Violent/Aggressive Patient

1. In certain patient populations (e.g., intoxicated patients, psychiatric patients, patients with a history of violent behaviour):
   1. Anticipate possible violent or aggressive behaviour.
   2. Recognize warning signs of violent/aggressive behaviour.
   3. Have a plan of action before assessing the patient (e.g., stay near the door, be accompanied by security or other personnel, prepare physical and/or chemical restraints if necessary).
2. In all violent or aggressive patients, including those who are intoxicated, rule out underlying medical or psychiatric conditions (e.g., hypoxemia, neurologic disorder, schizophrenia) in a timely fashion (i.e., don`t wait for them to sober up, and realize that their calming down with or without sedation does not necessarily mean they are better).
3. In a violent or aggressive patient, ensure the safety (including appropriate restraints) of the patient and staff before assessing the patient.
4. In managing your practice environment (e.g., office, emergency department), draw up a plan to deal with patients who are verbally or physically aggressive, and ensure your staff is aware of this plan and able to apply it.

Prevention

• Signs that aggression and violence are not tolerated
  • Note: Aggressive behaviour may be related to a medical problem, so these patients still need to be assessed and treated
• Functioning duress system and protocols for responding
• No dangerous objects in assessment area
• Risk
  • Young Male
  • Low SES
  • History of violence
  • Legal history
  • History of physical abuse
  • Substance use disorder
  • Mental illness
  • Victimization

Assessment

• Rule out organic cause
  • Hypoxia, hypercarbia
  • Hypoglycemia
  • CNS (injury, hemorrhage, CVA, seizure)
  • Infection (meningitis, encephalitis, sepsis)
  • Metabolic (hyponatremia, hypoglycemia, thiamine deficiency, hypercalcemia)
  • Hyper/hypothermia
  • Liver/renal failure
  • Withdrawal (alcohol, benzodiazepines)
  • Medication/substance (amphetamine, steroids, alcohol)
  • Psychiatric
• Physical examination
  • Vitals
  • Risk of impending aggression:
    • Dilated pupils, rapid respirations, perspiration, flushing skin
  • Orientation
  • Neurological exam (meningism)
• Labs
  • CBC, electrolytes (glucose), LFT, renal function
  • Blood alcohol level, urine drug screen
  • UA, urine culture
  • CT head +/- LP

Management

• Consider personal safety at all times
  • Never turn back to individual (don't walk ahead of patient)
  • Ensure adequate personal space
  • Ensure access to personal duress alarm
  • Ensure you have a safe escape route
  • Remove dangerour objects
• Consider safety of other patients and visitors
• Place patient in quiet secure area, inform other staff

De-Escalation

• Empathic nonconfrontational approach, but set boundaries
• Address agitation directly (name the emotion)
• Listen to the patient, avoid excessive stimulation
• Recruit family, friends, case managers to help
• Address medical issues (pain, discomfort)
• Ascertain the patient's wishes and the level of urgency

Indications to Restrain/Sedate

• Prevent harm to patient/other patients/caregiver/staff
• Prevent serious damage to the environment
• Assist in assessment and management of patient
• Never use restraints for convenience

Pharmacological management

Benzodiazepines (avoid in elderly)

• Diazepam 5-10mg PO/IV (max 30mg per event)
• Lorazepam 2mg (max 10mg in 24h)
• Midazolam 5-10mg IM (max 20mg per event)
  • Short-acting, rapid sedation (peak in 10mins, lasts up to 2h)

Antipsychotics

• Olanzapine 5-10mg oral (max 30mg per event)
• Quetiapine 25-200mg PO
• Risperidone 0.25-2mg PO/SL
• Haloperidol 5-10mg IM (max 20mg per event)
  • Risk of dystonia
• Acute dystonia - Benztropine 2mg PO or IM or IV