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Management Of Violent Patient
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.