Introduction     References     Annotated Bibliography

Violent Patients

Case Presentation

This presentation addresses the management of violent patients who present in the Emergency Department. Several areas will be discussed, including:

1) Epidemiology

2) De-escalation

3) Restraints and seclusion

4) Medications and pharmacologic management

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Violent Patients

Introduction

Emergency physicians encounter violent patients as predictably as they encounter airways. Fundamentally, the approach to violence in the ED is analogous to the approach to the airway.  There are many routes to airways compromise, yet regardless of the cause, the  physician must control the airway before subsequent treatment.  Similarly, violent behavior is an endpoint for many different medical and psychiatric pathologies; the emergency physician must control the behavior, to prevent escalation and injury,  before moving on to further evaluation.

 

At the same time, it is imperative that the physician suspect any decompensated behavior to be the result of a medical or surgical condition, until proven otherwise.  Treatment of conditions that may cause agitation, such as hypoxia, may in fact resolve behavioral problems.  But often, the behavior itself will need to be addressed before definitive care can take place.

 

The focus of this presentation is to review the emergent treatment of violent behavior, not to dwell on the pathologies that may have led to the behavior. Since the definitive medical or psychiatric diagnosis in these patients is often not possible in the emergency situation, it is imperative to have a clear management approach to behaviorally discontrolled patients.

 

 

Definitions and Epidemiology

 

Violent behavior constitutes any set of actions that are forceful or directed enough to cause injury to the patient or others. In nature, violent behavior may be an appropriate response to a given set of environmental circumstances.  Individual responses to environmental circumstance will be fashioned by many factors, such as personality characteristics, (or disorders), such as aggressiveness, poor impulse control, antisocial or manipulative traits. Emotions, especially fear, powerlessness,  anger and rage play a key role in the propensity for violent response, and may be most amenable to verbal intervention. Agitation, or a state of psychomotor hyperactivity, and psychosis, a breakdown of rational perception, may be due to either medical or psychiatric causes.

 

However, any violent behavior in the ED usually constitutes maladaptive behavior and should be considered  a pathologic state that could lead to morbidity or mortality.  Appropriate prevention or intervention becomes warranted. A history of violence, regardless of diagnosis, is the most uniform predictor of violent behavior in the ED.  Many ED’s have a system for documenting and notifying ED staff about patients with prior violent visits to the ED.

 

As with the airway, recognition of the potential for deterioration, and preparation for decompensation are the best assurance for the safety  patients and staff.  Three progressive but integrated strategies are outlined:  de-escalation, restraints and seclusion, and pharmacologic interventions. The “ least restrictive alternative doctrine” dictates that the least  invasive means be used to control the violent. ¹⁴

 

 

De-Escalation

 

The apparent chaos of the ED may contribute to the behavioral deterioration of patients at risk, but  there are environmental variables which can be addressed to help alleviate the potential for decompensation.  Waiting times, frustrating for anyone, can be minimized.  Placing at risk patients in a quiet or private exam room will decrease  external stimuli.  Patients may need to be separated from other loud or aggressive patients, friends or family.  Alternatively, if cooperative, those same people can be enlisted for support. Show your concern for patient well-being by offering comfort in the form of warm clothing or blankets, a chair or stretcher, food or drink.  Question patients early and directly about weapons or potential weapons, and remove them.

 

When talking to the patient, (verbal de-escalation), the overriding principle is that staff convey their professional concern for the well-being of the patient, that the staff is in control, and that no harm will come to the patient.  When you are with the patient, be sure that you have a means of egress; you should be closer to the door than the patient, but aware that you don’t convey a feeling of entrapment, and never locked in.  Be aware of body language; crossed arms, hands behind the back, a forward leaning frontal posture, prolonged or intense eye contact can be perceived as threatening or challenging.  Respect personal space. 

 

When speaking to at risk patients it is important to maintain a calm, controlled tone.  Never express anger or hostility, and never minimize or “write off” patient threats or feelings. Express your empathy and concern; statements such as, “ I understand you are feeling frustrated, that you’re having a hard time”, and “you’re here to get help, let’s try to figure out what’s going on”, convey both. Emphasize that they are safe, that the staff is there for them.  However, you also need to clearly define limits for patient behavior, and consequences of their actions.  Provide reasonable alternatives to aggressive behavior.  It is crucial that your staff be consistent in their approach; manipulative patients may attempt to split staff who do not have a unified strategy.

 

Always be alert for changes in patient mood, loud or aggressive speech or actions, increasing psychomotor activity, which may signal impending loss of control. The ultimate gauge for impending danger is the care giver’s visceral perceptions; if one feels unsafe or threatened in the face of a potentially hostile patient, it is best to abort the interaction until interventions are instituted to restore confidence. Security personnel or local police can be a show of force that may dissuade inappropriate behaviors.  They can also be instrumental in the ultimate implementation of physical restraints / containment.

 

Sometimes, in spite of your best efforts at de-escalation, patient behavior will deteriorate. If less restrictive efforts are unsuccessful, restraints, seclusion and/or medication may used in response to emergent or imminently dangerous behavior. ²⁴

 

Once the decision has been made to proceed with restraints or seclusion there must be sufficient trained personnel so that the procedure can be carried out safely and effectively if physical force becomes warranted.  At all times the staff must convey confidence, calmness, and proceed with implementation as if it were a routine procedure.  Overtly violent encounters are stressful for both patients and staff and can contribute to deterioration of morale, depression, and anxiety.  It is appropriate to have some type of debriefing that offers the opportunity for staff to discuss the event and the associated feelings.

 

 

Restraints / Seclusion

Seclusion: Seclusion can be useful for agitated patients by decreasing the external stimuli and permitting the patient “time-out” to regain behavioral control   A  seclusion room must be safe, above all, and free of objects that could be used to injure self or others.  Medical conditions which are unstable and require close physical interactions or monitoring preclude the use of seclusion. 

 

Prior to seclusion, it is imperative that potentially dangerous items be removed.  At first the door can remain open, but if agitation continues the door is locked for safety. The patient must always be aware of the consequences of his behavior; and be given periodic opportunities to comply with defined behavioral parameters in order to be released from seclusion. Medications can be offered to avoid further restrictive measures. The patient in seclusion should be checked no less than every 15 minutes or, if available, monitored by closed-circuit television. Staff must clearly document the need for seclusion, intervening steps, and medications given. ¹

 

Restraints:  The implementation of restraints is a disheartening procedure, but it is often the best option, generally reserved for those situations where there is the potential for imminent harm to patient or staff through patient behavior.  Again, once the decision is made, the overriding principles are that it be done swiftly and humanely,  and that the patient be reassured that it is felt to be in their best interest.

    

The implementation of physical restraints is a dangerous procedure, both for staff and patient.  It should never be attempted unless there is sufficient manpower to ensure that it can be done with a minimum of struggle.  A minimum of 5 staff members is recommended, one for each limb and an extra or team leader. The presence of staff may also assist in the calming the patient, thus aborting the need for restraints.  But once the decision is made to proceed, implementation must be completed and negotiations temporarily suspended.  The team leader,  just as in team resuscitation, will oversee the others and ensure completeness.  It is usually best that the physician avoid physical participation in subduing a combative patient as this may corrupt the therapeutic relationship.  If possible, provide the patient or family with an ongoing explanation of the reasons for the procedure, and what to expect. Secure all four limbs firmly to the bedframe, snug without impairing circulation (allow one finger space between the skin and the restraint).  Elevate the patients’ head slightly to minimize the risk of aspiration.

 

Hospital policies should address the frequency and parameters of patient monitoring while in restraints, i.e., skin integrity, vital signs, pulses, etc.  Once the patient is controlled, conduct a thorough physical exam, if not yet completed. Evaluate the patient periodically to asses the need for continued restraints.  The chart should reflect the reasons for restraints, why less restrictive methods were not utilized, medications given, course of treatment and response.^13,15  After the patient is in control, the staff can decide to remove the restraints one limb at a time, while monitoring the patient for behavioral control.

 

 

Medications

 

Pharmacologic management of the violent or agitated patient may serve as primary therapy, or as an adjunct to the other efforts.  Whenever possible, the patient is given choices, which can allow them to regain some measure of control.  Oral administration will presumably address control issues and best retain dignity for all, but if parenteral routes are agreeable, the effects will be more rapid. There are times that pharmacologic therapies are necessary in addition to physical restraint.  This would include continued high risk behavior, such as spitting, biting, disruptive verbal threats, and struggling against the restraints and medical care, i.e; blood drawing and other testing.  This is especially true where there is a primary medical condition that can be complicated by continued struggle or agitation.  Clearly, medical conditions that may contribute to agitation, such as pain or hypoxia, need to be addressed concomitantly.    Physicians are often hesitant to give sedating medications for fear of complications or obscuring the physical exam. That said, the risk of over sedation is outweighed by the risk of continued struggle, for instance, in the intoxicated patient with a c-spine injury.

 

Antipsychotic medications, alternately referred to as neuroleptics or psychotropics, were developed in the 1940's.  Maintenance therapy with these medications revolutionized our management of the mentally ill. These same medications, given rapidly, in large doses, were found  effective in acute control of behavior; by the 1970's,  rapid tranquilization was well defined in the psychiatric literature, and more recently in the emergency literature.  The goal of rapid tranquilization is simply to control behavior, without over sedation, without loss of airway or cardiovascular stability, such that definitive evaluation and care can be completed.  It is not diagnosis specific; it is effective for violent behavior due to psychiatric, emotional, or medical causes.

 

 

Antipsychotics

 

The psychotropic medications are broadly classified as high potency, such as haloperidol, and low potency, such as chlorpromazine.   All of the antipsychotics are effective in controlling psychotic features of any etiology, and they all have in common a therapeutic index that makes them safe. The predominant side effects of the low potency medications are anticholinergic and sedating, while the high potency medications cause more extrapyramidal side effects.

 

The primary action of neuroleptics results from dopamine receptor blockade in the CNS. It is presumed that dopamine antagonism in the cortex and limbic system is clinically expressed as reduced interest in the environment, decreased response to both internal and external stimuli, and inhibition of self-motivated and exploratory behavior.  Extrapyramidal effects, namely dystonia, akathisia and tardive dyskinesia, are ascribed to the interference with dopamine in the basal ganglia.  The anticholinergic activity and alpha blocking effects of these drugs may result in postural hypotension, tachycardia, urinary retention, dry mouth, and constipation, which can usually be managed conservatively in the acute setting. Tardive dyskinesia is due to long term therapy, and not an issue in the acute setting. (NMS) is a rare side effect.

 

Haloperidol:  Haloperidol has become the standard for rapid tranquilization due to its strength and desirable side effect profile;  it is a powerful antipsychotic with minimal sedating and cardiovascular effects.    It may be given orally (PO) or intramuscular (IM), and though not FDA approved for intravenous (IV) use, it is commonly given by that route with no reported complications.   Peak serum levels are achieved 20 to 40 minutes after IM administration, at 3 to 6 hours when given orally, and the half-life is 10 to 19 hours. ²²   When used for rapid tranquilization, halperidol is dosed at 5 to 10 mgs PO, IM, or IV, every 10 to 30 minutes, and titrated to desired effect. ^9,10   Dosing starts with 2 mg in the elderly or those with comorbidity.   It has repeatedly been shown safe and effective for control of behavior in the acute setting, both in the psychiatric and emergency literature.  ^2,7,10

 

The predominant side effect is acute dystonia, usually manifested as torticollis, opisthotonos or oculogyric crisis.  Rarely, airway protection becomes an issue.  Dystonia is most commonly seen in the first 24 hours, in young healthy individuals, and not dose related.  Akathisia, or the subjective feeling of restlessness,  or “crawling out of one's skin”, is less common, but probably underdetected because it is subjective, or misdiagnosed as breakthrough agitation.   This can occur in the first weeks of therapy, most commonly in elderly women.  Fortunately, both of these effects are relieved quickly with diphenhydramine, 25-50 mg IM or IV, or benztropine, 2 mg PO or IM.  Relief usually occurs in minutes and is complete.  Repeat doses can be given, and for those few that do not respond, benzodiazepines may be used.  The symptoms can recur after initial relief, and this needs to be anticipated when patients are transferred or discharged.

 

Antipsychotic medications in general can lower the seizure threshold in animal studies and alter EEG patterns.  However, there are no reports of induced seizures clearly due to haloperidol despite its documented use in high risk populations, such as alcoholics and post-ictal patients.²⁶ Since antipsychotics have anticholinergic properties and a quinidine like effect, their use in overdoses of medications having similar properties is cautioned.

                                   

Droperidol:  Droperidol is a butyrophenone distinct from haloperidol by a single substitution on the piperidine ring.  It has been used for years in Europe as an antipsychotic, and as an adjunct for anesthesia in the U.S. for its sedating and antiemetic properties.  Only recently has it been used in U.S. psychiatric and emergency  practice.  It is given either IM or IV, at a dose of 2.5 to 10 mg, titrated to effect, with  onset of clinical effect in just minutes after IM administration, and a half-life of 2 to 4 hours. ⁸The safety and efficacy of droperidol in acute behavior control has been documented in  both the psychiatric and emergency literature.^{12, 20, 26} , with dosing up to 50 mg.²³   In comparison to haloperidol,  droperidol was found more effective at  equal doses given IM, though the advantage appeared to fade with the IV route ^{18, 25}

 

 

Benzodiazepine and Combination Pharmacotherapy

 

Benzodiazepines (BNZ) have been used for years in psychiatric practice as an adjunctive therapy for behavior control in mania, psychosis and agitation. ^{5, 25}    They are the drug of choice in agitation due to withdrawal states and catecholamine toxidromes such as cocaine or amphetamine ingestions. Currently, the most commonly studied  BNZ is  lorazepam which has the advantage of safety, rapid IM absorption, and reliability. ^{5, 17}    

 

Rapid tranquilization combining a benzodiazepine and antipsychotic offers the advantage of minimizing the amount of any single drug given and combining the sedation of the benzodiazepine with the behavioral modification of the antipsychotic. Historically, the available sedatives were chlorpromazine and barbiturates; by adding a barbiturate, the dosage of chlorpromazine could be decreased, minimizing it's propensity to cause hypotension.  The introduction of BNZs provided a safer adjunct, and allowed for a lower antipsychotic dose and less extrapyramidal side effects, possibly due to their own muscle relaxant properties.  Studies have shown that a 5 mg. Haloperidol in combined with 2-4 mg lorazapam is more effective than either drug alone in controlling behavior in the emergency setting. ^{3, 11}

Rapid tranquilization has been shown to be safe and effective.  Titratability is a key concept.   Rare reports of complications do not support the trepidation that many physicians feel .  Side effects are uncommon and, if anticipated,  will rarely cause excessive anxiety for the physician or life-threat for the patient.  There is arguably a trend, supported by the literature, towards using droperidol or combination therapy, when compared to haloperidol used alone.  Droperidol is superior to haloperidol when given IM due to its rapid absorption and shorter half-life, and may have a lower incidence of extrapyramidal side effects.  This is significant in the emergency setting due to the difficulties in obtaining IV access in the agitated patient.  It is unclear that there is any superiority when given IV.   Combination therapy allows the reduction of dosing of both of the component medications, mitigating side effect potential, and offers efficacy at least equal to the single drugs. Ultimately, however,  the choice of medication for behavior control is far less important, and less complicated, than the decision to use medication.  

 

 

Summary

 

The encounter with the violently agitated patient begins with a verbal attempt to control the situation.  Throughout the encounter, staff must avoid placing themselves in danger and always attempt to communicate concern for the patient’s well being.  The emphasis of the verbal strategies is an on-going effort.  At all times throughout the encounter, attention must be directed to the possibility of underlying medical disorders which could be causing or potentiating the behavior.  Once the potential for violence is neutralized, definitive evaluation can be completed. Medications are the mainstay of behavior control and used when verbal control is incomplete or unsuccessful.  When refused, administration may need to be forced. Droperidol, haloperidol or combination with a benzodiazapine may be used.  Titrated to effect, the strategy of rapid tranquilization is safe and effective. 

 

Medications may need to be given in conjunction with physical restraints.  The application of restraints is a potentially dangerous procedure placing both patient an staff at risk.  However, with adequate staff and well organized teamwork, this intervention offers the best chance of definitively neutralizing ongoing threat of harm.  Medications  may need to be administered in the face of ongoing agitation.

 

The legal measure for overriding the patient’s right to refuse medication, seclusion or restraint is that it must be deemed in the patients best interest.  There are times where the rights of society will become an issue such as, when violent patients try to escape, or when specific threats are voiced  by patients.  If behavior control is carried out against patients wishes, the physician is obligated to document the reasons, and to administer the treatments in question professionally and in the patient’s interest.

 

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Violent Patients

Reference List

1.  American Psychiatric Association: Seclusion and Restraint (Task Force Report No. 22). Washington, DC, APA, 1984

 

2.  Ayd FJ:  Haloperidol:  Twenty years clinical experience.  J Clin Psych  39: 807, 1978.

 

3.  Battaglia J, Moss S, Rush J, et al:  Haloperidol, lorazepam, or both for psychotic agitation? A multi- center prospective, double-blind, emergency department study.  Am J Emerg Med, 15:335,1997

 

4.  Beck JC, White KA, Gage B: Emergency psychiatric assessment of violence. Amer J Psych,  148, 1991

 

5.  Bodkin JA:  Emerging uses for high potency benzodiazapines in psycotic disorders.  J Clin Psych, 51(suppl):41, 1990

 

6.  Burrowes, KL, Hales RE, Arrington E: Research on the biologic aspects of violence. Psych Clin No Am, 11:4, 1988

 

7.  Clinton JE, Sterner S, Steimacheers Z, et al: Haloperidol for sedation of disruptive emergency patients.  Ann Emerg Med 16:319, 1987

 

8.  Cressman WA, Plostnieks J, Johnson PC: Absorption, metabolism, and excretion of droperidol in human subjects following IM and Intravenous administration. Anesthesiology  38:363, 1973

 

9.  Donlon PT, Hopkin J,Tupin JP:  Overview:  Safety and efficacy of radid neuroleptization method with injectable haloperidol.  Am J Psych,  136:273, 1979

 

10.  Dubin WR, Feld JA:   Rapid tranquilization of the violent patient.  Am J Emerg Med, 7:313, 1989

 

11.  Garza-Travino ES, Hollister LL, Overall JE, et al:  Efficacy of combinations of intramuscular antipsychotics and sedative-hypnotics for control of psychotic agitation.  Am J Psych, 146:1598, 1989

 

12.  Grancher RP, Ruth, DD:  Droperidol in acute agitation.  Currr Ther Res,  25:361, 1979

 

13.  JCAHO: Comprehensive Accreditation Manual for Hospitals. Oakbrook Terrace, 1996

 

14.  Kaplan HI, Sadock BJ: Legal issues in psychiatry. In Comprehensive Textbook of

Psychiatry.  Vol 2, 6th ed. Baltimore: Williams & Wilkins, 1995, p 2759

 

15.  Lavoi FW: Consent, involuntary treatment, and the use of force in an urban emergency department.  Ann Emerg Med 21:1, 1992

 

16.  Mendoza R, Djenderedjian AH, Adams J, et al:  Midazolam in acute psychotic patients with hyperarousal.  J Clin Psych,  48:291, 1987

 

17.  Modell JG, Lenox RH, Weiner S:  Inpatient cinical trail of lorazepam for the management of manic agitation.  J Clin Psychopharm,  5:109, 1985

 

18.  Resnick,m, Burton, B:  Droperidol vs. Haloperidol in the management of acutely agitated patients.  J Clin Psych, 45:298, 1984

 

19.  Richards JR, Derlet RW, Duncan DR:  Chemical restraint for the agitated patient in the emergency department: lorazepam versus droperidol.  J Emerg Med, 16:567,   1998

 

20.  Rosen CL, Ratcliff AF, Wolfe RE, et al: The efficacy of intravenous droperidol in the prehospital setting. J Emerg Med, 15:13, 1997

 

21.  Salzman C, Solomom D, Miyawaki E, et al:  Parenteral lorazepam versus parenteral haloperidol for the control of psychotic disruptive behavior.  J Clin Psych, 52:177,  1991

 

22.  Schaffer CB, Shahid A, Javaid JI, et al;  Bioavailability of intramuscular versus oral haloperidol in schizophrenic patients.  J Clin Psychopharm  2:274, 1981

 

23.  Szuba MP,  Bergman KS, Baxter, I, et al:  Safety and efficacy of high-dose droperidol in agitated patients.  J Clin Psycopharm 12:144, 1992

 

24.  Tardiff K: The psychiatric uses of seclusion and restraints. Washington, DC, American Psychiatric Press, 1984

 

25.  Thomas H, Schwartz E, Petrilli R:  Droperidol versus haloperidol for chemical restraint of agitated  and combative patients.  Ann Emerg Med, 21:407, 1992

           

26.  Wilbur,R, Kulik, F.A.;  Anticonvulsant Drugs in Alchohol Withdrawal;  Use of Phenytoin, primidone, carbemazapine, valproic acid, and the sedative anticonvulsants.  Am J Hosp Pharm.  38: 1138-43.  1981

 

 

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Violent Patients

 

Annotated Bibliography

 

American Psychiatric Association: Seclusion and Restraint (Task Force Report No. 22). Washington, DC, APA, 1984

 

JCAHO: Comprehensive Accreditation Manual for Hospitals. Oakbrook Terrace, 1996 

 

Tardiff, K: The current state of psychiatry in the treatment of violent patients. Arch Gen Psychiatry, 49:0000, 1992

 

Tardiff, K: Management of the violent patient in an emergency situation.  Psychiatric Clin  No Amer, 11:4, 1988

 

Tardiff K: The psychiatric uses of seclusion and restraints. Washington, DC, American Psychiatric Press, 1984

 

These are more relevant for policy and administrative issues, and more based in pychiatric practice than emergency.

 

 

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