1. APPROACH TO VIOLENT PATIENT IN EMERGENCY DEPARTMENT
Dr Vanitha a/p Kandasamy Pakar Perubatan Kecemasan Md(UKM), MAST. Em MED (UKM) SGH

2. Overview INTRODUCTION DISTINGUISHING ORGANIC & FUNCTIONAL CAUSE OF
VIOLENCE
TYPES OF RESTRAIN
PHYSICAL RESTRAIN
CHEMICAL RESTRAIN

3. WHO…?! ED Nurses are particularly to be assaulted
Nearly 70% of all emergency nurses are assaulted on duty during their career
Mahony BS. The extent, nature and respose to
victimization of emergency nurses in Pennsylvania.
J Emer med Nurs 1991; 17(5):

4. WHEN AND WHERE?!
60-70% of ED violence takes place during the evening and night shifts, usually between 7 p.m. and 3:30 a.m.
The high risk area are:
Triage, waiting area, Trauma rooms and psychiatric area.

5. WHY ED PRONE TO VIOLENCE?
Stressful Emotional Environment
Long waiting hour
Overcrowding
24hours open door policy
Widespread drug abuse/alcohol abuse
Weapon
Miscommunication
Gangsters

6. Definitions
Violent Patient: Is a patient who has intentionally used physical force against another person or oneself
Extreme Violence: It is present when a patient, visitor, or other individual threatens the life or safety of other patient, visitors, or person by physical force or the use of weapon.

7. Types of violence
1. Physical violence
2. Verbal violence

8. Physical violence Biting Chasing Defecating Grabbing Hair pulling
Hitting
Kicking
Pinching
Poking
Punching
Pushing
Scratching
Slapping
Spitting
Stabbing
Swinging
Throwing
Unwanted physical contact
Urinating

9. Verbal violence Abusive language Bullying Ethnic slurs Intimidation
Ridicule
Swearing
Threatening gestures
Threats of injury
Threats of violence
Yelling

10. Signs of impending violence
Agitation
Anger
Catatonia
Chanting
Clenched fists
Clenched jaw
Cursing
Darting eye movements
Demanding immediate attention
Dilated pupils
Excitement
Flared nares
Flushed face
Hostility
Impulsivity
Loud outbursts
Name calling
Obscene language
Opening and closing the fist
Pacing
Pointing
Possession of a weapon
Profane language
Pushing furniture
Restlessness
Scars
Slamming objects
Smell of alcohol on breath
Staring eyes
Sudden movements
Tattoos
Tension
Uncooperativeness
Widened eyes

11. IMPORTANT RULED OUT ANY ORGANIC CAUSES
SO WHAT CAUSE OF ABNORMAL BEHAVIOR?!

13. Emergency Department Evaluation
Medical clearance:
It refers to the process of screening supposedly “ psychiatric patient” for medical illnesses.
Patient who are medically cleared may then be valuated by a psychiatry

14. Emergency Department Evaluation
Medical clearance can done by:
History
Mental status examination
Physical examination
Diagnostic studies

15. DISTINGUSHING ORGANIC VS FUNCTIONAL VIOLENT BEHAVIOR

16. DISTINGUSHING ORGANIC VS FUNCTIONAL VIOLENT BEHAVIOR

17. DISTINGUSHING ORGANIC VS FUNCTIONAL VIOLENT BEHAVIOR

18. Emergency Department Evaluation
Diagnostic studies:
Dextrose stick
ABG
FBC RP
LFT
Toxicology
CT scan / plain X-ray
Alcohol level
Serum osmolarity
B12, folate
ECG

21. MANAGEMENT OF VIOLENT PATIENT
Calm patient via empathy but firm verbal
Establish a collaborative relationship between patient and treating team
Appear calm, unthreatened and in control and concern about your safety
Speaking softly in non judgemental way
Not to gaze into patient’s eye
No surprises
Avoid countertranference
Deescalation therapy

22. Cont-deescalating therapy
Do not interview alone
At least another person always present
Examination room door open all the time
Unrestricted access to door

23. Physical Restraints
Indication for emergency seclusion and restraint are:
1- to prevent imminent harm to others
2- to prevent imminent harm to the patient
3- to prevent serious disruption of the treatment program or significant damage to the environment
4- as a part of on going behavior treatment program

24. Patient Restraint through History
Prior to the development of the major tranquilizers, most patients with delirium, dementia, or psychosis were restrained in various fashions.

25. Patient Restraint Through History
Straight jackets and padded rooms were common.

26. Patient Restraint Through History
Development of the major tranquilizers offered significant improvements and allowed some people to finally be deinstitutionalized.

27. Patient Restraint
Today, some people must be restrained in order to prevent them from harming themselves or others.
Patient restraint is a significant decision that must be made by law enforcement personnel, EMS personnel, medical personnel, or a combination of these.

28. Physical Restraints
Hand cuffs are among the most frequently used restraint system of law enforcement.

29. The Literature Case 1: 24 y/o white man with pendulant abdomen
Psychiatric history
Violent arrest (fought PD, struck twice with night stick)
Handcuffed and hog tied and placed prone in patrol car
Dead after 5-7 minute ride to ED (for night stick wounds)
Autopsy relatively unremarkable
TOX: + lithium, caffeine
Death: Positional asphyxia

30. Physical Restraints
Application of restrains = running a resuscitation !
Restrain team consists of at least 6 people including team leader. The leader is the only person giving orders and should be the person with most experience in implementing restraints

31. Physical Restraints Number and position of restraints:
Alternate restraints: one arm , opposite leg
Four point or five points restraints: all four limbs and possibly waist or chest restraints
Restraining on their side will help to prevent aspiration

32. Physical Restraints Fabric restraints:
Leather or specially designed polymer cuffs are optimal restraints try to avoid using gauze, bandage which can tighten around the limb and can restrict distal circulation.
some advised to apply Philadelphia collar to patient’s neck to prevent head banging and biting

33. Physical Restraints After Restraints:
Proper documentation and close monitoring should be done to patient’s GCS, vital signs and distal circulation
Restraints and death: death has been reported in patients who has been restrained, especially in patients who restrained in the prone or hobble position
( arms and legs restrained behind the patient) the death presumed due to positional asphyxia*
*Reay DR, Fligner CL, Stilwell AD et al positional asphyxia
during law enforcement transport. Am J Frens Med Pathol 1992;13:90

34. Chemical Restraints
May be used in conjunction with physical restraints.
Rapid Tranquilization (RT) : is the term applied to quick chemical control of the agitated patient. It allows physician to quickly calm the patient, proper evaluation and treatment and prevents the patient from harming him/herself

35. Chemical restraint:
Goal is to subdue excessive agitation and struggling against physical restraints.
Intervention should change the patient’s behavior without reaching the point of amnesia or altering the patient’s level of consciousness.

36. Chemical restraint:
Butyrophenones and/or benzodiazipines are most frequently used.

37. Chemical restraint: Butyrphenones: Benzodiazepines:
Haloperidol (Haldol)
Droperidol (Inapsine)
Benzodiazepines:
Diazepam (Valium)
Lorazepam (Ativan)
Midazolam (Versed)
All can be given IV or IM

38. Chemical Restraints - Butyrophenon
Haloperidol (Haldol)
- Drug of choice to sedate a violent patient
- Dose 2.5 – 10.0 mg I/M at 30 – 60 min interval. Elderly 2.5 – 5 mg boluses
- Effect seen in 10 – 30 min
- Although no ceiling dose but one source suggest that not more than six doses in 24 hrs

39. Chemical Restraints - Butyrophenon
- Haloperidol is not FDA approved for iv use but it is widely used via this route till they reach 30 mg iv over 24 hrs without adverse effects.

40. Chemical Restraints Benzodiazepines
Can be used in RT
Lorazepam (Ativan) is superior to other due to rapidity of action, effectiveness, short half life and lack of active metabolism
It is one of few BZD that is rapidly effective when given im
Dose 1-2 mg up to 120 mg in 24 hrs

41. Chemical Restraints Benzodiazepines
Midazolam
Has been reported to be safe and rapid in onst when given im with a shorter half life than lorazepam
Dose mg/ kg
Side effects;
sedation, confusion, ataxia, nausea and respiratory depression

42. Chemical Restraints Combination butyrophenon and benzo
The combination of lorazepam with haloperidol has been studied prospectively and has been shown superior to either drug alone.
Therefore, combination therapy has been recommended as the treatment of choice for RT of the acutely agitated pt. with minimal side effects
Battaglia J, Moss S, Rush J et al. haloperidol, lorazepam,or both for psychotic agitation. Am J Emerg Med 1997;15:335

43. KEY POINTS Predicting violence Medical evaluation Male
Previous hx of violence
Drug/alcohol abuser
Differentiate organic with functional
4 screening criteria (disorientation, abn vital sign, alter consciousness, no previous psychiatric illness)

44. KEY POINTS Diagnostic testing Management General Bedside glucose
Priority attention
Restrain team
Physical restrain
Chemical restrain (Haloperidol, Midazolam)
Staff Training (risk assessment & techniques)

45. THANK YOU