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  1. THE VIOLENT PATIENT ÜlkümenRodoplu,MD

  2. Overview • Violence in the Emergency Department • Recognition of potential for violence • Causes of violence in the emergency room • Violence Management • Physical methods • Protocols & Procedures

  3. Psychiatricemergency • Disturbance in behavior, feelingorthinking • If not attendedto, can result in harmtothepatientorsomeone else. • Duetoexternalorinternalstressoverwhelmingtheperson’sabilitytocope.

  4. Prevalence – Emergency Department • ED often first point of entry • Atmosphere of the ED is oftenone of confusionandrapidplace. • Intoxication, concealed weapons and stress potentially all present at the same time

  5. Why ? • Staff in the ED receive the most amount of verbal and physical abuse out of any other department. • Nature of the work implies exposure to violence. • Methods of violence management are vital

  6. Violence and the Airway • E.P.s predictably encounter both • Final outcome of many pathologies • Failure to manage appropriately leads to injury and/ or death

  7. Recognition of Violence • Aggression • towards an individual • toward creating fear • Stress behaviours in individuals include • use of profanity and verbal outbursts • pacing or frequent alteration of body position or posture • indicate increasing agitation

  8. Causes of Violence • Not always gang related; and not all gang members are violent in certain situations (i.e. child birth) • Understand root of behaviour • psychiatric • drug induced (either intoxication or withdrawal) • child, elder or spousal abuse • frustration due to long waits, unrealistic expectation

  9. Causes of Violence • Overcrowding • Creates volatile situations • Increased waiting times • Neglect of patients who require urgent attention • Proximity of rival groups • gangs • intoxicated driver in close proximity to victims

  10. Incidence • USA • 127 EmergencyDepartment… Result: • Oneverbalthreatdaily (n=41, %32) • Oneweaponthreatdaily(n=23,%18) Lavoie FW, Carter GL, Danzl DF, et al.Emergencydepartmentviolence in United Statesteachinghospitals. AnnEmergMed 1988;17(11):1227-33.

  11. Incidence 5 yearfollowup: • 72 (%57) hospital had theirstaffthretenedwithgun (once). • 55 (%43) hospital had theiremergencystaffthreatenededphysically (once). • 102 (%80) hospital had injury. • 9 (%7) hospital had death. Lavoie FW, Carter GL, Danzl DF, et al.Emergencydepartmentviolence in United Statesteachinghospitals. AnnEmergMed 1988;17(11):1227-33.

  12. Incidence - 2003, StateHospital in Hong Kong - 3 Months 25 caseswith 26 violentpatient … - %64 verbalviolence - None had gun CH Chung. Emergencydepartmentviolence: a localscene. Hong Kong Journal of EmergencyMedicine. Volume 10 Number 1, January 2003

  13. Incidence Reasonsforviolence: • Longwaiting time (%36) • Mentaldisorder(%28) • Dissatisfactionforthecaregiven (%20) • %69 male, 21-50 years of age.. CH Chung. Emergencydepartmentviolence: a localscene. Hong Kong Journal of EmergencyMedicine. Volume 10 Number 1, January 2003

  14. Pathophysiology • Increasedincidence of violenceexists in XYY men. • Increasedtestosterone in manandpremenstrualsyndrome in womenproposed as causes of violentbehavior. • Lowlevels of CSF 5-HIAA found in somewhocommitviolentcrimes • Violentcriminalsdecreasedviolencewithadministration of 2-5-hydroxytryptophan, seratoninprecursor.

  15. Organicreasons • No history of physiatricdisorder • Suddenonsetagitation • Violence → ??? Age 40 ↑

  16. Organicreasons • Intoxication • Hypoglisemia/ Hypoxia • Infection(septisemia, menengitidis) • Organ failure (liver, kidney) • Heatstroke

  17. OrganicReasons • OrganicBrainSyndrome (seizure, trauma, tumor) • Delirium • Trauma • AIDS • Electrolyteabnormality

  18. Pshyciatricdisorders • Schizophrenia • Paranoidideation • Catatonicexcitement • Mania • Bipolaraffectivedisorder

  19. PersonalityDisorders • Borderline • Antisocial • Delusionaldepression • Posttraumaticstressdisorder.

  20. Treatment Modalities • Interview Techniques • Environmental Factors • Physical Restraints • Chemical Control

  21. Case Presentation • 69 yo M, Brought by family after lighting a fire in bathroom.Patient has no complaints.Hx of SchizophreniaP=110, BP 150/90, RR 20, T 37.9No distress, refusing to speak.

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

  23. Interview Considerations • Calm and Direct • Empathic • Assurance of priorities • Verbalize limits/expectations • Consistency among staff

  24. Interview Techniques • Eye Contact • Personal Space • Door Position • Body Language • Angle of confrontation • Hand and arm position

  25. Management throughPhysical Methods • Access control • Minimised unguarded entrances; lock extraneous entrances / exits at night • Secure sensitive areas with access control • Hand-held metal detectors used by security • Enforce visible identification of all staff • Plexiglass between waiting room & ED dept • Block unauthorised vehicle access to the emergency department • Visible security inside & outside

  26. Management throughPhysical Methods • Rankins and Hendey suggest that removing weapons did not decrease number of assaults • Training of ED staff to handle violent situations remains crucial

  27. Management throughProtocol & Procedure • Develop a safety plan with hospital security • Rehearse response mechanisms • Code word called out when violence erupts • Close contact with law enforcement during high-volume or disaster management scenarios • Debrief after major incidents to refine procedures • Access patient history either by records, friends or family to gain proper perspective on a patient • Undress patients to reveal concealed weapons and disarm if necessary

  28. Management throughProtocol & Procedure • Security should recognise an escalating situation • Either between parties or individual misconduct • Separate rival gang members or victim-perpetrator groups • Do not show condescension towards gang members. Cultural differences and language barriers may already cause tension • Immediately use chemical and/or physical restraints with sufficient personnel

  29. Chemical Control • Rapid Tranquilization • Safety • Titratability • Haloperidol • Benzodiazapine • Droperidol

  30. Haloperidol • Buteryphenone antipsychotic • 5- 10 mg. IM, PO, IV • onset 20 minutes • t1/2 of 19 hours • Side Effects

  31. Side Effects • Dystonic Reaction • Akathesia • Neuroleptic Malignant Syndrome • Cardiovascular Effects • Seizure Threshold

  32. Benzodiazapines • Lorazepam • Less predictable effect • Paradoxical disinhibition • Dose requirements • Less titratability • Less Antipsychotic effect • Greater risk of cardiorespiratory depression

  33. Droperidol • Buteryphenone antipsychotic • 2.5- 5 mg IM or IV • Onset minutes • t 1/2 2-4 hours • Side effects

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

  35. Physical Restraints • For Imminent Threat of Harm • Preparations • Overwhelming Show of Force • Initiate only When Prepared • Preparation

  36. Physical Restraint • Once Initiated, Swift and Definitive • Suspend Negotiations • Team Leader • Secure Large Joints • Constant Reassurance

  37. What do you do if he tries to leave before you have sufficient personnel? • A: Physically block him • B: Have the nurse physically block him • C: Offer him money to stay • D: Notify local constabulary

  38. Monitoring • Documentation • Neurovascular • Cardiovascular • Airway • Consideration of removal • Transfer Considerations

  39. Summary • Multifactorial approach • Teamwork • Early intervention • Life saving when necessary