Management of the Violent Patient in the Emergency Department

1
Management of the Violent Patient in the
Emergency Department

• Scot Hill, MD
• Department of Emergency Medicine
• Mount Sinai Hospital

2
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?

3
Treatment Modalities

• Interview Techniques
• Environmental Factors
• Physical Restraints
• Chemical Control

4
69 yo M, Brought by family after lighting a fire
in bathroom.Patient has no complaints.Hx of
SchizophreniaP110, BP 150/90, RR 20, T 37.9No
distress, refusing to speak.Nonfocal exam.
Case Presentation
5
What is your assessment of violence potential,
and Why?

• Low, because he didnt 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

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Definitions

• Personality
• Emotions
• Agitation
• Psychosis
• Violence

7
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.

8
Environmental Factors

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

9
Interview Considerations

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

10
Interview Techniques

• Eye Contact
• Personal Space
• Door Position
• Body Language
• Angle of confrontation
• Hand and arm position

11
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

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Chemical Control

• Rapid Tranquilization
• Safety
• Titratability
• Haloperidol
• Haloperidol and Benzodiazapine
• Droperidol

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Haloperidol

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

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Side Effects

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

15
Benzodiazapines

• Lorazepam, vs others
• Less predictable effect
• Paradoxical disinhibition
• Dose requirements
• Less titratability
• Less Antipsychotic effect
• Greater risk of cardiorespiratory depression

16
Droperidol

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

17
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

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Physical Restraints

• For Imminent Threat of Harm
• Preparations
• Overwhelming Show of Force
• Beware the Ninja
• Initiate only When Prepared
• Preparation / De-escalation

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Physical Restraint

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

20
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

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Monitoring

• Documentation
• Neurovascular
• Cardiovascular
• Airway
• Consideration of removal
• Transfer Considerations

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Summary

• Multifactorial approach
• Teamwork
• Early intervention
• Life saving when necessary