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97 MANAGEMENT OF THE VIOLENT PATIENTDouglas Ikelheimer, MD, MA

1. Isviolenceaproblemintheemergencydepartment(ED)?Yes. Only a small percentage of ED patients are violent, disruptive, or abusive to staff yet they require disproportionate staff attention and resources. About 4% of patients in the ED need restraints during their stay. According to a prospective observational study from an urban ED, 29.2% of restraint episodes were for violent and disruptive behavior, 25.2% for agitation, and 7.4% for alcohol or drug intoxication. Restraints were less frequently used for confusion (6.4%) or dementia (1.7%), but note that 40% of the patients who were restrained had multiple reasons for restraints. Approximately 30% of agitated patients require a combination of physical and chemical restraint.

2. Whydidthepatientbecomeviolentinthefirstplace?Common causes of violence and agitation include acute intoxication, acute withdrawal and associated delirium, metabolic disorders, trauma, infectious disease, sepsis, cardiovascular disorders, psychiatric disorders, hypoxia, or intracranial processes such as stroke or hemorrhage. Note that the rate of violence is the same between patients with mental illness and those without mental illness. Better predictors of violence include recent history of violence and the presence of personality disorder or substance abuse.

1. Hypoxia

2. Hypoglycemia

3. Acute intoxication or withdrawal syndromes

4. Meningoencephalitis

5. Intracranial injury or bleed

6. Hyponatremia or hypernatremia

7. Drug side effects

KEY POINTS: COMMON MEDICAL CONDITIONS THAT MANIFEST AS VIOLENT BEHAVIOR

3. Whatcanhospitalsdotodecreasetheriskofviolence?n Limit hospital access to only a few entrances staffed and monitored by trained security

personnel.n Metal detectors should be used to screen patients and visitors for weapons.n Continuous surveillance or closed-circuit television monitors should be used to help ensure

safety in the parking areas and the immediate grounds of the hospital.n Multiple methods of summoning police or security must be available to the ED without

having to go through the hospital operator.

Chapter 97 MANAGEMENT OF THE VIOLENT PATIENT 671

4. Whatcanbedonetopreemptaviolentepisode?n Be aware of early signs of impending violent behavior, such as agitation, intoxication,

delirium, abusive language, and challenges to authority.n Completely undress all patients and place in a gown; remove from reach any items that

may be used as a weapon.

5. Whatistheinitialapproachaphysiciancantaketocontrolanagitatedorviolentpatient?The first approach should be verbal redirection. The physician should appear calm and in control but empathetic while explaining to the patient that he or she is in a safe environment and that the ED staff is there to help. Active listening may go a long way toward calming the patient. Keep hands in a neutral position, not crossed across your chest or behind your back. Make an attempt to make the patient more comfortable by offering a drink or a warm blanket. Be clear that violence will not be tolerated and that ED staff must maintain a safe environment for treating patients. Security officers in the patient’s presence may dissuade further inappropriate behavior. It may be beneficial to offer nicotine replacement such as gum or a patch or other voluntary meds for agitation including oral haloperidol, lorazepam, olanzapine, or ziprasidone (see section on medications). Care providers must be aware of their own emotions when dealing with agitated patients; yelling or exchanging threats with the patient only further escalates the situation.

KEY POINTS: DE-ESCALATING A VIOLENT PATIENT

1. Use verbal redirection.

2. Use nonconfrontational body language.

3. Reassure the patient’s safety.

4. Use empathy.

5. Maintain and emphasize control over the ED.

6. Be honest and direct.

7. Offer nicotine replacement, food, water, or blanket.

8. Offer voluntary meds for agitation.

6. Whatifthatdoesn’twork?When aggressive behavior cannot be managed by verbal de-escalation and a patient becomes an increasing risk of violence or elopement, physical or chemical restraint may be indicated. Physical restraint usually involves four-point locking leather cuffs (both wrists and both ankles). A team of five staff members should place the restraints—one care provider for each limb and one at the head of the patient to provide an ongoing explanation to the patient of what is happening and why. The physician should not be involved in this action because it may further jeopardize his or her therapeutic relationship with the patient. Soft restraints or two-point restraints may be best for the disoriented patient at risk of pulling lines and tubes. When the patient becomes calm, he or she is often brought down to two-point restraints or released from restraints completely.

7. WhatdoIneedtorememberwhenphysicallyrestrainingapatient?Restraints must be snug enough to control the patient but not impede circulation. There should be enough room to allow one finger to move easily between the patient’s skin and the cuff. Ensure that side rails are up. Due to risk of suffocation, never restrain a patient in the

Chapter 97 MANAGEMENT OF THE VIOLENT PATIENT672

prone position and any patient at risk of aspiration should be positioned on his or her side. Patients in restraints must be monitored directly and continuously. As the agitation resolves, restraining measures can be downgraded or discontinued. Documentation is required regarding the patient’s behavior and mental status, attempts at less restrictive measures, and monitoring of vital signs. The Joint Commission has specific guidelines for use of physical restraints. There are additional hospital protocols regarding restraints, and the physician should be familiar with all of these guidelines.

8. AmIlegallyallowedtorestrainsomeone?Yes. Chemical or physical restraint is indicated when patients become imminently dangerous and less restrictive measures have failed. The courts have held both physicians and hospitals liable for injuries that have occurred when violent or otherwise incapacitated patients escaped hospital grounds or are discharged. The ED staff must therefore prevent certain patients from leaving until they can be examined and thoroughly evaluated. If the patient elopes, avoid personal heroics and instead call the local authorities. Regarding a patient’s right to refuse medications, this does not apply to patients who exhibit violent or acutely psychotic behavior in the ED. Courts have routinely held that physicians may involuntarily administer medications to patients who would otherwise present an imminent risk of dangerous behavior.

9. Whatmedicationsarerecommendedforchemicalrestraint?Three primary classes of drugs are used for chemical restraint: (1) benzodiazepines, such as lorazepam and diazepam; (2) traditional antipsychotics such as haloperidol and chlorpromazine; and (3) atypical antipsychotics such as olanzapine, risperidone, and ziprasidone.

Benzodiazepines: These are useful in agitation, mania, psychosis, alcohol withdrawal, benzodiazepine withdrawal, and sympathomimetic toxidromes like cocaine or amphetamine toxicity. Doses of 1 to 2 mg intramuscularly (IM) or intravenously (IV) of lorazepam may be given every hour as needed. Diazepam may be given as follows: 5 to 10 mg PO, IV, IM, or per rectum (PR) every hour as needed. Another choice is midazolam alone or in combination with haloperidol. Midazolam, 5 mg IM, has been shown to have a more rapid onset than lorazepam or haloperidol and also has the benefit of having a shorter time to arousal.

Traditional Antipsychotics: Although the antipsychotic effects of these medications may take days to achieve, their usefulness in the acute setting with any patient (with or without psychosis) is due to their sedating properties. Haloperidol in doses of 5 to 10 mg per os (by mouth; PO), IM, or IV can be an effective medication for controlling agitation due to psychosis, delirium, or intoxication. These doses may be repeated every hour until the patient is calm; maximum recommended daily dose of haloperidol is 30 mg. Chlorpromazine at a dose of 100 mg PO or 50 mg IM may be given hourly as needed. In 2001, the Food and Drug Administration (FDA) issued a black box warning for droperidol, citing a risk of QTc prolongation and torsades de pointes. However, the evidence for this is in dispute and many practitioners believe that the risks associated with use of droperidol are outweighed by the beneficial effects, particularly when routine electrocardiogram (ECG) screening is employed. Whenever using a traditional antipsychotic such as haloperidol, it is advisable to provide protection from possible extrapyramidal symptoms (EPS) by coadministration of an anticholinergic agent such as diphenhydramine at a dose of 50 mg PO, IM, or IV, or benztropine at a dose of 1 mg PO, IM, or IV.

Atypical Antipsychotics: Although the atypicals can be more expensive, they are effective at controlling agitation without overly sedating the patient, thus offering potential benefits with regard to more expedient disposition of the patient. Risperidone 2 to 4 mg PO or olanzapine 10 to 20 mg PO or 10 mg IM can be effective in controlling agitation. Ziprasidone 80 to 120 mg PO or 10 to 20 mg IM (with or without lorazepam) is also indicated for acute agitation. Be advised that coadminstration of benzodiazepines with IM olanzapine is not recommended due to risk of respiratory depression.

Chapter 97 MANAGEMENT OF THE VIOLENT PATIENT 673

10. Whatiftwodosesofhaloperidolhavenotsedatedthepatient?Don’t give a third dose. Supplement the haloperidol with a benzodiazepine; the two together have a synergistic effect. If you used haloperidol 5 mg IM and repeated this once, try adding lorazepam 2 mg IM or IV or diazepam 5 mg IM or IV. Alternatively, add an atypical antipsychotic such as ziprasidone, risperidone, or olanzapine.

11. Howdoyouusechemicalrestraintforsedationinapediatricpatient?Very few of the psychotropic medications used for restraint in adults have been approved for use in children. The most frequently used medication for rapid sedation in children is lorazepam due to its rapid onset, short half-life, and multiple routes of administration (see doses), but be wary of dysinhibition/paradoxical agitation. Haloperidol is a safe and effective alternative and may be given IM or PO (see Table 97-1). Intravenous haloperidol has not been approved by the FDA but may be effective. Haloperidol and lorazepam may be mixed together in one syringe; this combination is safe and effective in the pediatric and adult population but may lead to prolonged sedation.

1. Haloperidol 5 to 10 mg PO or IM; may repeat every hour as needed; max 30 mg; consider adding diphenhydramine 50 mg PO or IM twice a day to reduce risk of EPS. Consider adding lorazepam 1 to 2 mg PO or IM.

2. Olanzapine 10 to 20 mg PO or 10 mg IM; do not combine intramuscular olanzapine with lorazepam due to risk of respiratory depression.

3. Lorazepam 1 to 2 mg PO, IM, or IV; may repeat hourly as needed.

KEY POINTS: PREFERRED DRUGS FOR CHEMICAL RESTRAINT

KEY POINTS: MAJOR SIDE EFFECTS OF HALOPERIDOL

1. Akathisias

2. Dystonic reactions

3. Neuroleptic malignant syndrome (rare)

4. Anticholinergic effects

5. Hypotension

6. Lowered seizure threshold

12. Summarizethemainsideeffectstowatchforwiththesedrugs.Benzodiazepines may rarely cause hypotension and respiratory depression. The traditional antipsychotics may cause hypotension and extrapyramidal or other dystonic symptoms (EPS). Hypotension is rare, but EPS occurs in approximately 1% of patients. The most common dystonic reactions are oculogyric crisis, torticollis, and opisthotonos, which are irregular movements of the eyes, neck, and back, respectively. These symptoms may be prevented or reversed with diphenhydramine or benztropine. Neuroleptic malignant syndrome (NMS) is a medical emergency characterized by rigidity, hypertension, hyperthermia, and altered mental status and can been seen after administration of antipsychotics. Treatment for NMS involves supportive care and dantrolene.

Chapter 97 MANAGEMENT OF THE VIOLENT PATIENT 674

Medication

Adult DosePediatric Dose

OnsetDuration

Side Effects

Benztropine1–4 m

g PO/IM/IV bid prn EPS

0.02–0.05 mg/kg/dose

n

IV 5–15 mins

n

IM 15–30 m

insn

PO 30–60 m

ins

6–12 hoursAnticholinergic effects

Chlorpromazine

100 mg PO q 60 m

in prn or 50 m

g IM q 60 m

in prn

n

PO 30–60 mins

n

IM 20–40 m

ins 4-6 hours

Akathisia, NMS, EPS

Diazepam2–10 m

g PO/IM/IV q 30–60 m

in prn

n

IV 1–5 m

insn

IM

20–30 mins

n

PO 30–40 mins

30–60 mins

Respiratory depression, paradoxical agitation, dysinhibition

Diphenhydramine

25–50 mg PO/IM

/IV q 6 h prn EPS

1.25 mg/kg/dose

n

IV 5–15 mins

n

IM 15–30 m

insn

PO 30–60 m

ins

4–6 hoursAnticholinergic effects

Droperidol*2.5–10 m

g IM/IV q

60 min prn

0.03–0.07 mg/kg/dose

(max 2.5 m

g)

n

IV 2–10 mins

n

IM 5–10 m

ins2–3 hours

Dystonias, akathisia, NMS hypotension,

QTc elevation, lower seizure threshold,

anticholinergic effects, hypotension

TABLE 97–1. QUICK REFERENCE FOR DOSING AND ADMINISTRATION OF MEDS FOR AGITATION

Chapter 97 MANAGEMENT OF THE VIOLENT PATIENT675

*FDA Black Box WarningEPS, extrapyramidal symptoms; IM, intramuscularly; IV, intravenously; NMS; neuroleptic malignant syndrome; PO, orally; PRN, as needed; q, every.

Haloperidol 2–10 mg PO/IM/IV q 30–60 min prn (max 30 mg)

0.025–0.075 mg/kg/dose n IV 2–5 minsn IM 30–40 minsn PO 30–60 mins

2–4 hours Dystonias, akathisia, NMS, hypoten-sion, QTc elevation, lower seizure threshold, anticholinergic effects

Lorazepam 0.5–4 mg PO/IM/IV q 30–60 min prn

0.05–0.1 mg/kg/dose PO/IV n IM/IV 5–10 minsn PO 30–40 mins

4–6 hours Respiratory depression, paradoxical agitation, disinhibition

Midazolam 1–5 mg IM/IV q 60 minprn

0.05–0.1 mg/kg/dose IV(max 1.0 mg)

n IV 1–5 minsn IM 15–20 mins

1–2 hours Respiratory depression, paradoxical agitation, disinhibition

Olanzapine 5–20 mg PO/SL q 60 min prn or2.5–10 mg IM tid prn (max 30 mg daily)

n PO/SL 30–60 mins

n IM 20–40 mins

2–4 hours NMS, akathisia; do not mix intramus-cular preparation with benzos

Risperidone 2-4 mg PO q 4 h (max 16 mg daily)

n PO 30–60 mins 2-4 hours Akathisia, NMS

Ziprasidone 80–120 mg PO bid or10–20 mg IM q 4 h (max IM dose 5 40 mg)

n PO 30–60 minsn IM 20–40 mins

2–4 hours Akathisia, QTc elevation

Chapter 97 MANAGEMENT OF THE VIOLENT PATIENT676

13. Giveaquickreferenceondosingandadministration.See Table 97-1.

14. Howshouldrestrainedpatientsbemonitored?Continuous pulse oximetry is indicated due to possible respiratory compromise, particularly when ethanol-intoxicated patients receive chemical restraint. The Joint Commission requires that physically restrained patients be directly and continuously monitored by trained staff.

15. DoestheEDstaffneedanytreatment?The effect of violence on ED employees can be devastating; physical and psychological trauma may have a long-lasting impact and such episodes may affect future job performance. A comprehensive program patterned after the critical incident stress debriefing model should be established to provide immediate and long-term psychological support, and staff should be encouraged to avail themselves of this support when the need arises.

WEBSITE

Restraints: www.emedicine.com

BIBLIOGRAPHY

1. American Psychiatric Association: Seclusion and restraint, Task Force Report No. 22. Washington, DC, 1984, American Psychiatric Association.

2. Battaglia SA, Ownby RL, Penalver A, et al: Haloperidol, lorazepam, or both for psychotic agitation? A multicenter, prospective, double-blind, ED study. Am J Emerg Med 15:335–340, 1997.

3. Buckley PF, Noffsinger SG, Smith DA, et al: Treatment of the psychotic patient who is violent. Psychiatr Clin North Am 26:231–272, 2003.

4. Chase PB, Biros MH: A retrospective review of the use and safety of droperidol in a large, high-risk, inner-city ED patient population. Acad Emerg Med 9:1402–1410, 2002.

5. Hill S, Petit J: Psychiatric emergencies. Emerg Med Clin North Am 18:201–315, 2000.

6. Kao LW, Moore GP, Jackimczyk KC, et al: The combative patient: chemical restraints. In Marx JA, Hockberger RS, Walls RM, et al, editors:: Rosen’s emergency medicine: concepts and clinical practice, ed 5, Mosby, 2002, St. Louis, pp 2595–2599.

7. Lavoe FW: Consent, involuntary treatment and the use of force in an urban ED. Ann Emerg Med 21:25–32, 1992.

8. Nobay F, Simon DC, Levitt MA, et al: A prospective, double-blind, randomized trial of midazolam versus haloperidol versus lorazepam in the chemical restraint of violent and severely agitated patients. Acad Emerg Med 11:744–749, 2004.

9. Sorrentino A: Chemical restraints for the agitated, violent, or psychotic pediatric patient in the ED: controversies and recommendations. Curr Opin Pediatr 16:201–205, 2004.

10. Zun LS: A prospective study of the complication rate of use of patient restraint in the ED. J Emerg Med 24:119–124, 2003.

ACKNOWLEDGMENT

The editors thank Danielle Raeburn, MD, and Katherine M. Bakes, MD for their contributions to this chapter in previous editions of this text.