MANAGEMENT OF THE

VIOLENT PATIENT

Joshua Radke, MD

UC Davis Emergency Medicine

Disclosures

None

Outline

Epidemiology

Verbal Management

Physical Restraints

Chemical Restraints

Case 50’s yo male brought in by police

Patient already handcuffed to the backboard, spit mask in place, otherwise naked

Thrashing on gurney, screaming at staff and police

Abrasions to face, smells of EtOH

Violent Society

Injury is the leading cause of death in those < 44 yo

Homicide is the 2nd leading cause of death in 15-24 yo

Rate of death from firearms is 8x in US than other countries

Violence in the Emergency Department (ED)

Survey of emergency care workers

Majority were verbally threatened

51% of physicians physically assaulted

67% of nurses physically assaulted

Gates DM, J Emerg Med 2006

Weapons in the ED

~4-8% of the ED population carries a weapon

In one study, 26.7% of major trauma patients had a weapon

Signs and Symptoms Provocative behavior

Angry demeanor

Pacing

Loud/pressured speech

Pounding walls

Throwing things

Gripping arm rails intensely

Clenched fists

Positive Predictors of Violence

Male gender

Prior history of violence

Psychiatric illness

Drug or ethanol abuse

Early Recognition Anger

Resist authority

Confrontational

Combative

Prevention

Isolate from other provocative patients/friends/family

Hospital gown

Anticipate combativeness while talking with patient

Management Options

Verbal de-escalation

Physical restraints

Chemical restraints

Verbal De-escalation

Calm, slow talking

Be firm and assertive

Avoid argumentative or condescending language

Physical Restraints

Prevention of harm to patient or others

Should not be applied for convenience or as a punitive measure

The Team Approach

5+ people

Team leader

1 person for each extremity

Physical Restraints

What Not To Do

What Not To Do

Hobble Restraint

Hobble Restraint• 30yo M, erratic bike riding in street• Handcuffed, hobble restraint, prone

transport• Unresponsive, agonal Asystolic• No ROSC with ACLS• +EtOH, nonlethal meth and amphetamine

Cause of Death: positional asphyxiawith excited delirium

Adverse Effects - Prone

Vomiting

Aspiration

Dysrhythmias

Commotio cordis

Skin breakdown

Limb ischemia

Neuropraxia

Fractures/ dislocations

Chemical Restraint

Benzodiazepines Typical antipsychotics Atypical antipsychotics Combination therapy Endotracheal Intubation

ACEP Policy

Level B recommendations• Use a benzodiazepine or a conventional

antipsychotic as effective monotherapy for the initial drug treatment of the acutely agitated undifferentiated patient in the ED.

Level C recommendations• The combination of a parenteral

benzodiazepine and haloperidol may produce more rapid sedation than monotherapy in the acutely agitated psychiatric patient in the ED.

Ideal Therapy

• Works rapidly• Effective with multiple routes of

administration• Does not interact with other sedating

agents• Not addictive• Immune to tolerance• Minimal cardiorespiratory depression• Low side effect profile

Benzodiazepines

Diazepam

Lorazepam

Midazolam

Diazepam

PODose: 5-10 mgOnset: 1-2 hoursHalf-Life: 30-60 minutes

IVDose: 2-10 mgOnset: 20-30 minutes

Lorazepam PO

Dose: 1-2 mgOnset: 16 hoursHalf-Life: 14 hours

IMDose: 0.5 – 2 mgOnset: 20-30 min

IVDose: <2 mg/minOnset: 5-20 min

Midazolam

IMDose: 5-15 mg (q15 min)Onset: 15-20 minHalf-Life: 2-6 hr

IVDose: 1-2 mg q2-3 minOnset: 1-5 minHalf-Life: 2-6 hr

Nobay et al, 2004• Midazolam > lorazepam and haloperidol in

time to sedation and arousal

• 5mg IM midaz, 5mg IM haldol, 2mg IM loraz• Academic EDs use these

• Measured time to sedation and arousal

• Lorazepam dropped midway in study

Nobay et al, 2004

SE: no sig differences in SBP, DBP, HR, RR, O2 sat

Typical Antipsychotics

Haloperidol

Droperidol

Haloperidol PO

Dose: 5-10 mgOnset: 2-6 hrHalf-Life: 12-18 hr

IMDose: 5-10 mgOnset: 30-60 min

IVDose: 1-2 mgOnset: 30-60 min

ACEP Clinical Policy

Level B recommendations• If rapid sedation is required,

consider droperidol instead of haloperidol.

Droperidol

IM/IVDose: 0.625-1.25 mgOnset: 30 minHalf-Life: 2-4 hr

Richards et al, 1998• Compare lorazepam to droperidol

• 5mg IV lorazepam or 5mg IV droperidol• If <50 kg, half dose• Can repeat @ 30” x1

• Measured sedation scale• 0 = very sedated ; 5 = not sedated

Richards et al, 1998

• SE: sig HR, SBP, RR, temp @ 60min both groups• 40 add’t doses lorazepam vs 8 doses droperidol

Droperidol

Extrapyramidal Symptoms

Atypical antipsychotics

Risperidone

Olanzapine

Risperidone

PODose: 1-3 mgOnset: 30-60 minHalf-Life: 20 hr

Olanzapine

PODose: 10-20 mgOnset: 5-8 hrHalf-Life: 20 hr

IMDose: 5-10 mg q4 hrOnset: 15-45 min

Other

KetamineIM

○ Dose: 4-5 mg/kg○ Onset:4-5 min○ Half-Life: 30-60 min

IV○ Dose: 1 mg/kg○ Onset:1 min○ Half-Life: 15 min

Beware• Excessive

secretions airway issues

• HTN and tachycardia

• Unknown interactions with PCP/special K

Combination Therapy

Benzo + antipsychotic

Lorazepam Haloperidol Combo

Decreased Agitation

+ ++ ++++

Cumulative Sleep

+++ ++ +++

Combination Therapy - Regimens Lorazepam + Haldol

2 mg Lorazepam5 mg HaldolIM/IV

Midazolam + Haldol5 mg Midazolam5 mg HaldolIM/IV

Endotracheal Intubation

• LOS 0.7d (not sig)

• $ (107%)

• RN care (4.5hrs QD)

• ICU time (2d)

Kuchinski, 1989

References Ng, Vivienne. “My Chemical Romance with the Agitated and Combative Patient.” Grand Rounds

Lecture 2011. Rosen, Peter, John A. Marx, Robert S. Hockberger, Ron M. Walls, James G. Adams, and Cynthia K.

Aaron. “Chapter 188: The Combative Patient." Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia: Mosby Elsevier, 2010.

Questions??