with her activities of daily living (ADLs). At a follow-up visit 2 weeks later, we switched the casts to long-arm thumb spica casts because of the patient’s ability to pronate and supinate her wrists in the short-arm versions. After one month of wearing the long-arm casts, we placed her back in bilateral short-arm casts for 2 weeks. Eight weeks after the fall, we removed the short-arm casts for reevaluation.

We obtained x-rays to assess for any new changes to the wrist and specifically the scaphoid bones. The x-rays showed almost completely healed scaphoid bones with good alignment, but the patient still had 5/10 pain in the left wrist and 8/10 pain in the right wrist with movement. We placed her in adjustable thermoformable polymer braces, which were removed when she bathed.

Scaphoid fractures are commonly missed on x-rays because they are usually nondisplaced and hidden by other structures superimposed on the image.

Due to the uniqueness of her injuries, our patient had weekly visits with her primary care provider (PCP) for the first 2 months of treatment, followed by bimonthly visits for the remainder. At 10 weeks after the fall, her pain with movement was almost gone and she began physical therapy. She also began removing the braces during sedentary activity in order to practice range-of-motion exercises to prevent excessive stiffness in her wrists. Our patient regained full strength and range of motion one month later.

One other published case report describes the successful union of bilateral scaphoid fractures using bilateral long-arm casts followed by short-arm casts.⁷ Similar to our patient’s case, full union of the scaphoid bones was achieved within 12 weeks.⁷ Together, these cases suggest that conservative treatment methods are a viable alternative to surgery.

TAKEAWAY

For patients presenting with wrist pain after trauma to the wrists, assess anatomical snuffbox tenderness and obtain x-rays. Do not be falsely reassured by negative x-rays in the presence of a positive physical exam, however, as scaphoid fractures are often hidden on x-rays. If tenderness at the anatomical snuffbox is present and doesn’t subside within a few days, apply a short-arm thumb splint and obtain subsequent imaging.

If tenderness at the anatomical snuffbox is present and doesn't subside within a few days, apply a short-arm thumb splint and obtain subsequent imaging.

If bilateral, nondisplaced, stable scaphoid fractures are diagnosed, conservative treatment with long-arm and short-arm casts is a viable alternative to surgery. This treatment decision should be made on an individual basis, however, as it requires the patient to have frequent PCP visits, assistance with ADLs, and complete adherence to the treatment plan.

THE CASE

A 12-year-old girl presented to my office (JH) with bilateral wrist pain. She had fallen on both wrists palmar-flexed and then, while trying to get up, landed on both wrists dorsi-flexed. The patient did not hear any “pops,” but felt immediate pain when her wrists hyperextended. Hand, wrist, and forearm x-rays were negative bilaterally for fractures. She was placed in bilateral thumb spica splints.

At follow-up one week later, the patient reported 6/10 pain in her left wrist and 7/10 pain in her right wrist. The pain increased to 10/10 bilaterally with movement and was not relieved by icing or nonsteroidal anti-inflammatory drugs. On physical exam, there was bilateral swelling of the wrists without ecchymosis or erythema. The patient had limited passive and active range of motion, especially during wrist extension. She also had tenderness to palpation over the anatomical snuff box, extending proximally to the distal radius bilaterally. She had no tenderness over the ulna or metacarpals, no loss of sensation in any area nerves, and she was neurovascularly intact bilaterally.

Based on the mechanism of injury, undetected fracture or full thickness ligament tear were both possible. Because of this, and because magnetic resonance imaging (MRI) entails no radiation exposure, MRI was chosen for additional imaging of both wrists.

THE DIAGNOSIS

The MRI revealed bilateral, nondisplaced, extra-articular fractures extending through the scaphoid waist, with surrounding bone marrow edema. In the right wrist, the patient also had a low-grade partial tear of the membranous portion of the scapholunate interosseous ligament (SLIL) at the scaphoid attachment (FIGURE 1). In the left wrist, she also had a low-grade sprain of the SLIL without tear (FIGURE 2).

DISCUSSION

Carpal fractures account for 6% of all fractures.¹ Scaphoid fractures are the most common carpal bone fracture among all age groups, but account for only 0.4% of all pediatric fractures.^1-3 They’re commonly missed on x-rays because they are usually nondisplaced and hidden by other structures superimposed on the image.^1,2,4 Undetected, scaphoid fractures can cause prolonged interruption to the bone’s architecture, leading to avascular necrosis of the proximal portion of the scaphoid bone.^5,6

Bilateral scaphoid fractures are extremely rare and account for less than 1% of all scaphoid fractures.⁷ Very few of these cases have been published in the literature, and those that have been published have talked about the fractures being secondary to chronic stress fractures and as being treated with internal fixation (regardless of whether the fractures were nondisplaced or if the ligaments were intact).^6-9

Our patient was placed in bilateral fiberglass short-arm thumb spica casts. We tried conservative treatment measures first because she had help with her activities of daily living (ADLs). At a follow-up visit 2 weeks later, we switched the casts to long-arm thumb spica casts because of the patient’s ability to pronate and supinate her wrists in the short-arm versions. After one month of wearing the long-arm casts, we placed her back in bilateral short-arm casts for 2 weeks. Eight weeks after the fall, we removed the short-arm casts for reevaluation.

We obtained x-rays to assess for any new changes to the wrist and specifically the scaphoid bones. The x-rays showed almost completely healed scaphoid bones with good alignment, but the patient still had 5/10 pain in the left wrist and 8/10 pain in the right wrist with movement. We placed her in adjustable thermoformable polymer braces, which were removed when she bathed.

Scaphoid fractures are commonly missed on x-rays because they are usually nondisplaced and hidden by other structures superimposed on the image.

Due to the uniqueness of her injuries, our patient had weekly visits with her primary care provider (PCP) for the first 2 months of treatment, followed by bimonthly visits for the remainder. At 10 weeks after the fall, her pain with movement was almost gone and she began physical therapy. She also began removing the braces during sedentary activity in order to practice range-of-motion exercises to prevent excessive stiffness in her wrists. Our patient regained full strength and range of motion one month later.

One other published case report describes the successful union of bilateral scaphoid fractures using bilateral long-arm casts followed by short-arm casts.⁷ Similar to our patient’s case, full union of the scaphoid bones was achieved within 12 weeks.⁷ Together, these cases suggest that conservative treatment methods are a viable alternative to surgery.

TAKEAWAY

For patients presenting with wrist pain after trauma to the wrists, assess anatomical snuffbox tenderness and obtain x-rays. Do not be falsely reassured by negative x-rays in the presence of a positive physical exam, however, as scaphoid fractures are often hidden on x-rays. If tenderness at the anatomical snuffbox is present and doesn’t subside within a few days, apply a short-arm thumb splint and obtain subsequent imaging.

If tenderness at the anatomical snuffbox is present and doesn't subside within a few days, apply a short-arm thumb splint and obtain subsequent imaging.

If bilateral, nondisplaced, stable scaphoid fractures are diagnosed, conservative treatment with long-arm and short-arm casts is a viable alternative to surgery. This treatment decision should be made on an individual basis, however, as it requires the patient to have frequent PCP visits, assistance with ADLs, and complete adherence to the treatment plan.

THE CASE

A 12-year-old girl presented to my office (JH) with bilateral wrist pain. She had fallen on both wrists palmar-flexed and then, while trying to get up, landed on both wrists dorsi-flexed. The patient did not hear any “pops,” but felt immediate pain when her wrists hyperextended. Hand, wrist, and forearm x-rays were negative bilaterally for fractures. She was placed in bilateral thumb spica splints.

At follow-up one week later, the patient reported 6/10 pain in her left wrist and 7/10 pain in her right wrist. The pain increased to 10/10 bilaterally with movement and was not relieved by icing or nonsteroidal anti-inflammatory drugs. On physical exam, there was bilateral swelling of the wrists without ecchymosis or erythema. The patient had limited passive and active range of motion, especially during wrist extension. She also had tenderness to palpation over the anatomical snuff box, extending proximally to the distal radius bilaterally. She had no tenderness over the ulna or metacarpals, no loss of sensation in any area nerves, and she was neurovascularly intact bilaterally.

Based on the mechanism of injury, undetected fracture or full thickness ligament tear were both possible. Because of this, and because magnetic resonance imaging (MRI) entails no radiation exposure, MRI was chosen for additional imaging of both wrists.

THE DIAGNOSIS

The MRI revealed bilateral, nondisplaced, extra-articular fractures extending through the scaphoid waist, with surrounding bone marrow edema. In the right wrist, the patient also had a low-grade partial tear of the membranous portion of the scapholunate interosseous ligament (SLIL) at the scaphoid attachment (FIGURE 1). In the left wrist, she also had a low-grade sprain of the SLIL without tear (FIGURE 2).

DISCUSSION

Carpal fractures account for 6% of all fractures.¹ Scaphoid fractures are the most common carpal bone fracture among all age groups, but account for only 0.4% of all pediatric fractures.^1-3 They’re commonly missed on x-rays because they are usually nondisplaced and hidden by other structures superimposed on the image.^1,2,4 Undetected, scaphoid fractures can cause prolonged interruption to the bone’s architecture, leading to avascular necrosis of the proximal portion of the scaphoid bone.^5,6

Bilateral scaphoid fractures are extremely rare and account for less than 1% of all scaphoid fractures.⁷ Very few of these cases have been published in the literature, and those that have been published have talked about the fractures being secondary to chronic stress fractures and as being treated with internal fixation (regardless of whether the fractures were nondisplaced or if the ligaments were intact).^6-9

Our patient was placed in bilateral fiberglass short-arm thumb spica casts. We tried conservative treatment measures first because she had help with her activities of daily living (ADLs). At a follow-up visit 2 weeks later, we switched the casts to long-arm thumb spica casts because of the patient’s ability to pronate and supinate her wrists in the short-arm versions. After one month of wearing the long-arm casts, we placed her back in bilateral short-arm casts for 2 weeks. Eight weeks after the fall, we removed the short-arm casts for reevaluation.

We obtained x-rays to assess for any new changes to the wrist and specifically the scaphoid bones. The x-rays showed almost completely healed scaphoid bones with good alignment, but the patient still had 5/10 pain in the left wrist and 8/10 pain in the right wrist with movement. We placed her in adjustable thermoformable polymer braces, which were removed when she bathed.

Scaphoid fractures are commonly missed on x-rays because they are usually nondisplaced and hidden by other structures superimposed on the image.

Due to the uniqueness of her injuries, our patient had weekly visits with her primary care provider (PCP) for the first 2 months of treatment, followed by bimonthly visits for the remainder. At 10 weeks after the fall, her pain with movement was almost gone and she began physical therapy. She also began removing the braces during sedentary activity in order to practice range-of-motion exercises to prevent excessive stiffness in her wrists. Our patient regained full strength and range of motion one month later.

One other published case report describes the successful union of bilateral scaphoid fractures using bilateral long-arm casts followed by short-arm casts.⁷ Similar to our patient’s case, full union of the scaphoid bones was achieved within 12 weeks.⁷ Together, these cases suggest that conservative treatment methods are a viable alternative to surgery.

TAKEAWAY

For patients presenting with wrist pain after trauma to the wrists, assess anatomical snuffbox tenderness and obtain x-rays. Do not be falsely reassured by negative x-rays in the presence of a positive physical exam, however, as scaphoid fractures are often hidden on x-rays. If tenderness at the anatomical snuffbox is present and doesn’t subside within a few days, apply a short-arm thumb splint and obtain subsequent imaging.

If tenderness at the anatomical snuffbox is present and doesn't subside within a few days, apply a short-arm thumb splint and obtain subsequent imaging.

If bilateral, nondisplaced, stable scaphoid fractures are diagnosed, conservative treatment with long-arm and short-arm casts is a viable alternative to surgery. This treatment decision should be made on an individual basis, however, as it requires the patient to have frequent PCP visits, assistance with ADLs, and complete adherence to the treatment plan.