Management of violent patient in emergency

MANAGEMENT OF VIOLENT PATIENTS

1. MANAGEMENT OF VIOLENT PATIENT IN EMERGENCY DEPARTMENT SUDARSHAN PANDEY INTERN, MBBS KUSMS

2. Violence and Aggression Violence and aggression refer to a range of behaviours or actions that can result in harm, hurt or injury to another person, regardless of whether the violence or aggression is physically or verbally expressed, physical harm is sustained or the intention is clear

3. Hypoxia CNS infection Seizure CVA Trauma Neoplasm Electrolyte abnormality Delirium Dementia Hypo/hyperthermia Endocrine disorder Alcohol (intoxication and withdrawal) Sedative-hypnotics (intoxication or withdrawal) Amphetamine/Cocaine LSD Anticholinergics Aromatic hydrocarbons (e.g., glue, paint, Steroids Schizophrenia Paranoid ideation Catatonic excitement Mania Personality disorders ( Borderline/Antisocial) Delusional Depression PTSD Decompensating OCD Homosexual panic

4. OTHER FACTORS Social factors: history of violence • Little impulse control • low self-esteem • frustration • delays in treatment • in police custody/gang affiliation • victim of crime

5. PRODROME OF VIOLANCE

6. ANXIOUS BEHAVIOUR   Pacing /hand-wringing body tensing, Facial tension, fidgety behavior, Asking repetitive questions speaking in a loud voice exhibiting pressured speech

7. DEFENSIVE BEHAVIOR  Verbal abuse, profanity, Power struggle chanting, staring /darting eyes, mumbling, flushed face, clenching hands, repeated approach to staffs

8. PHYSICAL AGGRESSION completely lost control over emotions and behaviors Physically violent acts : a danger to property, staff, other patients, visitors, and themselves

9. MANAGEMENT OF VIOLENT PATIENT C ONTAINMENT & SAFETY A SSESSMENT N ON VIOLENT DE-ESCALATION I NTERVENTION T AKE DOWN AND RESTRAINT

10. The American Psychiatric Association recommends that the presence of any one of the following in a violent patient should prompt a search for an organic etiology: a patient >40 years of age with no previous psychiatric history; disorientation, lethargy, or stupor; abnormal vital signs; visual hallucinations.

11. INVESTIGATION Pulse oxymetry Blood glucose ECGs Chest Xray blood Biochemistries, toxicology screening, CT head scans lumbar puncture

12. DE-ESCALATION DE-ESCALATION The use of techniques (including verbal and non verbal communication skills) aimed at defusing anger and averting aggression DE-ESCALATORY SKILLS • Explain intentions to patients and others; • Try to appear calm and self-controlled; • Ensure own non-verbal communication is non-threatening; • Engage in conversation, acknowledge concerns and feelings; • Ask open-ended questions; • Ask for any weapons to be put down (not handed over)’ and • Know how to call for help in an emergency.

13. PHYSICAL RESTRAIN MANUAL STRAIN • team approach to manual restraint • When using manual restraint, avoid taking the subject to the floor, but ‘if this becomes necessary’, use the supine (face up) position if possible, and if face down position does have to be used, use it for as short a time as possible MECHANICAL STRAIN • managing extreme violence directed at other people or • limiting self-injurious behaviour of extremely high frequency or intensity. Using Handcuffs , Restraining belts

14. Chemical Restraint

15. MEDICATION/CHEMICAL RESTRAINT Chemical restraint refers to the administration of a medication that is used to control behavior or freedom of movement but that is not a part of a patient’s daily medication regimen Rapid tranquilization refers to giving medication every half hour to every hour to target symptoms of agitation,hostility , and motor excitement

16. Drugs Adult Dosage Route   Adverse Effects Benzodiazepines   Lorazepam 2–4 mg IV, IM, PO C/I in alcohol intoxication, respiratory and neurologic depression, coma   Midazolam 0.01–0.07 mg/kg IV, IM Respiratory and neurologic depression, amnesia, hypotension Typical antipsychotics   Haloperidol 2–5 mg IV, IM EPS, QT-interval prolongation, NMS, tardive dyskinesia with long-term use Atypical antipsychotics   Olanzapine 5–10 mg IM, PO Drowsiness, agitation, dizziness, akathisia   Risperidone 2-8 mg PO Anaphylactoid reactions,hypotension , NMS

17. Dangers of Emergency sedation Sedative drugs may mask important signs of underlying illness, eg an intracranial haematoma requiring urgent treatment. The normal protective reflexes (including airway refl exes, such as gag and cough response) will be suppressed. Respiratory depression and the need for tracheal intubation and IPPV may develop. Adverse cardiovascular events ( eg hypotension and arrhythmias) may be provoked, particularly in a struggling, hypoxic individual. Individual side effects of the drugs

18. SECLUSION The supervised confinement of a patient in a room, which may be locked. Its sole aim is to contain severely disturbed behaviour that is likely to cause harm to others

19. Algorithm for decision making regarding use of seclusion and restraint.

20. Phineas Gage

21. REFERENCE Violence and aggression: NICE guideline Draft for consultation, November 2014 Tintinalli's Emergency Medicine 7 th edition Management of the Acutely Violent Patient, Jorge R. Petit, MD