1. Management of The
Violent Patient
Dr. Varalee Aphinives
Bhumibol Adulyadej Hospital

2. Is violence a problem in the ED?
 Yes
 Acts of violence resulting in death have
occurred in 7% of major teaching
hospitals.

3. The patient become violent in
the first place
 Acute intoxication  Acute withdrawal
 Metabolic disorder  Trauma
 Infectious disease  Environmental injury
 Cardiovascular  Psychiatric
disorder disorders
 Intracranial disorder  Hypoxia

4. What can be done preempt a
violent episode?
 1. Be aware of early sighs of impending violent
behavior, such as agitation, abusive language,
and challenges to authority.
 2.Completely undress major trauma victims as
soon as possible, removing any weapons on
their persons.
 3.Do not leave any instruments that can be
used as weapons near a potentially violent
patient

5. What is the initial approach a physician can
take to control an agitated or violent patient?
 First approach to any agitated patient should be verbal
descalation.
 The physician should remind the patient is in a safe environment.
 Improving the patient’s comfort.
 Stationing security officers may dissuade further inappropriate
behavior.
 Most important, care providers must check their own emotion.
 Yelling back or exchanging threats with the patient only further
escalates the situation

6. What if doesn’t work?
 Multiple different restraint techniques
-Two-point restraint
-Four-point restraint
Precaution: Physical restraints often may
increase patients’ agitation
 Chemical restraint
-depends on what is cuasing the agitation.
 Sometime both are neccessary

7. Chemical restraint
 Two class of drugs
 1.Butyrophenones such as halaperidol
and droperidol
 2.Benzodiazepine such as larazepam and
diazepam

8. Butyrophenones
 Haloperidol 5-10 mg iv (about two dose)
 don’t give three dose( avoid toxicity)
 Switch to benzodiazepine
 Side effect is extrapyramidal or other
dystonic reaction.hypotension is rare.
 Prophylaxis with diphenhydramine or
benztropine mesylate (Cogentin) for 2 to 3
days after.

9. Benzodiazepine
 Sympathomimetic-induced(e.g.,amphetamine,
PCP, and cocaine)
 Preferred suppectd anticholinergic toxicity
because they reduce CNS production of
catecholamines
 Initial dose :Diazepam 5 to 10 mg iv and
repeated dosed of 2 to 10 mg every 20 to 30
minutes as need

10. Do I have any alternatives to
restraining a patient?
 Ideally, an ED should have isolation room
which agitated patients can be placed
 This room should be monitored
easily(e.g.,through windows or video camera)
 Emptied of any objects that can be used as
weapons.

11. What can hospital do to
decrease the risk of violence?
 1.All unnecessary doors should be locked and access into the
hospital limited to a few patrolled entrances.
 2.Metal detectors should be used to screen patients and visitors
for weapons.
 3.Continuous-surveillance, closed-circuit television monitors help
to ensure safety in the parking areas and the immediate grounds
of the hospital.
 4.Multiple methods of sommoning police or security must be
available to the ED without having to go through the hospital
operator.
 5.Responding police or security officers should be trained and
equipped appropriately.
 6.Clear documentation in the medical record.
 7.A comprehensive program patterned after the critical incident
stress debriefing model provide immediate and long-term
psychological support.

12. Reference
Emergency Medicine Secrets third edition
Vincent j.Markovchick,MD,
Facep Peter T. Pons,MD, Facep