Managing the Violent Patient in the ER

1. Managing the Violent Patient in the ER Prepared by Shane Barclay

2. Objectives 1. Assessing the violent, agitated patient. 2. To review the three strategies of dealing with violent patients: Verbal and non verbal Physical Restraints Chemical Restraints

3. What we all want to avoid in the ER!

4. ‘Disclaimer’ Although much of what will be presented here can be applied to psychiatric patients, this presentation is meant to be for the violent, aggressive non psychiatric patient. This usually relates to chemical overdose, intoxication etc.

5. Facts to Remember Up to 50% of health care workers are victims of violence in their work place during their career. Drug and alcohol intoxication and withdrawal are the most common causes of severe agitation and violence in the ER.

6. Assessing a patient for violent behavior Any angry patient should be considered potentially violent. Although the ‘usual’ scenario is Anger, then Resist Authority and finally Confrontation, Violence can erupt at any time. Generally doctors and nurses tend to be poor at predicting violent behavior.

7. Assessing a patient for violent behavior Any obviously angry patient should be considered potentially violent if they display any of the following: • Provocative behavior • Angry demeanor • Tense posturing (clenching fists, gripping arm rails,..) • Pacing, changing body position frequently • Loud aggressive speech • Aggressive behavior (throwing objects, pounding on the bed/walls etc)

8. Management of agitated patients • Assume all violent patients are armed until proven otherwise. • Make sure they are not armed. • Remove patient to a quiet area. • Setting should be private but not isolated. • Nothing should be between the clinician and the door/exit. • Increase waiting times correlates with escalation of aggression. Often seeing a patient right away can help de-escalate them.

9. Management of agitated patients • Verbal techniques • Non verbal cues • Physical Restraints • Chemical Restraints

10. Verbal Management of agitated patients Always try verbal techniques first. Be non confrontational but attentive without conveying weakness. Avoid direct eye contact. Address the violence directly – ie ask the patient if they feel like hurting themselves or someone else. Maintain personal space – at least 2 arms lengths. Don’t be provocative – relaxed hands and body posture, do not stare at the patient.

11. Verbal Management of agitated patients Set limits – ie tell patient violence will not be tolerated. Offer choices (empower the patient). Use concise and simple language. Don’t command the patient to ‘calm down’. Patients often interpret this as a challenge. Don’t criticize or interrupt the patient or respond defensively.

12. Verbal Management of agitated patients Take all threats seriously. Don’t assume that if you know the patient, the prior doctor-patient relationship will ensure your safety. If verbal means are unsuccessful and escalation continues, excuse yourself and seek help.

13. Non-Verbal Management of agitated patients You verbally may be saying something, even while smiling, but your body language may say something completely different. What is your body language saying to the agitated patient? Hands Arms Legs Posture Personal Space

14. Non-Verbal Management of agitated patients Hands: Palms facing the patient displays non confrontation and signaling trying to calm a tense situation. Palms up displays a plea or gesture for agreement or support.

15. Non-Verbal Management of agitated patients Hands: Rubbing or touching your nose usually signifies distaste, disagreement or even the willingness to ‘fight’.

16. Non-Verbal Management of agitated patients Hands: Hands on your hips (akimbo) or tucked fingers or thumb into a belt or pocket can signal dislike for another or even considering a ‘fight’.

17. Non-Verbal Management of agitated patients Arms Crossed arms can signal you are uncomfortable and don’t agree with the other person or are unwilling to listen.

18. Non-Verbal Management of agitated patients Legs Crossing a leg (especially with the arms folded across the chest) is the ‘closed posture’ signaling disagreement with the other person

19. Non-Verbal Management of agitated patients Leaning against the wall or door. Can signal ‘ownership’ and a sense of dominance over the other person.

20. Non-Verbal Management of agitated patients Personal Space: Most North Americans feel comfortable when 1.5 – 4 feet apart from someone they are speaking to (Personal zone) Less than 1.5 feet (Intimate zone) can feel threatening or cause discomfort if you are not well known or intimate with that person.

21. So you tried verbal management, watching your non verbal cues, but things escalate. What do you do next? You excuse yourself and tell the patient (politely…)

23. Physical Restraints There are moral and personal reasons why some health care members do not want to physically restrain patients. The object here is to not try to change anyone’s views. However physical restraint is not only about protecting the patient from self harm, it is about protecting other health care members from harm. As a ‘team leader’ you have that responsibility for your co-workers.

24. Physical Restraints The team leader should assign roles to the members. All team members should remove personal effects which the patient could use against them (stethoscopes, neck chains, pens, ties, etc) The team should enter professionally and not threatening. The team leader should explain to the patient what is going to happen – ie lie on the stretch and have restraints applied. If the patient ‘gives in’, do not negotiate. Continue to apply physical restraints.

25. Physical Restraints Certain drug overdoses (PCP, ‘bath salts’, Flakka, Cocaine etc) can cause severe violence in patients as well as hyper-metabolic states. Once physically restrained then use ‘chemical restraint’. There is definitely a ‘wrong way’ and a ‘right way’. The ‘object’ is to restraint the patient, not injure them in any way.

26. The ‘Wrong Ways’ to restrain a patient. • Never try ‘martial arts’ holds or pressure points. Patients on certain street drugs have been known to break their wrists, nearly chew off their arms etc with no sensation of pain. 2. Don’t use the traditional 4 point restraints where each ankle is strapped to the side of the bed and wrists strapped by their sides to the stretcher. In this position the patient can kick you as well as sit up and bite you. (this will be demonstrated in the sim lab) 3. Don’t use towels, sheets, cloth (ie anything you have to tie knots). Leather is good, but the new ‘Pinel’ restraints are excellent.

27. The ‘Right Way’ to restrain a patient. Consider the patient to have ‘5 weapons’ – 2 hands, 2 feet and their teeth. Ideally have 6 people to restrain a patient correctly. -1 at the head, 1 on each arm, 1 across the legs, 1 for the restraints. - 1 to administer drugs The following picture shows the correct way to restrain a patient on a stretcher using single strap restraints. Different restraint systems will vary in how they restrain.

29. Team Member Roles • One to hold the left arm down • One to hold the right arm down • One to lay across the thighs, holding on to the other side of the stretcher to keep thighs down. • One to hold the forehead down and ideally provide an oxygen mask (oxygen can be calming and the mask can prevent spitting and biting). • One to secure restraints • One to give the IM medications then help secure restraints.

30. Sequence of restraint – with single restraint system. 1. Tie one hand up over the patients head. This immobilizes one hand as well as the ability of the patient to lift his head up to bite. 2. Then tie the other hand to the side of the stretcher 3. Finally secure the feet. 4. If using single leg straps, secure the right leg to the left side of the stretcher and the left leg to the right side of the stretcher. This prevents kicking a team member in the groin.

31. Sequence of restraint - with single restraint system. 5. Don’t use chest restraints as this can restrict breathing. 6. Ensure the head of the bed is elevated 30 degrees or more (in case they vomit) 7. Alternate arm over the head every 30-40 minutes. (although should be sedated by then) Obviously if you have more team members more restraints can be applied at the same time.

32. Sequence of restraint - Pinel This sequence is different if using Pinel restraints.

33. Sequence of restraints - Pinel • Using 6 team members, you can either restrain the arms first, but both arms at the side of the stretcher. • Then secure the torso with the shoulder/neck restraints as in the video. • Then secure the legs. • For both arms and legs the ‘cross’ straps will prevent the patient from kicking or striking out with the limbs.

34. Sequence of restraints - Pinel This short video shows the basics of using the Pinel system.

35. Sequence of restraints - Pinel You only need to watch for first 6 ½ minutes of this video which deals with the violent patient. The remainder deals with geriatric patients.

36. Sequence of restraints - Pinel The one thing the video does not demonstrate is that after a patient is restrained, the head of the bed should be elevated 30 - 40 degrees to avoid aspiration complications.

37. Are Physical Restraints safe? A 2012 study in Germany (10.3238/arztebl.2012.0027) examined 27,353 deaths in patients that were physically restrained 22 (0.05%) were felt to be caused by the physical restraint. In 21 of these 22 cases the restraints were fastened incorrectly (19) or weird things were used (2). In most cases, the error was not using side straps or raising the bedrails.

38. Chemical Restraints So you now have the patient physically restrained, what do you give them? As well, you can give the chemical restraints whenever the nurse/doctor can administer them ie while the physical restraints are being applied.

39. Droperidol Works quickly, within 3-5 minutes. Half life is 2 hours. Was the ‘Perfect drug’ – but as of January 31, 2016, Sandoz stopped making it!!

40. Comparison of IM Sedation Medications AcadEmerg Med. 2004 Jul;11(7):744-9.                                 Time to onset          Time to arousal Lorazepam (2 mg IM) 32 min                             217 min Haloperidol (5 mg IM) 28 min                              127 min Midazolam (5 mg IM) 18 min                              82 min Other studies have shown midazolam sedation onset to be as quickly as 4-5 minutes IM and 15 minutes intranasal.

41. So now what for chemical restraints? Haloperidol and Midazolam ? Haloperidol 5 mg and Midazolam 2 - 5 mg IM. Can add Benadryl 50 mg to prevent dystonic reaction Midazolam alone 10 – 15 mg IM for adults.

42. Haldol and Midazolam When using this combination, the Midazolam ‘puts the patient down’ whereas the Haldol ‘keeps them down’. Arousal from Haldol can occur after about 2 hours, however the half life of IM Haldol is around 20 hours. So once sedated, monitor the patient and if you need more sedation, you may only need to give additional Haldol doses.

43. Haldol and Midazolam There may be concern with respiratory depression after giving Midazolam. Providing enough time has occurred for the Haldol to take effect (20-30 minutes), you can reverse the Midazolam with Flumazenil. ..or you may need to maintain the airway with a chin life/jaw thrust.

44. Other chemical restraints. Ketamine IM (1-2 mg/kg for sub-dissociative dose) (4-5 mg/kg for dissociative dose) The only issue with Ketamine is the volume. It comes in 50 mg/ml which if using 5 mg/kg can be some 3.5 cc IM for average weight patient.

45. Haloperidol and Midazolam – same syringe? Some authorities (Island Health) feel Haloperidol and Midazolam shouldn’t be mixed in the same syringe. However other literature sources suggests they can be mixed and are used routinely. http://www.australianprescriber.com/magazine/31/4/article/970.pdf http://www.emrpcc.org.au/wp-content/uploads/2013/08/Syringe-Driver-Drug-Compatibilities-Guide-to-Practice-2013.pdf http://www.australianprescriber.com/magazine/31/4/article/970.pdf

46. Once Restrained – now what? Once chemically and physically restrained: • Complete vitals, mental status and neurological exam (which may be limited due to sedation) • Blood glucose, ECG, CBC, LFT, GFR, blood cultures, urine drug screen, ABG if suspected drug OD. • Apply SpO2 monitor with alarm. • Assess the patient continually. • If you have restrained with one hand over their head, the arms need to be alternated q 30 minutes.

47. “Take Home Points” • If your ‘Spidey senses are tingling’ about a patient – take heed. • Always try verbal techniques first. • Be aware of your non verbal communication. • Restrain earlier rather than later. • Make sure you have adequate trained ‘team members’ available before trying a physical restraint. They need to be familiar with whatever restraint system you are using. • Pick your favorite sedation agent, be familiar and comfortable with it.

48. Comments andQuestions so far?

49. “Clinical Scenario” 37 year old male obviously very agitated brought to ER by RCMP. Not handcuffed. Is sitting in waiting area of the ER with the 2 RCMP officers standing by. After talking with the man for several minutes you feel he will need sedation and possible restraints if he does not comply. You then instruct the nurse to get “Dr. Pinel” to assist on Bed 4 in the ER. The nurse leaves and calls a code white, as well as gets the stretcher ready.

50. “Clinical Scenario” The nurse then gets a oxygen mask (or NRB) hooked up and running 15 lpm. The nurse applies the hand and foot restraints to the stretcher, tucking them up and out of view. The long shoulder strap is placed beside the stretch. The nurse then draws up Haldol 5 mg and Midazolam 5 mg in a syringe. (or what ever meds the doctor has ordered) The nurse then returns to the waiting area to inform the doctor all is ready. She will be designated the medication nurse.