Approach to

Aggressive
Patients
Team A
 Verbal
abuse

Introduction Physical
Threat
force

AGGRESSION

injury to the
patient, staff,
other patients or
visitors

2
 Stages of
Aggression

Triggering Post crisis

Escalation Crisis Recovery
event depression

● It consists of
5 phases:

3
 “
Triggering Event Crisis
- pain, substance abuse, ● When the
unrealistic aggressive patient
expectations,
miscommunication,
becomes physically
home situation violent.

Escalation
● patient is getting more
aggressive:
❖ Rude words
Appearance:
Clenching of jaw/hands, Narrowed eyes, Frowning ❖ Aggressive body Appearance:
angry/upset/anxious language Piercing stare, anger, profuse sweating
Speech: Speech:
● Intervention at this point
Sarcastic, loud Inappropriate, Shouting, Repetitive
can divert an aggressive
Movement: Movement:
Exaggerated movement incident. Making fists, Pounding
Behavior: Behavior:
Demanding
-

Threatening, Pushing, Punching, Kicking,

Crying
Hostile
Throwing items
4
“
5
 “
Recovery
● The body & mind relaxes.
● Monitoring of the patient at
this point is critical to avoid
the re-ignition of the crisis.
Post Crisis Depression
● fatigue, depression,
feelings of guilt
appear.
6
 Demographic/personal Clinical variable 2. Patient factors:
history: 1. Medical factors: ● inability to
● History of communicate
substance/alcohol abuse ● Intoxication/withdrawal
from drugs or alcohol effectively
expression of intent to fear, anger,
Risk Factors
● ● Active symptoms of ●
harm others schizophrenia or mania anxiety
● History of violent -hallucinations, delusion ● not in control of
behaviour ● Head injury with vascular
lesions one’s own
● Previous use of weapons ● Meningitis/encephalitis situation
● Verbal threat of violence ● Delirium ● feeling
● Evidence of recent ● Hypoglycemia overwhelmed by
severe stress ● Neoplastic conditions information or
● Dementia lack of
● Drug effects information
● Poorly controlled pain

7
Risk Factors Situational variable

● Long waiting time in outpatient setting

● Overcrowding and lack of privacy
● Lack of personal space, or place to store possessions
securely
● Inadequate nutrition
● Possession or access to weapon
● Unpredictable routine and structure

8
Management
The management of patients with
aggression follows the ABCDE algorithm:
A- Assessment
B- Behaviour stabilization ± Breakaway
Technique
C- Choice of medication ± Control &
restraint
D- Documentation & Debriefing
E- Event reporting
 Aggressive person in Ministry Security C-Choice of
of Health Facilities guards/police medication ± Control

“
NO should be notified & Restraint
Registered patient immediately
YES
D-Documentation &
Possession of weapons YES Debriefing
NO
A-Assessment Establish cause of aggression
& respond accordingly
E- Event reporting

YES NO
B- Behavior stabilization ±
Breakaway Technique Behavior
stabilised?
•De-escalation technique
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Assessment
Identify risks for medical causes of
aggressive behavior:
A
● First onset of psychiatric symptoms
● The elderly
● History of medical illness
● Active user of illicit substances
● Medically ill patients who are non-adherent to
healthcare treatment and management
● Abnormalities in vital signs, physical examination
and mental status examination

11
Behavior stabilisation
● De-escalation technique B
used prior to other interventions such as 10 domains of
pharmacological or physical interventions as they are de-escalation:
less intrusive for the patient
1. Respect personal space
2. Do not be provocative
3. Establish verbal contact
4. Be concise
5. Identify wants and feelings
6. Listen closely to what the
aggressive patient is saying
7. Agree or agree to disagree
8. Lay down the law and set clear
limits
9. Offer choices and optimism
10. Debrief the aggressive patient and
the healthcare providers.
12
 Respect personal space Do not be provocative Establish verbal
● maintain two times ● show active listening, won’t contact
arm’s length distance harm the aggressive patient
10 domains of ●
rule.
Do not make the
and want everyone to be
● Only one person
should verbally
safe.
de-escalation aggressive patient feel
trapped
● Avoid closed body language:
arms crossed or turning away
interact with the
aggressive patient
● If an aggressive
patient tells you to from the patient - lack of ● Healthcare providers
“get out of the way”: interest. should introduce
do so immediately
themselves to the
aggressive patient and
provide reassurance
that they are there to
keep patient safe.
Be concise Identify wants & feelings
● Use short sentences ● Ask what patient wants
and simple vocabulary ● Show that we are paying
● Allow patient time to
attention and is
process information
understanding what
and to respond. patient is saying

13
 Listen closely Agree to disagree Lay down the law &
● verbal ● Healthcare providers set limits
10 domains of acknowledgement
and body
should agree with the
aggressive patient as
● inform about
acceptable and
de-escalation language that they
●
much as possible
If there is no method to
unacceptable
are really listening behaviors with
and paying agree honestly with the
consequences.
patient then agree to
attention to Ensure that this is not
disagree. ●
patient perceived as a threat

Offer choices
● Be assertive and quickly offer
aggressive patient alternatives
- such as food, blankets or access to
phone.
-do not promise patients something that
cannot be provided.
Debrief
● Some patients will end up in
seclusion or restraints when
de-escalation fails.
● restore therapeutic relationship
with the patient and staff after
intervention. 14
 ●
●
1. Choice of medication
Used if patient fail to respond to verbal de-escalation
The choice of medication depends on the underlying cause
C
of the aggression:

Aggression associated Aggression associated Aggression due to Undifferentiated

with psychosis in patient with delirium: intoxication: aggression/complex
with known psychiatric - intoxication by CNS presentation:
-If benzodiazepine or
disorder: alcohol withdrawal is stimulants: - If cause of aggression
benzodiazepines undetermined:
-antipsychotics are suspected use a long
acting benzodiazepine - intoxication by CNS -- If there are psychotic
preferred over depressants (i.e: features,
benzodiazepines - If not, use antipsychotics alcohol) : antipsychotics should
benzodiazepines be considered.
--address the underlying avoided to reduce the
-Otherwise,
psychosis risk of respiratory
depression. benzodiazepines can
be used.

15
 Intramuscular (IM) administration is sedative agents in aggressive patients is
preferred
-more rapidly administered, less risk of needlestick injury trying to obtain IV
access
-if IV line in situ: safer and quicker
Choice of
Level of sedation should ensure that the patient is drowsy but rousable
treatment

16
“
17
 Route of
Medication Common side effects
administration/Dosage

First generation antipsychotics (FGA)

Choice of Oral (tablet) Acute dystonia

medication 5-10mg, repeat in 30-60 min
(max 10-20mg)
Parkinsonism
Neuroleptic Malignant
Pediatric:
Oral Syndrome Seizure
0.01mg/kg to 0.1mg/kg 12 Prolonged QT
hourly (max 0.5mg per day)

Haloperidol IM (Haloperidol lactate)

5mg, repeat in 30-60 min
(max 10-20mg)
Pediatric:
IM 0.025-0.075mg/kg/dose
(max 2.5mg)
Adolescent >12 years can
receive the adult dose
(2.5-5mg)
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 Route of
Medication Onset of Action Common side effects
administration/Dosage

“
First generation antipsychotics (FGA)

Oral (tablet) IM 15-30 minutes Acute dystonia

5-10mg, repeat in 30-60 IV 10 minutes Parkinsonism
min (max 10-20mg)
Neuroleptic Malignant
Choice of Pediatric:
Syndrome Seizure
Oral
medication 0.01mg/kg to 0.1mg/kg 12 Prolonged QT
hourly (max 0.5mg per
day)

IM (Haloperidol lactate)
Haloperidol 5mg, repeat in 30-60
min
(max 10-20mg)
Pediatric:
IM
0.025-0.075mg/kg/dose
(max 2.5mg)
Adolescent >12 years can
receive the adult dose 19
(2.5-5mg)
 Route of
Medication Onset of Action Common side effects
administration/Dosage

Benzodiazepines
Choice of
medication Oral IM 15-30 minutes Over sedation
1-2mg, repeat in 30-60 IV 2-5 minuts Respiratory
min (max 4-8mg)
IM 4mg/ml must be depression
diluted 1:1 with water for Abuse/dependence
Lorazepam injection or normal
saline (max 4mg)
Pediatric (6-12 year
old):
PO/IM 0.05mg/kg (max
4mg/dose)

Oral or IV 5-10mg, repeat IM 15-30 minutes

in 30-60 min (max IV 2-5 minutes
Diazepam 20-60mg)

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 Route of
Medication Onset of Action Common side effects
administration/Dosage

Choice of
medication
Benzodiazepines

IM 10-15 minutes Over sedation

IV 1-5 minutes Respiratory
IM 0.07-0.08mg/kg
(usual dose 5mg) IM depression
IV 5-10mg (max Abuse/dependenc
Midazolam dose 20mg) e
Pediatric:
0.1-0.2mg/kg up to
0.5mg/kg

21
 Be aware
Post Documentation
of
Monitor vital signs potential
tranquilisation and observation
side
effects
management

Continuous monitoring

22
 DISPOSITION TRANSFER

“
Post Sedation/Post Restraint Aggressive patients require sedation for
Appropriate disposition determined after transfer
predominant aetiology During transfer, vital signs need to be
-psychiatry monitored and watch out for signs of
-medical respiratory depression

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 2. Control & Restraint
C
Indication:
● When other less restrictive
method to calm patient down
are not successful
● Prevent patient from causing
injury to himself/others
The Four-Point
Restraint
an application of limb
restraints on both arms and
legs using soft, padded cuffs
that are wrapped around
the aggressive patients’
wrists or ankles and
attached to the frame of the
bed.
24
Positioning:
● Supine position

“
● Hand position changed hourly
● Head of bed elevated to approx. 30
degrees to decrease risk of aspiration

Position B is preferred to
position A as it is more secure
and less exhaustive to patient

25
“
26
Approach to 4
point restraint
-Apply
restraint 1 limb
at a time
-secure limbs
Explain to patient: restraint at MUST be
Continously
base of examined
-what is done bed/stretcher for
assessed +
-reason monitored
-DO NOT circulatory
apply compromise
restraints to
bed rail

27
Review by staff
nurses,
paramedics
every 30 mins +
vital signs +
circulation chart
Monitoring Ensure basic
needs (Food,
Review by
MO at least during physical bedding,
clothing,
every 2-4 hygiene)
hours restraint
Review by
specialist if
restraints
exceed 8 hours 28
 Abrasion,
Wounds,
Fracture,
Muscle strain,
Poor circulation,
Reduced
sensation
Complications
Risk of
suffocation
in prone
when restraining
position
patients
Prolonged
struggling ->
hyperthermia,
lactic acidosis,
29
elevated CK
 Debriefing
D
Aim:
● Identify risks and physical harm
● Communicate concerns related to incident
● Discuss alternatives to manage future aggression
● Avoid blame
● Promote good practice

30
 Event Reporting
● Incident Report
E
1. Incident report should be made in the case
of patient or healthcare worker being
harmed in MOH facilities.
- For healthcare facility to learn from
previous incidents to prevent recurrence

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Summary

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Thanks!
Any questions?
Reference:
1.Guidelines on Management
of Aggressive Patients in
Ministry of Health Facilities,
KKM 2016
33