Management of the aggressive patient

1. The aggressive patient in
the Emergency Department
Dr Ioana Vlad
Emergency Department Consultant

2. Objectives
 Why are patients aggressive
 Recognize the aggressive patient
 Management of the aggressive patient
 When
 How
 Behaviour + cause

3. Psychiatric emergency
• Disturbance in behaviour, feeling or thinking
• Final outcome of many pathologies or
external stress overwhelming the person’s
ability to cope
• If not attended to, can result in harm to the
patient or someone else

4. Why?
 ED is the place where acutely unwell patients
are brought from the community
- intoxicated or withdrawing
- psychiatric illnesses
- organic illnesses
 atmosphere of the ED is often one of confusion, injuries,
bad news, crowding
- proximity of rival groups
o gangs
o intoxicated driver and family of victim

5. Recognize
 Stress behaviours indicating
increasing agitation
 use of profanity and
verbal outbursts
 pacing or frequent
alteration of body
position or posture

6. Recognize
 Aggression
 towards an individual
 aiming to create fear
• Eye contact – direct / non-hostile
• Personal space
• Door position
• Body language
• Move chairs, hide scissors, remove lanyards etc.

7. Prevent
 Patient history – alerts / medical or psychiatric records
 Compulsory search / change into hospital gowns
 Hospital protocol / “code blacks”
 Separate rival gang members or victim-perpetrator
groups
 Use chemical and / or physical restraints early

8. When is chemical restraint
NOT appropriate?
- aggressive behaviour (verbal or physical) and no evidence of
an acute medical or psychiatric illness that is impairing their
cognition
- should be escorted out by security rather than be restrained
- police assistance can be sought

9. Chemical restraint
• Rapid tranquilization
– Safe
– Titratable
• Benzodiazepines
• Neuroleptics
• (Ketamine)
• (Clonidine, dexmedetomidine)
• (Propofol)

10. Benzodiazepines
Midazolam
- IM or IV
- max effect 10 min, lasts 2 hrs
Diazepam
- PO or IV; erratic absorption IM
- painful when administered IV
- longer acting than midazolam
Lorazepam
- only available as PO
Complications
Oversedation
Hypotension
Airway or ventilatory
compromise
Paradoxical reactions
Delirium
Tolerance

11. Neuroleptics
Droperidol / (haloperidol)
- IM or IV
- 2.5 – 10 mg
Olanzapine
- IM or SL or PO
- max 30 mg / 24 hrs
Risperidone
- 0.25-2mg PO/SL
- works well in elderly
- orthostatic hypotension common
Complications
Oversedation
Hypotension
Acute dystonia
Anticholinergic delirium
(Seizures)
(QT prolongation)

12. Knott JC & al. Ann Emerg Med. 2006
• RCT iv midazolam or
droperidol
• Primary endpoint =
time to sedation (from
the initial dose until a
score of 2 or less
5 highly aroused and
violent
4 highly aroused
3 moderately aroused
2 mildly aroused and pacing
1 settled
0 asleep
Knott JC & al. Randomized Clinical Trial Comparing Intravenous Midazolam and Droperidol for Sedation of
the Acutely Agitated Patient in the Emergency Department. Ann Emerg Med. 2006;47:61-67

13. Knott JC & al. Ann Emerg Med. 2006
Knott JC & al. Randomized Clinical Trial Comparing Intravenous Midazolam and Droperidol for Sedation of
the Acutely Agitated Patient in the Emergency Department. Ann Emerg Med. 2006;47:61-67

14. DORM study (Isbister GK& al. Ann Emerg Med. 2010)
• RCT
• im droperidol 10 mg,
midazolam 10 mg, or
droperidol 5
mg/midazolam 5 mg
Isbister GK & al. Randomized Controlled Trial of Intramuscular Droperidol Versus Midazolam for Violence
and Acute Behavioral Disturbance: The DORM Study. Ann Emerg Med. 2010;56:392-401

15. DORM study (Isbister GK& al. Ann Emerg Med. 2010)
Isbister GK & al. Randomized Controlled Trial of Intramuscular Droperidol Versus Midazolam for Violence
and Acute Behavioral Disturbance: The DORM Study. Ann Emerg Med. 2010;56:392-401

16. When do you stop?

17. When do you stop?

18. RESPONSIVENESS SPEECH
SCORE
+3 Combative, violent, out of control Continual loud outbursts
+1 to +3 Agitation
+2 Very anxious and agitated Loud outbursts
+1 Anxious / restless Normal / Talkative
0 Awake / calm Speaks Normally
ZERO
-1 Asleep but rouses if name is called Slurring or slowing
-1 to -3 Sedation
-2 Responds to physical stimulation Few recognisable words
-3 No response to stimulation Nil
When do you stop?
SEDATION ASSESSMENT TOOL (S.A.T.)

19. Post sedation care
– Document
• Why?
• How?
• What next?
– One-to-one nurse special
– O2 applied via Hudson mask
– Continuous O2 sats monitoring and end-tidal CO2 monitoring
– Continuous cardiac monitoring

20. Post sedation care
– BP checked 5 minutely for 20 minutes post
each sedation dose, then half hourly
– Bladder care
• bladder scans every 3-4 hrs if they do not void OR postvoid
• IDC should be inserted when bladder volume is > 400 mls
– BSL checked 2 hourly if ≥ 4 mmol/L, or hourly if it is < 4
mmol/L (Rx if < 3.5 mmol/L)
– Pressure care – turn every 2 hours to prevent pressure areas
– Temperature control

21. When do you decide to
physically restrain a patient?
• risk of harm
• failed negotiations
• usually combined with chemical restrain
• secure large joints
• documentation
– regular review of need to continue restraints
– neurovascular obs

22. What do you do after physically
restraining a patient?
American Joint Commission on Accreditation
of Hospital Organizations
1. Protection and preservation of patient rights,
dignity, and well-being
1. Use based on patient’s assessed needs
2. Use of least restrictive method
3. Safe application and removal by competent staff
4. Monitoring and reassessment of the patient during use
5. Meeting of patient needs during use
6. Time limitation of orders that are provided by licensed practitioners
7. Documentation in the medical record

24. 4:30 pm Sunday afternoon
Code black R3
33 M transferred from Fresh start
clinic after having a naltrexone
implant 3 hours previously
He is extremely agitated, confused,
sweaty, pulling monitoring leads off.

26. 4:30 am
Code black at triage
43 M brought in by police after being
noticed to behave eratically in a
petrol station
Being held by 4 police officers; sweaty,
swearing…..

27. - Retrospective study
- 298 patients evaluated for psychiatric complaints in the ED
- 4% of patients had acute medical conditions
Tintinalli JE, Peacock FW, Wright MA. Emergency medical evaluation of psychiatric patients.
Ann Emerg Med 1994;23:859-862
Tintinalli JE & al. Ann Emerg Med 1994

31. 6:30 pm
Code black C23
56 M manic / on forms 1 & 3 awaiting
transfer to Graylands hospital
He needs to go at the casino to meet
his mates, so he’s out of here!

33. • Cycles of extreme mood swings and behaviours that
can result in loss of job, relationships
• Impulsiveness with little regard for personal safety or
consequences of actions - high risk for “accidentally” or
intentionally killing self
• Racing thoughts, tangential thinking make it difficult to follow
directions or complete tasks e.g. giving UA
• Confusion as to why others are concerned about them
The bipolar / manic

34. • Keep directions/statements short and simple (may have to
repeat them)
• Don’t argue with the patient
• Medicate early for agitation
• Assume patient will be unpredictable and plan for it
• New onset mania needs medical workup
The bipolar / manic

36. • Traumatic childhood abuse or neglect
• Rigid or fixed perception of the world
• Poor self-image, chaotic personal relationships,
“emotional dysregulation” with intense reactions to
situations, extreme fear of abandonment and ineffective
coping skills in crisis
• Often associated eating disorders, substance abuse
The borderline personality disordered

37. • Manipulative , passive-agressive communication
• Tend to want you to know what they want, without
telling you directly
• Unpredictable, provocative; high risk for self-harming behaviours
/ can be chronically suicidal with many “attempts”
• Anxiety around being poorly treated, ignored is common trigger
for acting out
The borderline personality disordered

38. • Avoid power struggles / give choices
• No punitive treatments, threats, ultimatums or
excessive restrictions - they will give the patient a reason to escalate
• Find out what they need and want; try to accommodate them if
you are able / explain why if you can’t
• Be aware of non-verbal communication
• Expedite process of evaluation
The borderline personality disordered

40. • Disorganised thinking, delusions/ hallucinations
• Drug induced or related to other disorders
• Typically don’t realize that their thinking is delusional or irrational /
may not understand what is happening to them
• Paranoid, hyper-vigilant; may extend their paranoia to include staff
/ believe that others are reading their thoughts, secretly plotting
against them
• Could be self-harming or suicidal, if having command hallucinations
The psychotic

41. • Can be very frightened, anxious
• Approach slowly, using non-threatening body language
• Don’t feed into delusions, but don’t directly contradict them either
e.g. “That sounds very frightening.”
• If the patient is there due to safety issues, ask what would be
helpful to them to feel safe in the ER
• Medicate early (neuroleptics)
• Consider organic cause if new symptoms
The psychotic

43. 1:30 am
Code black cubicle 15
89 F from nursing home
Triage: increasingly aggressive behaviour
Reason for code black: shouting, trying
to get out of bed and to kick nursing
staff who are trying to assess her

44. Dementia demographics
• 2011 estimated
– 298,000 Australians had dementia
• in 2007 projected number for 2011 was 222,000
– 163,849 permanent residents care facilities
• 85,159 (52%) had a diagnosis of dementia
Australian Institute of Health and Welfare 2012. Dementia in Australia. Cat. no. AGE 70. Canberra: AIHW

45. www.cihi.ca
Dementia demographics

46. Dementia demographics
www.cihi.ca

47. Behavioural problems in dementia
• Agitation and aggression
= inappropriate verbal or motor behaviour
- occurs in 60% of people who have dementia
- spectrum
- usual reasons: pain, physical illness, medications
(anticholinergics / hypnosedatives), disorientation,
separation from family or other unmet needs

48. Types of behavioural problems

49. Types of behavioural problems

50. Behavioural problems in dementia
• 25% of people with dementia will experience psychosis
– delusions tend to reflect underlying memory loss or
perceptual changes (people stealing money or
personal items, that their spouse or caregiver is an
imposter, or about infidelity in their spouse)

51. Behavioural problems in dementia
• Visual hallucinations
– may be very vivid in dementia with Lewy Bodies (DLB) –
eg seeing people in fancy dress having a party in the
room
• Auditory hallucinations
– uncommon in dementia
– may be observed with the person misinterpreting noises
and voices

52. Behavioural problems in dementia
• Misidentifications due to perceptual disturbances
– believing someone else is in the house
– perceiving familiar people as imposters
– thinking that events on television are happening to them
– being unable to recognise own reflection in the mirror

53. What makes a behaviour a problem?
• Dysfunction
• Aggression so severe that it puts their placement
in jeopardy by harming others or themselves
• Disruptive vocalizations so intense that their
safety is at risk from the aggressive peers
• Generalized restlessness so profound it leads to
falls / injuries

54. What makes a behaviour a problem?
• The context
– In a small nursing home a person who walks constantly
may be pacing whereas at a larger facility they are
“walking the halls”
– Frail resident means little threat of injury to others if
aggressive
– Non-compliance with multivitamin vs. insulin
– Continued soft spoken talking vs. yelling

55. – Antipsychotics / mood stabilizers / antidepressants in
dementia provide modest benefit (especially for
behavioural problems)
– Treating the cause and minimizing the environmental
change are essential
Frightened patients with no insight
into their situation are trying to
defend themselves.

56. Take home points
• Violence rarely erupts without
warning
• Not all patients need to be
sedated
• Personalized regimen
• Post-sedation care
• Not all violence is psych or
alcohol related
• Drunk people get hit by cars

57. “Anger is an emotion that makes your mouth work
faster than your brain”