Management of the Violent Patient in the

Emergency Department

Scot Hill, MDDepartment of Emergency Medicine

Mount Sinai Hospital

Scot Hill, MD

Violence and the Airway E.P.s predictably encounter both Final outcome of many pathologies Failure to manage appropriately leads

to injury and/ or death The Defining Difference:

Who is at risk?

Scot Hill, MD

Treatment Modalities

Interview Techniques Environmental Factors Physical Restraints Chemical Control

Scot Hill, MD

69 yo M, Brought by family after lighting a fire in bathroom.

Patient has no complaints.Hx of Schizophrenia

P=110, BP 150/90, RR 20, T 37.9No distress, refusing to speak.Nonfocal exam.

Case Presentation

Scot Hill, MD

What is your assessment of violence potential, and Why?

Low, because he didn’t burn your bathroom

Moderate, because his vital signs are only moderately abnormal

High, because of the setting the question is being asked in

High, for these specific reasons:

Scot Hill, MD

Definitions

Personality Emotions Agitation Psychosis Violence

Scot Hill, MD

What actions are reasonable at this point?

A: One to one observation B: Undress and fully examine the patient C: Offer the patient medication D: Round up sufficient personnel to restrain

the patient E: Stall until you can sign out to your

partner before taking any definitive action F: Medically clear him, transfer to Psych.

Scot Hill, MD

Environmental Factors

Privacy vs. Isolation Available Assistance Weapons Detection Seclusion if Available Ninja Implements

Scot Hill, MD

Interview Considerations Calm and Direct Empathic Assurance of priorities Verbalize limits/expectations Consistency among staff

Scot Hill, MD

Interview Techniques Eye Contact Personal Space Door Position Body Language

– Angle of confrontation

– Hand and arm position

Scot Hill, MD

What medication would you choose?

A: Valium 5 mg PO B: Haloperidol 10 mg IM C: Haloperidol 5 mg and

Lorazepam 2 mg IM D: Droperidol 2.5 mg IM E: Respiridol F: Medazolam 2 mg IV

Scot Hill, MD

Chemical Control Rapid Tranquilization

– Safety

– Titratability Haloperidol Haloperidol and Benzodiazapine Droperidol

Scot Hill, MD

Haloperidol Buteryphenone antipsychotic 5- 10 mg. IM, PO, IV onset 20 minutes t1/2 of 19 hours Side Effects

Scot Hill, MD

Side Effects Dystonic Reaction Akathesia Neuroleptic Malignant Syndrome Cardiovascular Effects Seizure Threshold

Scot Hill, MD

Benzodiazapines Lorazepam, vs others Less predictable effect

– Paradoxical disinhibition– Dose requirements

Less titratability Less Antipsychotic effect Greater risk of cardiorespiratory depression

Scot Hill, MD

Droperidol Buteryphenone antipsychotic 2.5- 5 mg IM or IV Onset minutes t 1/2 2-4 hours Side effects

Scot Hill, MD

He is still uncooperative. At what point do you

decide to physically restrain this patient? A: Before he does any damage B: After a psychiatrist has evaluated him

and determined a lack of capacity C: After he does some damage D: When danger becomes imminent

Scot Hill, MD

Physical Restraints For Imminent Threat of Harm Preparations

– Overwhelming Show of Force

– Beware the Ninja

– Initiate only When Prepared

– Preparation / De-escalation

Scot Hill, MD

Physical Restraint Once Initiated, Swift and Definitive Suspend Negotiations Team Leader Secure Large Joints Constant Reassurance

Scot Hill, MD

What do you do if he tries to leave before you have sufficient personnel?

A: Physically block him B: Have the nurse physically block him C: Offer him money to stay D: Notify local constabulary

Scot Hill, MD

Monitoring Documentation

– Neurovascular

– Cardiovascular

– Airway Consideration of removal Transfer Considerations

Scot Hill, MD

Summary Multifactorial approach Teamwork Early intervention Life saving when necessary