Post on 24-Feb-2016
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The Combative PatientIndiana University Emergency Medicine
Case• 28 yo male brought into ED by
police after fighting at a local fast food restaurant
• Bystanders report history of drug and alcohol abuse
• Sustained several lacerations and abrasions while resisting arrest
Physical Examination• Belligerent and spitting• Strong odor of ETOH• HEENT: PERRL with nystagmus • Forehead laceration• Many contusions and abrasions• Demanding release from the ED
What do you do now?• He wants to leave - Can he?• Should you sedate him? Restrain
him? Wouldn’t that be assault? • What is the standard of care in the
diagnosis and treatment of this patient?
• How can you protect yourself and your ED staff from harm?
Another scenario• You see a patient in the ED who is
loudly unhappy with their care• Security is summoned to escort the
patient out of the ED• The patient threatens to wait for
you after your shift
ED is Prone to Violence• Duty to see and treat everyone• 24 hour open door • High stress• Waiting times• Availability of hostages• Limited security
Violence in healthcare is common• ~50% of providers become victims of
violence– ED, Psych, Geriatric units most prevalent
• 1992 survey of ED residents– 62% concerned about personal safety – 50% feel security measures inadequate
• 1997 survey of psychiatry residents– 73% threatened, 36% assaulted – 66% not trained to manage violent pts
Violence against ED workers• Gates DM J Emerg Med 2005; 31(3): 331-7• Survey of ED workers in 5 Cincinnati
hospitals (n =242)• In the previous 6 months:
– 96% of physicians reported verbal harassment or threats
– 51% of physicians reported physical violence
– 8% had had violence management training in the previous year
Weapons carriage in the ED• Estimated 4-8% of ED patients• Major trauma victims often
armed• Rapid escalation
Is there a way to predict who will become violent?
Risk assessment• Positive predictors of violent behavior
– Male gender– Prior history of violent behavior– Drug or alcohol abuse
• NOT predictive: age, ethnicity, education, diagnosis, marital status
• Clinicians are notoriously poor at predicting who will become violent
Verbal and nonverbal cues“Pre-violent agitation”• Provocative behavior• Angry demeanor• Pacing, gripping arm rails• Clenched fists• Tense posture, loud speech
What is the #1 patient characteristic that predicts violent behavior?
Intoxication
ED Evaluation the Violent
Patient
Goals of ED Evaluation• Ensure provider and patient safety• Functional vs. organic disease
– Organic disease may be reversible (hypoxia, hypoglycemia)
– Rapid deterioration possible with organic disease
• Appropriate disposition
Disarm all patients• Prior to interview• Weapons detectors at the
door• Undressing and placing in a
gown is a non-confrontational search
• Routine disarming results in increased feeling of safety for patients and staff
Setting of Interview• Privacy but not isolation• Seclusion room
– Ideally two exits available– No heavy objects or potential weapons– Heavy furniture, bolted down
• Easy access to security– Security button, or verbal code such as
“I need Dr Armstrong in here.”
Setting of Interview• Examiner sits closest to door or
equidistant from door• Remove personal accessories
– Glasses, watch, ties, necklaces, pocketknives
• Be aware of objects on pt’s body which can be used as weapons
Verbal Techniques• Be honest and straightforward• Non-confrontational demeanor
– Avoid direct eye contact– No sudden movements
• Act as a patient advocate– Offer food or drink (cold)
Verbal Techniques• Be attentive and listen• Address violence directly
– “You seem angry”– “I want to help you, but I cannot allow you to threaten
me or the ED staff”• Do not challenge the patient’s ego• Do not lie to the patient• Never downplay threatening behavior• Excuse yourself if escalation occurs
Functional vs. OrganicFunctional• Rarely present >45
years old• Alert and oriented• History of
psychiatric illness• Situational factors
Organic• All ages• Altered alertness• Impaired
orientation• Abnormal vital
signs• Acute onset
Functional vs. Organic• Unrecognized medical emergencies
admitted to psychiatric units. Am J EM 2000; 18(4): 390-3.
• 64 psychiatric pts transferred to medical floor w/i 24 hours of admission
• Most common eventual diagnoses:– Drug/alcohol toxicity/withdrawal (66%)– Metabolic (14%)– Infection (9%)
• Documentation very poor
Organic Disorders• Hypoxia• Hypoglycemia• Intoxication or withdrawal• CNS infection• Endocrine disorders• Medication reaction• Many others
History• Psychiatric, medical, social history• Drug/alcohol use• Prior episodes of violence• Medication use and changes• Interview family and friends, as
patient may not be a reliable historian
Physical Examination• Vital signs including temp, pulse ox• Neurologic and mental status exam• Signs of drug or alcohol use
– Nystagmus, ataxia, pupils, needle tracks• Toxic syndrome identification
– Anticholinergic, sympathomimetic
Diagnostic Studies• Studies guided by clinical findings• Laboratory
– Rapid glucose– Electrolytes, medication levels– “Tox screens” of limited benefit– CSF analysis
• Radiology/Other– CT/MRI, EEG, EKG
Disposition• Who needs to be admitted/observed?
– Suicidal/homicidal ideation– Psychotic– Organic etiology– Intoxicated
• Consider psychiatric consultation prior to discharge
• Specific follow up is mandatory
Restraining the violent patient
Physical Restraints• Humane and effective • Facilitate diagnosis and treatment• Legal issues
– Documentation, agreement of others• Courts have supported physicians
who restrain patients for safety
Physical Restraints• Indications:
– Prevent harm to patient/others– Prevent significant disruption or
damage to surroundings• NOT indications:
– Convenience– Punitive response
Type of Restraints Used• Leather restraints are strongest• Soft restraints most commonly used• Posey vest• C-collar• NOT bandage gauze• Facemask if spitting
How to restrain a patient• Assemble a restraint team
– At least five persons including team leader– One female if patient is female
• Leader outlines restraint protocol• Enter the room in force with professional
attitude• Do not negotiate• Restrain to solid frame of bed
The patient has been successfully restrained
Monitoring• Frequent monitoring• Standardized form• Complications: circulatory
obstruction, pressure sores, paresthesias
• Rhabdomyolysis, acidosis, and death are reported in pts struggling against restraints
Physical Restraints• Factors Associated with Sudden Death for
Individuals Requiring Restraint for Excited DeliriumStratton SJ et al. J Emerg Med 2001: 19:187.
• Case series of 18 patient deaths• Factors most associated:
– Hobble/hogtie position– Continued struggling in restraints– Stimulant drug use
• Do not place patients in the Hobble Position!
Physical Restraints
• Do NOT allow a patient to struggle in restraints!
• Sedation and monitoring are very important
Chemical Restraints
Ideal chemical restraint• Effective & rapid acting• IV/IM/PO• No addiction• No tolerance• No adverse effects• Does not exist!
Haloperidol• Commonly used• 2.5 - 10 mg IM/IV q 30-60 min • Maximum 6 doses/24 hours• Effective within 10-30 min
Haloperidol: Adverse Effects• Dystonic reaction, akathisia
– May treat with diphenhydramine or benztropine
• Neuroleptic malignant syndrome (<1%)– Autonomic instability– Hyperthermia– Lead-pipe rigidity– Idiosyncratic reaction
• QT prolongation
Benzodiazepines• Used alone or with haloperidol• Lorazepam (Ativan®)• 2-4 mg IV/IM q 15-30 minutes• Titrate to effect• Side effects: Sedation, respiratory
depression• Bonus: Treats ETOH and benzo
withdrawal
Haloperidol, Lorazepam, or Both?• Am J Emerg Med 1997;15:335-40.• Prospective double-blind RCT of 98
agitated pts• IM haloperidol (5mg) vs. IM lorazepam
(2mg) vs. both• Similar rate of adverse events• Tranquilization achieved more rapidly with
combination treatment
Newer (atypical) antipsychotics• Olanzapine (Zyprexa®)• Ziprasidone (Geodon®)• Risperidone (Risperdal®)• Aripiprazole (Abilify®)
Newer (atypical) antipsychotics• Oral or IM dosing
– Rapidly dissolving oral tablets– Oral dosing requires patient cooperation
• Fewer movement disorders than typical antipsychotics
• A number of studies demonstrate utility in acute agitation
• Reasonable alternative to traditional agents, but role in ED not fully defined
What if you are assaulted?
Assault• Immediately summon help• Defend yourself without attacking
– Deflect rather than inflict– If bitten, push toward the mouth and
hold nares– If choking attempted, tuck in chin to
protect airway/carotids
If the assailant is armed
• Comply with demands• Try to remain calm• Do not argue, lie, or bargain• Attempt to establish a human
connection, tend to injured hostages
Assault• Each hospital should have a plan of
action to be utilized in case of extreme violence– Prevention and safety measures– Notification of security and police– Evacuation– Medical treatment– Crisis intervention
Medicolegal Considerations
Consent• Voluntary agreement by competent
individual to undergo medical care• Competent individual may refuse care• If competency is in question
– Substituted consent from family/guardian– Assistance from colleagues, psychiatry, legal– Err on the side of treatment– Document thoroughly
Standard of Care• Defined by professional literature
and practice standards• In a combative patient:
– Diagnose and treat organic etiology– Use physical and chemical restraints
to permit evaluation and treatment while preventing harm
– Arrange appropriate disposition
Duty to warn• Tarasoff v. U of California
– Patient told of intent to kill a woman– Psychologist called police, pt questioned– Patient killed victim 2 months later and her
parents successfully sued psychologist• Warn intended victim and authorities if a
violent patient communicates intent to harm a “foreseeable” victim
Restraint of patients• Youngberg v Romeo 1982• A young man with repeated episodes of
violence was allowed to be restrained and involuntarily committed
• Supreme Court supports the use of restraints to protect patients and others
• Assumes best interest according to reasonable medical judgment
“Involuntary hold”• If a patient is a danger to self or
others, they can be held for a predetermined length of time for evaluation (24-72 hours)
• Document the need, have others corroborate
• Specific forms available
Medicolegal Summary• Be aware of the above concepts• The best defense is the best
practice of medicine• Act in the best interest of the
patient while maintaining a a safe ED environment
Back to our patient• Verbal techniques unsuccessful• Restrained, sedated with haloperidol and
lorazepam• Evaluated per ATLS protocol
– C-spine series, head CT are negative• Laboratory values
– Chem-7 & EKG wnl, ETOH 320 mg/dL• Admitted for alcohol detoxification
Take Home Points• Safety first• Know your resources• Rule out organic etiology of violence• Risk assessment and verbal techniques• Physical/chemical restraints
– Frequent monitoring• Act in the best interest of the patient• Document thoroughly