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 SchizophreniaP=110, 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 didn’t 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:

6. 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

12. Chemical Control • Rapid Tranquilization • Safety • Titratability • Haloperidol • Haloperidol and Benzodiazapine • Droperidol

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

14. 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

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

19. 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

21. Monitoring • Documentation • Neurovascular • Cardiovascular • Airway • Consideration of removal • Transfer Considerations

22. Summary • Multifactorial approach • Teamwork • Early intervention • Life saving when necessary