Management of the Violent Patient in the Emergency Department Scot Hill, MD Department of Emergency Medicine Mount Sinai Hospital

Scot Hill, MD Violence and the Airway u E.P.s predictably encounter both u Final outcome of many pathologies u Failure to manage appropriately leads to injury and/ or death u The Defining Difference: Who is at risk?

Scot Hill, MD Treatment Modalities u Interview Techniques u Environmental Factors u Physical Restraints u Chemical Control

Scot Hill, MD 69 yo M, Brought by family after lighting a fire in bathroom. Patient has no complaints. Hx of Schizophrenia P=110, BP 150/90, RR 20, T 37.9 No distress, refusing to speak. Nonfocal exam. Case Presentation

Scot Hill, MD What is your assessment of violence potential, and Why? u Low, because he didn’t burn your bathroom u Moderate, because his vital signs are only moderately abnormal u High, because of the setting the question is being asked in u High, for these specific reasons:

Scot Hill, MD Definitions u Personality u Emotions u Agitation u Psychosis u Violence

Scot Hill, MD What actions are reasonable at this point? u A: One to one observation u B: Undress and fully examine the patient u C: Offer the patient medication u D: Round up sufficient personnel to restrain the patient u E: Stall until you can sign out to your partner before taking any definitive action u F: Medically clear him, transfer to Psych.

Scot Hill, MD Environmental Factors u Privacy vs. Isolation u Available Assistance u Weapons Detection u Seclusion if Available u Ninja Implements

Scot Hill, MD Interview Considerations u Calm and Direct u Empathic u Assurance of priorities u Verbalize limits/expectations u Consistency among staff

Scot Hill, MD Interview Techniques u Eye Contact u Personal Space u Door Position u Body Language –Angle of confrontation –Hand and arm position

Scot Hill, MD What medication would you choose? u A: Valium 5 mg PO u B: Haloperidol 10 mg IM u C: Haloperidol 5 mg and Lorazepam 2 mg IM u D: Droperidol 2.5 mg IM u E: Respiridol u F: Medazolam 2 mg IV

Scot Hill, MD Chemical Control u Rapid Tranquilization –Safety –Titratability u Haloperidol u Haloperidol and Benzodiazapine u Droperidol

Scot Hill, MD Haloperidol u Buteryphenone antipsychotic u mg. IM, PO, IV u onset 20 minutes u t1/2 of 19 hours u Side Effects

Scot Hill, MD Side Effects u Dystonic Reaction u Akathesia u Neuroleptic Malignant Syndrome u Cardiovascular Effects u Seizure Threshold

Scot Hill, MD Benzodiazapines u Lorazepam, vs others u Less predictable effect –Paradoxical disinhibition –Dose requirements u Less titratability u Less Antipsychotic effect u Greater risk of cardiorespiratory depression

Scot Hill, MD Droperidol u Buteryphenone antipsychotic u mg IM or IV u Onset minutes u t 1/2 2-4 hours u Side effects

Scot Hill, MD He is still uncooperative. At what point do you decide to physically restrain this patient ? u A: Before he does any damage u B: After a psychiatrist has evaluated him and determined a lack of capacity u C: After he does some damage u D: When danger becomes imminent

Scot Hill, MD Physical Restraints u For Imminent Threat of Harm u Preparations –Overwhelming Show of Force –Beware the Ninja –Initiate only When Prepared –Preparation / De-escalation

Scot Hill, MD Physical Restraint u Once Initiated, Swift and Definitive u Suspend Negotiations u Team Leader u Secure Large Joints u Constant Reassurance

Scot Hill, MD What do you do if he tries to leave before you have sufficient personnel ? u A: Physically block him u B: Have the nurse physically block him u C: Offer him money to stay u D: Notify local constabulary

Scot Hill, MD Monitoring u Documentation –Neurovascular –Cardiovascular –Airway u Consideration of removal u Transfer Considerations

Scot Hill, MD Summary u Multifactorial approach u Teamwork u Early intervention u Life saving when necessary