violent patient in emergency department
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a topic discussion on pathogenesis, evaluation & management of an agitated patient in emergency department
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violent patient in emergency department
- 1. The Violent Patient in Emergency Department Dr Subhankar Paul
- 2. “Violence is referred to as our nation’s shameful epidemic” -Rosen
- 3. INTRODUCTION • Workplace violence at educational institutions and government facilities captures the headlines, • physicians and nurses are victims of nonfatal violent crime more than any other profession • ED personnel are victims as well as witnesses of violence in the ED • Violent events and confrontations have consequences for both the patient and staff members
- 4. Factors for ED Violence • unlimited & unrestricted access to patient care areas, • family and friends of critically ill patients • substance abusers, • prolonged waiting times, • staff shortages, • overcrowding, • patient financial problems, • high expectations of the patients. • 24 ×7 operation : night-time violence • Poor Communication-skill & Counselling
- 6. Problems Organic Diseases Drugs Psychiatric Hypoxia CNS infection Seizure CVA Trauma Neoplasm Electrolyte abnormality Delirium Dementia Hypo/hyperthermia Vitamin deficiency Endocrine disorder •Alcohol (intoxication and withdrawal) •Sedative-hypnotics (intoxication or withdrawal) •Amphetamine/Cocaine •LSD •Anticholinergics •Aromatic hydrocarbons (e.g., glue, paint, •Steroids •Schizophrenia •Paranoid ideation •Catatonic excitement •Mania •Personality disorders(Borderline/ Antisocial) •Delusional Depression •PTSD •Decompensating OCD •Homosexual panic
- 7. • The American Psychiatric Association recommends that the presence of any one of the following in a violent patient should prompt a search for an organic etiology: 1. a patient >40 years of age with no previous psychiatric history; 2. disorientation, lethargy, or stupor; 3. abnormal vital signs; 4. visual hallucinations.
- 8. Investigations • Pulse oxymetry • URGENT CBG • ECGs • Chest Xray • blood Biochemistries, • toxicology screening, • CT head scans • lumbar puncture
- 10. Vital Signs and Toxic Syndromes TOXIN P BP RR T PUPIL SKIN Sympathomimetic : COCAINE ↑ ↑ ↑ ↑ ↑ Wet Anticholinergic : DIPHENHYDRAMINE ↑ ↑/↓ ↑/ ↓ ↑ ↑ DRY Cholinergic: OP ↑/↓ ↑/↓ ---- ---- ↓ Wet Opiates : MORPHINE ↓ ↓ ↓ ↓ ↓ ---- Sedatives : LORAZEPAM ↓ ↓ ↓ ↓ ↑/↓ ---- Withdrawal (ethanol, sedative-hypnotics) ↑ ↑ ↑ ↑ ↑ Wet
- 11. Pick it Up Early
- 12. Warning signs of impending violence • Angry facial expressions, gestures, and posture • Restlessness, overt irritation, discontentment, pacing about,over-arousal (dilated pupils, tachycardia, increased respiratory rate). • Prolonged eye contact. • Loud speech and changes in tone of voice. • Verbally threatening and/or reporting feelings of anger/violence. • Repeating behaviour, which has previously preceded violent episodes. • Blocking escape routes
- 13. Phases of Violent Behavior • In general physically violent behavior does not occur suddenly • preceded by a series of escalating behaviors • The stages of behavior are not clearly bounded and may overlap / already passed through • At each stage, the appropriate response of the professional involved should match the behavior being demonstrated
- 14. Phase 1: Anxiety Phase 2: Defensive behavior Phase 3: Physical aggression
- 15. Anxious Behavior Behavioral clues Appropriate Response NON-DIRECTED ENERGY EXPENDITURE LISTEN & REASSURE • Pacing /hand-wringing • body tensing, • Facial tension, • fidgety behavior, • Asking repetitive questions • speaking in a loud voice •exhibiting pressured speech Listen, address concerns,show empathy Avoid confrontation Stay Calm, Answer Directly, clear and honest answer offer support Avoid a judgmental attitude
- 16. Defensive Behavior • Behavioral clues Appropriate Response •Volatile,irrational and may be unrelated Limit Setting , to prevent total loss of control by the patient • Verbal abuse, •profanity, •complaints unrelated to C/C •Power struggle, limit testing, •chanting, staring /darting eyes, mumbling, pacing,flushed face, clenching hands, •repeated approach to staffs Reasonable limit setting, Explaning consequences firm in tone and action but professional and calm enforce limits
- 17. Physical Aggression • Behavioral clues Appropriate Response •completely lost control over emotions and behaviors Seclusion Physical restraint chemical restraint • Physically violent acts : a danger to property, staff, other patients, visitors, and themselves For the interest of patient care and safety for others, not as punishment, and enables the staff to provide necessary care for a violent patient
- 18. Seclusion
- 19. Seclusion • better alternative to physical restraint • medically safer. • seclusion must be undertaken with great care, as even empty rooms with observation windows can be fertile grounds for self-harm in the agitated patient. • may also have negative effects on psychiatrically ill or other vulnerable patients • Only 25% of ED directors report using seclusion measures for acutely agitated patients
- 21. Physical Restraint • Only licensed independent practitioners can order restraints • written or computerized order must include the type of restraint, reason for restraint, time limit of the order. • If a licensed independent practitioner is not, trained caregivers may institute the restraint, but a licensed independent practitioner must perform a face-to-face evaluation within 1 hour of restraint.
- 22. Physical Restraint …. Cont.. • Ensure all appropriate personnel and equipment assembled. • Soft restraints are not acceptable for use in the violent patient. • A trained security person or hospital staff should act as the team leader. • can be dangerous and may result in traumatic injury to the patient and/or provider. • In general, patients arriving in handcuffs should remain in handcuffs until the threat of violence and medical condition is assessed
- 26. Medication/Chemical Restraint • Pharmacological restraint using sedative drugs • last resort, • should only be given on the advice of senior and experienced staff. • staff need to be aware of medicolegal implications of carrying out any restraint • Little data exist regarding the use of chemical restraints when physical restraint has failed
- 27. Dangers of Emergency sedation 1. Sedative drugs may mask important signs of underlying illness, eg an intracranial haematoma requiring urgent treatment. 2. The normal protective reflexes (including airway refl exes, such as gag and cough response) will be suppressed. 3. Respiratory depression and the need for tracheal intubation and IPPV may develop. 4. Adverse cardiovascular events (eg hypotension and arrhythmias) may be provoked, particularly in a struggling, hypoxic individual. 5. Individual side effects of the drugs
- 28. Drugs Adult Dosage Route Adverse Effects Benzodiazepines Lorazepam 2–4 mg IV, IM, PO C/I in alcohol intoxication, respiratory and neurologic depression, coma Midazolam 0.5–5 mg IV, IM Respiratory and neurologic depression, amnesia, hypotension Typical antipsychotics Haloperidol 2–10 mg IV, IM EPS, QT-interval prolongation, NMS, tardive dyskinesia with long-term use Atypical antipsychotics Quetiapine 25–50mg PO Orthostasis, QT-interval, NMS, weight gain (chronic use) Olanzapine 5–10 mg IM, PO Drowsiness, agitation, dizziness, akathisia Risperidone 0.5–2mg PO Anaphylactoid reactions,hypotension, NMS
- 29. After the violent episode • ensure that the staff involved record full detailed notes and standard local incident forms are completed. • Report the episode to the senior member of staff and to the police (as appropriate), if they are not already involved. • Subsequently, when dealing with the violent patient, do not purposely avoid the patient or treat him obviously differently, since this will merely emphasize concepts of his own unacceptability and may lead to further aggression.
- 31. Tension Reduction regain a personal sense of control emotionally and physically drained Rebuild Therapeutic Rapport and Communication & professional relationship fear, confusion, and remorse withdrawn or embarrassed. . Let the patient know that he or she is safe and that ongoing care will be provided for the medical complain sometimes helpful to ask the patient to take a few deep breaths The plan for the examination and treatment should be explained to the patient
- 33. Violence Prevention • The single best way to handle a violent patient or curtail the potential for violence in the ED is by prevention and refusal to tolerate even the smallest display of violence potential • Preventative actions careful planning, cooperation with hospital security personnel, Improvement of overall security system
- 34. • training of all ED personnel regarding predictors and theories of violence, recognition of the early stages of violence, response and diffusion of verbally and physically violent situations, review of hospital policy and safety plans, follow-up after a violent event
- 36. REFERENCE • Tintinalli's Emergency Medicine 7th edition • Oxford Handbook of Emergency Medicine 4th edition • ROSEN’S EMERGENCY MEDICINE Concepts and Clinical Practice , 8th edition
Editor's Notes
- Multiple factors contribute to verbal and physical assaults on ED staff members: unlimited and unrestricted access to patient care areas, family and friends of critically ill patients who have heightened levels of frustration and anxiety, patients who are substance abusers, prolonged waiting times, staff shortages, overcrowding, patient financial problems, and high expectations of the patients.
- Hiararchy of analysis …………… underlying medical condition > drus/intoxications > psychiatric problems
- Violent episodes can frequently be predicted and often prevented. The experienced practitioner may be able to spot the signs of approaching trouble at an earlier stage. Warning signs include the following: • Angry facial expressions, gestures, and posture (aggressive body language). • Restlessness, overt irritation, discontentment, pacing about, over-arousal (dilated pupils, tachycardia, increased respiratory rate). • Prolonged eye contact. • Loud speech and changes in tone of voice. • Verbally threatening and/or reporting feelings of anger/violence. • Repeating behaviour, which has previously preceded violent episodes. • Blocking escape routes
- The first stage of behavior in a potentially violent patient is anxiety. The behaviors exhibited during this stage represent a noticeable change from the person's baseline andinclude nondirected energy expenditures
- seclusion must be undertaken with great care, as even empty rooms with observation windows can be fertile grounds for self-harm in the agitated patient. Seclusion may also have negative effects on psychiatrically ill or other vulnerable patients, as they may feel punished and become distrusting of staff when isolated. Only 25% of ED directors report using seclusion measures for acutely agitated patients
- If a licensed independent practitioner is not present when the need for restraint is determined, trained caregivers may institute the restraint, but a licensed independent practitioner must perform a face-to-face evaluation within 1 hour of restraint.
- In the tension reduction stage, the patient is beginning to regain a personal sense of control and will be emotionally and physically drained.18 The patient is vulnerable at this point and may be experiencing a range of emotions, such as fear, confusion, and remorse.18 The patient may also be withdrawn or embarrassed . Let the patient know that he or she is safe and that ongoing care will be provided for the medical complain