MANAGEMENT OF VIOLENT PATIENT

IN EMERGENCY DEPARTMENT

SUDARSHAN PANDEY
INTERN, MBBS
KUSMS
 Violence and Aggression
• Violence and aggression refer to a range of
behaviours or actions that can result in harm,
hurt or injury to another person, regardless of
whether the violence or aggression is
physically or verbally expressed, physical harm
is sustained or the intention is clear
 Causes

Organic Drugs Psychiatric

Diseases
•Schizophrenia
Hypoxia •Alcohol (intoxication •Paranoid ideation
CNS infection and withdrawal) •Catatonic excitement
Seizure •Sedative-hypnotics •Mania
CVA (intoxication or •Personality
Trauma withdrawal)
Neoplasm disorders(Borderline/
•Amphetamine/Cocaine Antisocial)
Electrolyte •LSD
abnormality •Delusional
•Anticholinergics Depression
Delirium
Dementia
•Aromatic hydrocarbons •PTSD
Hypo/hyperthermia (e.g., glue, paint, •Decompensating
Endocrine disorder •Steroids OCD
•Homosexual panic
 OTHER FACTORS

Social factors:
• history of violence
• Little impulse control
• low self-esteem
• frustration
• delays in treatment
• in police custody/gang affiliation
• victim of crime
 PRODROME OF VIOLANCE

Phase 1: Anxiety

Phase 2: Defensive behavior

Phase 3: Physical aggression

 ANXIOUS BEHAVIOUR
• Pacing /hand-wringing
• body tensing,
• Facial tension,
• fidgety behavior,
• Asking repetitive questions
• speaking in a loud voice
• exhibiting pressured speech
 DEFENSIVE BEHAVIOR
• Verbal abuse,
• profanity,
• Power struggle
• chanting, staring /darting eyes, mumbling,
flushed face, clenching hands,
• repeated approach to staffs
 PHYSICAL AGGRESSION
• completely lost control over emotions and
behaviors
• Physically violent acts
: a danger to property, staff, other patients,
visitors, and themselves
 MANAGEMENT OF VIOLENT PATIENT
• CONTAINMENT & SAFETY
• ASSESSMENT
• NON VIOLENT DE-
ESCALATION
• INTERVENTION
• TAKE DOWN AND
RESTRAINT
• The American Psychiatric Association
recommends that the presence of any one of
the following in a violent patient should
prompt a search for an organic etiology:
1. a patient >40 years of age with no previous
psychiatric history;
2. disorientation, lethargy, or stupor;
3. abnormal vital signs;
4. visual hallucinations.
 INVESTIGATION
• Pulse oxymetry
• Blood glucose
• ECGs
• Chest Xray
• blood Biochemistries,
• toxicology screening,
• CT head scans
• lumbar puncture
 DE-ESCALATION
DE-ESCALATION
The use of techniques
(including verbal and non
verbal communication skills)
aimed at defusing anger and
averting aggression
DE-ESCALATORY SKILLS
• Explain intentions to patients and
others;
• Try to appear calm and self-
controlled;
• Ensure own non-verbal
communication is non-threatening;
• Engage in conversation, acknowledge
concerns and feelings;
• Ask open-ended questions;
• Ask for any weapons to be put down
(not handed over)’ and
• Know how to call for help in an
emergency.
 PHYSICAL RESTRAIN
MANUAL STRAIN
• team approach to manual
restraint
• When using manual
restraint, avoid taking the
subject to the floor, but ‘if
this becomes necessary’,
use the supine (face up)
position if possible, and if
face down position does
have to be used, use it for
as short a time as possible
MECHANICAL STRAIN
• managing extreme violence
directed at other people or
• limiting self-injurious
behaviour of extremely high
frequency or intensity.
• Using Handcuffs ,
Restraining belts
Chemical
Restraint
 MEDICATION/CHEMICAL RESTRAINT
Chemical restraint refers to the administration
of a medication that is used to control
behavior or freedom of movement but that is
not a part of a patient’s daily medication
regimen
Rapid tranquilization refers to giving medication
every half hour to every hour to target
symptoms of agitation,hostility, and motor
excitement
 Adult Route Adverse Effects
Drugs
Dosage
Benzodiazepines
Lorazepam 2–4 mg IV, IM, C/I in alcohol intoxication, respiratory and
PO neurologic depression, coma
Midazolam 0.01–0.07 IV, IM Respiratory and neurologic depression,
mg/kg amnesia, hypotension
Typical antipsychotics
Haloperidol 2–5 mg IV, IM EPS, QT-interval prolongation, NMS,
tardive dyskinesia with long-term use
Atypical antipsychotics
Olanzapine 5–10 mg IM, PO Drowsiness, agitation, dizziness, akathisia

Risperidone 2-8 mg PO Anaphylactoid reactions,hypotension, NMS

 Dangers of Emergency sedation
1. Sedative drugs may mask important signs of
underlying illness, eg an intracranial haematoma
requiring urgent treatment.
2. The normal protective reflexes (including airway refl
exes, such as gag and cough response) will be
suppressed.
3. Respiratory depression and the need for tracheal
intubation and IPPV may develop.
4. Adverse cardiovascular events (eg hypotension and
arrhythmias) may be provoked, particularly in a
struggling, hypoxic individual.
5. Individual side effects of the drugs
 SECLUSION
• The supervised confinement of a patient in a
room, which may be locked.
• Its sole aim is to contain severely disturbed
behaviour that is likely to cause harm to
others
Algorithm for decision making regarding use of
seclusion and restraint.
Phineas Gage
 REFERENCE
• Violence and aggression: NICE guideline
Draft for consultation, November 2014
• Tintinalli's Emergency Medicine 7th
edition
• Management of the Acutely Violent
Patient, Jorge R. Petit, MD