The Violent Patient in

Emergency Department

Dr Subhankar Paul

“Violence is referred to as our nation’s shameful

epidemic” -Rosen

INTRODUCTION• Workplace violence at educational institutions

and government facilities captures the headlines,

• physicians and nurses are victims of nonfatal violent crime more than any other profession

• ED personnel are victims as well as witnesses of violence in the ED

• Violent events and confrontations have consequences for both the patient and staff members

Factors for ED Violence • unlimited & unrestricted access to patient care

areas,

• family and friends of critically ill patients

• substance abusers,

• prolonged waiting times,

• staff shortages,

• overcrowding,

• patient financial problems,

• high expectations of the patients.

• 24 ×7 operation : night-time violence

• Poor Communication-skill & Counselling

Problems beneath

“THE PROBLEM PATIENT”

Problems

Organic Diseases

Drugs Psychiatric

HypoxiaCNS infectionSeizureCVATraumaNeoplasmElectrolyte abnormalityDeliriumDementiaHypo/hyperthermiaVitamin deficiencyEndocrine disorder

•Alcohol (intoxication and withdrawal)•Sedative-hypnotics (intoxication or withdrawal)•Amphetamine/Cocaine•LSD•Anticholinergics•Aromatic hydrocarbons (e.g., glue, paint, •Steroids

•Schizophrenia•Paranoid ideation•Catatonic excitement•Mania•Personality disorders(Borderline/Antisocial)•Delusional Depression•PTSD•DecompensatingOCD•Homosexual panic

• 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.

Investigations

• Pulse oxymetry

• URGENT CBG

• ECGs

• Chest Xray

• blood Biochemistries,

• toxicology screening,

• CT head scans

• lumbar puncture

Vital Signs and Toxic SyndromesTOXIN P BP RR T PUPIL SKIN

Sympathomimetic : COCAINE

↑ ↑ ↑ ↑ ↑ Wet

Anticholinergic : DIPHENHYDRAMINE

↑ ↑/↓ ↑/↓

↑ ↑ DRY

Cholinergic: OP ↑/↓ ↑/↓ ---- ---- ↓ Wet

Opiates : MORPHINE ↓ ↓ ↓ ↓ ↓ ----

Sedatives : LORAZEPAM

↓ ↓ ↓ ↓ ↑/↓ ----

Withdrawal (ethanol, sedative-hypnotics)

↑ ↑ ↑ ↑ ↑ Wet

Pickit UpEarly

Warning signs of impending violence• Angry facial expressions, gestures, and posture

• Restlessness, overt irritation, discontentment, pacing about,over-arousal (dilated pupils, tachycardia, increased respiratory rate).

• Prolonged eye contact.

• Loud speech and changes in tone of voice.

• Verbally threatening and/or reporting feelings of anger/violence.

• Repeating behaviour, which has previously preceded violent episodes.

• Blocking escape routes

Phases of Violent Behavior

• In general physically violent behavior does not occur suddenly

• preceded by a series of escalating behaviors

• The stages of behavior are not clearly bounded and may overlap / already passed through

• At each stage, the appropriate response of the professional involved should match the behavior being demonstrated

Phase 1: Anxiety

Phase 2: Defensive behavior

Phase 3: Physical aggression

Anxious Behavior

Behavioral clues Appropriate Response

NON-DIRECTED ENERGYEXPENDITURE

LISTEN & REASSURE

• Pacing /hand-wringing• body tensing,• Facial tension,• fidgety behavior, • Asking repetitivequestions• speaking in a loud voice•exhibiting pressured speech

Listen,address concerns,showempathyAvoid confrontationStay Calm, Answer Directly, clear and honest answeroffer supportAvoid a judgmental attitude

Defensive Behavior• Behavioral clues Appropriate Response

•Volatile,irrational and may be unrelated

Limit Setting , to prevent total loss of control by the patient

• Verbal abuse,•profanity,•complaints unrelated to C/C•Power struggle, limit testing,•chanting, staring /darting eyes, mumbling, pacing,flushed face, clenching hands,•repeated approach to staffs

Reasonable limit setting, Explaning consequencesfirm in tone and action but professional and calm enforce limits

Physical Aggression

• Behavioral clues Appropriate Response

•completely lost control over emotions and behaviors

SeclusionPhysical restraintchemical restraint

• Physically violent acts: a danger to property, staff, other patients, visitors, and themselves

For the interest of patient care and safety for others, not as punishment, and enables the staff to provide necessary care for a violent patient

Seclusion

Seclusion• better alternative to physical restraint

• medically safer.

• seclusion must be undertaken with great care, as even empty rooms with observation windows can be fertile grounds for self-harm in the agitated patient.

• may also have negative effects on psychiatrically ill or other vulnerable patients

• Only 25% of ED directors report using seclusion measures for acutely agitated patients

Physical Restraint

Physical Restraint

• Only licensed independent practitioners can order restraints

• written or computerized order must include the type of restraint, reason for restraint, time limit of the order.• If a licensed independent practitioner is not,

trained caregivers may institute the restraint, but a licensed independent practitioner must perform a face-to-face evaluation within 1 hour of restraint.

Physical Restraint …. Cont..• Ensure all appropriate personnel and equipment

assembled. • Soft restraints are not acceptable for use in the

violent patient. • A trained security person or hospital staff should

act as the team leader. • can be dangerous and may result in traumatic

injury to the patient and/or provider.• In general, patients arriving in handcuffs should

remain in handcuffs until the threat of violence and medical condition is assessed

Chemical Restraint

Medication/Chemical Restraint

• Pharmacological restraint using sedative drugs

• last resort,

• should only be given on the advice of senior and experienced staff.

• staff need to be aware of medicolegalimplications of carrying out any restraint

• Little data exist regarding the use of chemical restraints when physical restraint has failed

Dangers of Emergency sedation 1. Sedative drugs may mask important signs of

underlying illness, eg an intracranial haematomarequiring urgent treatment.

2. The normal protective reflexes (including airway reflexes, 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

DrugsAdult Dosage

Route Adverse Effects

Benzodiazepines

Lorazepam 2–4 mg IV, IM, PO

C/I in alcohol intoxication, respiratory and neurologic depression, coma

Midazolam 0.5–5 mg IV, IM Respiratory and neurologic depression, amnesia, hypotension

Typical antipsychotics

Haloperidol 2–10 mg IV, IM EPS, QT-interval prolongation, NMS, tardive dyskinesia with long-term use

Atypical antipsychotics

Quetiapine 25–50mg PO Orthostasis, QT-interval, NMS, weight gain (chronic use)

Olanzapine 5–10 mg IM, PO Drowsiness, agitation, dizziness, akathisia

Risperidone 0.5–2mg PO Anaphylactoid reactions,hypotension, NMS

After the violent episode

• ensure that the staff involved record full detailed notes and standard local incident forms are completed.

• Report the episode to the senior member of staff and to the police (as appropriate), if they are not already involved.

• Subsequently, when dealing with the violent patient, do not purposely avoid the patient or treat him obviously differently, since this will merely emphasize concepts of his own unacceptability and may lead to further aggression.

Tension Reduction

regain a personal sense of control emotionally and physically drained

Rebuild Therapeutic Rapport and Communication & professional relationship

fear, confusion, and remorsewithdrawn or embarrassed.

. Let the patient know that he or she is safe and that ongoing care will be provided for the medical complainsometimes helpful to ask the patient to take a few deep breathsThe plan for the examination and treatment should be explained to the patient

“Prevention is Better than

Cure”

Violence Prevention

• The single best way to handle a violent patient or curtail the potential for violence in the ED is by prevention and refusal to tolerate even the smallest display of violence potential

• Preventative actions

careful planning,

cooperation with hospital security personnel,

Improvement of overall security system

• training of all ED personnel regarding

predictors and theories of violence,

recognition of the early stages of violence,

response and diffusion of verbally and physically violent situations,

review of hospital policy and safety plans,

follow-up after a violent event

REFERENCE

• Tintinalli's Emergency Medicine 7th

edition

• Oxford Handbook of Emergency Medicine 4th edition

• ROSEN’S EMERGENCY MEDICINE Concepts and Clinical Practice , 8th

edition