Management of the Violent Patient
Table of Contents
- Introduction
- Violence and the Airway
- Treatment Modalities
- Case Presentation
- Definitions
- Reasonable Actions
- Medication Choices
- Physical Restraint Considerations
- Monitoring
- Summary
Introduction
Management of the Violent Patient
Presented by: RAFAT ALOWESIE, MD CONSULTANT PSYCHIATRIST
Violence and the Airway
- E.P.s predictably encounter both violence and airway issues.
- The final outcome of many pathologies.
- Failure to manage appropriately leads to injury and/or death.
- The Defining Difference: Who is at risk?
Treatment Modalities
- Interview Techniques
- Environmental Factors
- Physical Restraints
- Chemical Control
Case Presentation
- 69 yo Male, brought by family after lighting a fire in the bathroom.
- Patient has no complaints.
- History of Schizophrenia.
- Vital Signs:
- P = 110
- BP = 150/90
- RR = 20
- T = 37.9
- No distress, refusing to speak.
- Nonfocal exam.
Assessment of Violence Potential
- 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:
Definitions
- Personality
- Emotions
- Agitation
- Psychosis
- Violence
Reasonable Actions
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.
Environmental Factors
- Privacy vs. Isolation
- Available Assistance
- Weapons Detection
- Seclusion if Available
- Ninja Implements
Interview Considerations
- Calm and Direct approach.
- Empathic communication.
- Assurance of priorities.
- Verbalize limits/expectations.
- Consistency among staff.
Interview Techniques
- Eye Contact
- Personal Space
- Door Position
- Body Language
- Angle of confrontation
- Hand and arm position
Medication Choices
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
Chemical Control
- Rapid Tranquilization
- Safety
- Titratability
- Haloperidol
- Haloperidol and Benzodiazepine
- Droperidol
Haloperidol
- Butyrophenone antipsychotic
- Dosage: 5-10 mg. IM, PO, IV
- Onset: 20 minutes
- t1/2: 19 hours
- Side Effects
Haloperidol Side Effects
- Dystonic Reaction
- Akathisia
- Neuroleptic Malignant Syndrome
- Cardiovascular Effects
- Seizure Threshold
Benzodiazepines
- Lorazepam, vs others
- Less predictable effect
- Paradoxical disinhibition
- Dose requirements
- Less titratability
- Less Antipsychotic effect
- Greater risk of cardiorespiratory depression
Droperidol
- Butyrophenone antipsychotic
- Dosage: 2.5-5 mg IM or IV
- Onset: minutes
- t1/2: 2-4 hours
- Side effects
Physical Restraint Considerations
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
Physical Restraints
- For Imminent Threat of Harm
- Preparations
- Overwhelming Show of Force
- Beware the Ninja
- Initiate only When Prepared
- Preparation / De-escalation
Physical Restraint Protocol
- Once Initiated, Swift and Definitive
- Suspend Negotiations
- Team Leader
- Secure Large Joints
- Constant Reassurance
Additional Scenarios
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
Monitoring
- Documentation
- Neurovascular
- Cardiovascular
- Airway
- Consideration of removal
- Transfer Considerations
Summary
- Multifactorial approach
- Teamwork
- Early intervention
- Life-saving when necessary