Author:

Katharine Y.Joo

Signs and Symptoms

• General risk factors for violence:
  • Prior history of violence OR being a victim of violence/abuse
  • Substance abuse history/intoxication
  • Poor impulse control
  • Low educational attainment
  • Unemployment
  • Limited social support
  • Male gender
  • Age <35 yr old
  • Gang involvement
  • Antisocial personality disorder or psychopathy
  • Active, untreated mania/psychosis + anger
• Warning signs of imminent violence risk:
  • Staring, aggressive eye contact OR avoidance of eye contact
  • Physical agitation or tension (pacing, clenching fists, darting eyes)
  • Abusive or provocative language OR refusal to talk
  • Making unreasonable demand s and unable to respond to limit setting
  • Ignoring physical environmental or personal boundaries

Essential Workup

• Identify early warning signs and risk factors
• Pay careful attention to findings during neurologic and mental status exams and note vital signs
• If required for safety, workup may be performed with the patient in restraints

Diagnostic Tests & Interpretation

• Follow clinical indicators for further testing, but if planning a psychiatric admission, labs, and /or imaging may be helpful
• Basic labs and ECG may be useful in assessing and monitoring risks associated with chemical restraint use

Prehospital

• Physically restrain violent patients and seek police assistance if necessary
• Notify receiving hospital if transporting a violent patient
• Keep weapons and dangerous items (sharp objects, medications, cords, etc.) out of the patient's reach

Initial Stabilization/Therapy

• Environmental modifications:
  • Continue to keep dangerous items out of the patient's reach; consider breakaway ID cords
  • Control access to ED: Secured doors, limited, and monitored entrances (e.g., CCTV)
  • Consider use of metal detectors, automatic lockdown systems, glass partitions around central staff areas
  • Visible security staff
  • Visibly posted signs stating weapons are not allowed and a no tolerance policy for violent behavior
  • Exam room exits clear of obstruction
• Procedural modifications:
  • Online alerts for patients with past history of violence in ED
  • Identify and flag high-risk patients at triage
  • Search/disrobe patients after triage; if imminent risk and involuntary, ensure careful documentation of reasons in terms of risk to patient and providers
  • Train all clinical staff to recognize and manage potentially violent situations
  • Clear ED protocols for managing violence and documenting interventions
  • Consider utilizing designated crisis management team
  • Installed panic buttons or code phrase to instruct others to call for security
  • Direct telephone line to police or security
  • Reduce ED wait times
  • Address comfort and pain needs expeditiously
• Approaching the potentially violent patient:
  • Ensure that you are within sight of other staff/security
  • Maintain open exit for both patient and staff
  • Remove your own personal articles that could be used as weapons (neckties, jewelry, trauma shears, etc.)
  • Keep 2 arms' lengths between you and patient; maintain an open stance
  • Introduce yourself and address the patient's concerns as soon as possible
  • Leave immediately and initiate seclusion or restraint if there is an open threat of violence or imminent violence seems likely

ED Treatment/Procedures

• Follow trauma-informed care principles as feasible
• Environmental modification:
  • Move patient to a calm, quiet, but nonisolated setting
  • If possible, room should not contain items easily thrown or used as weapons (e.g., chair, IV pole)
• Verbal de-escalation:
  • Best to use one point person with the best rapport to communicate with patient
  • If unable to maintain calm demeanor with patient, defer to another team member
  • Attempt to clarify and validate patient's immediate concerns
  • Address violent behavior or escalation in a direct but nonconfrontational manner
  • Always take patient threats seriously
  • Avoid lying (even to placate), interrupting, or criticizing the patient
  • Calmly explain potential need for a restraint if de-escalation is not successful
  • Offer patient choice of possible interventions (e.g., PO vs. IM medication, type of antipsychotic) but only after the patient has had opportunity to express their needs
  • If patient is cognitively impaired, delirious, or psychotic, verbal de-escalation may be less successful
• Seclusion:
  • If an appropriate room is available, this may obviate the need for restraint
• Physical restraint:
  • Follow your institutional protocol; document appropriate reason for restraint, attempts to verbally de-escalate, and plans for appropriate monitoring and reassessments
  • Note that coercive interventions in some instances may escalate violent behavior
  • Whenever possible, treating physician should not be part of restraint team
  • Supine position if patient needs to be examined; side position if aspiration risk is significant
  • If restraint in prone position is needed, ensure adequate airway is maintained
  • In rare cases when violent patient is pregnant and requires physical restraint, use left lateral position
• Chemical restraint:
  • Offer voluntary PO/IM sedative medication prior to initiating involuntary restraint
  • Avoid PO medications for involuntary restraint due to bite risk
  • Choice of medication should depend on underlying cause; either a benzodiazepine or a neuroleptic or both may be appropriate:
    • If agitation results from delirium or other medical condition, first attempt to treat the underlying cause
    • Consider benzodiazepines for hyperadrenergic state (e.g., cocaine intoxication) or if there is a contraindication to neuroleptics
    • Consider neuroleptics for most primary medical or psychiatric causes, sedative intoxication, or primary behavioral cause
    • Often used in combination
  • Contraindications/relative contraindications to neuroleptics:
    • Parkinson disease, dementia with Lewy bodies, or frontotemporal dementia
    • Neuroleptic malignant syndrome, dystonic reaction, or catatonia
    • Prolonged QTc
    • Anticholinergic overdose
  • Potential adverse effects:
    • Dystonia: Treat with IM benztropine 1 mg or IM diphenhydramine 50 mg
    • QTc prolongation and /or torsades de pointes (rare)
    • Neuroleptic malignant syndrome (rare): Stop all antipsychotics; begin intensive monitoring and supportive care

Medication

• First line:
  • Haloperidol: 5-10 mg IV/IM/PO
    • If first dose of IM haloperidol is ineffective, may be repeated after 30-60 min
  • Lorazepam: 1-2 mg IV/IM/PO
• Second line:
  • Droperidol: 2.5-5 mg IV/IM; watch QTc
  • Olanzapine: 5-10 mg IM/PO, not to exceed 30 mg IM per day; if IM, do not give with IM/IV benzodiazepines due to risk of respiratory depression
  • Risperidone: 1-2.5 mg PO
  • Ziprasidone: 10 mg IM, not to exceed 40 mg IM per day

Disposition

Additional Therapies

Follow-up Recommendations

• Patients with psychiatric illness should follow-up with community mental health provider
• Patients who are using substances should be offered counseling and /or detox

• ClaudiusIA, DesaiS, DavisE, et al. Case-controlled analysis of patient-based risk factors for assault in the healthcare workplace . West J Emerg Med. 2017;18:1153-1158.
• GillespieGL, PekarB, ByczkowskiTL, et al. Worker, workplace, and community/environmental risk factors for workplace violence in emergency departments . Arch Environ Occup Health. 2017;72:79-86.
• KowalenkoT, CunninghamR, SachsCJ, et al. Workplace violence in emergency medicine: Current knowledge and future directions . J Emerg Med. 2012;43:523-531.
• RichmondJS, BerlinJS, FishkindAB, et al. Verbal de-escalation of the agitated patient: Consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup . West J Emerg Med. 2012;13:17-25.
• TishlerCL, ReissNS, DundasJ. The assessment and management of the violent patient in critical hospital settings . Gen Hosp Psychiatry. 2013;35:181-185.
• UllrichS, KeersR, CoidJW. Delusions, anger, and serious violence: New findings from the MacArthur Violence Risk Assessment Study . Schizophr Bull. 2014;40:1174-1181.

See Also (Topic, Algorithm, Electronic Media Element)

• Psychosis, Acute
• Delirium
• Agitation

ICD9

• 292.89 Other specified drug-induced mental disorders

• 312.9 Unspecified disturbance of conduct

• 312.30 Impulse control disorder, unspecified

• 298.9 Unspecified psychosis

ICD10

• F19.929 Oth psychoactive substance use, unsp with intoxication, unsp

• F63.9 Impulse disorder, unspecified

• R45.6 Violent behavior

• F29 Unsp psychosis not due to a substance or known physiol cond

SNOMED

• 410237006 Violence control management (procedure)

• 66347000 Impulse control disorder (disorder)

• 191483003 Drug-induced psychosis (disorder)

• 65108000 At risk for violence (finding)

• 285263006 Thoughts of violence (finding)

• 69322001 Psychotic disorder (disorder)