Violent Patients

CC Exequiel Dimaano May 22, 2012

Violence

physical force used so as to injure or damage others a behavior, not a psychiatric diagnosis

Causes of Violence:
Psychiatric Syndromes Drugs Seizure activity Organic Brain Syndromes Alcohol Medical Illness

Three Groups of Patients:

Those who become violent or threatening only after their presentation at the ER. Those who are brought to the ER already labeled as violent or threatening Those who present with violent ideation but are not an immediate threat tot the ER staff

Assessing and Predicting Violent Behavior:

Risk of Violence (+) violent ideation, wish, intent, pain, implementation of plan, wish for help Demographic indicators
Sex (male) Age (15-24) Socioeconomic status (low) Support System (few)

Assessing and Predicting Violent Behavior:

Risk of Violence Consider the patients history for:
Violence Nonviolent antisocial acts Impulsive behavior Consider overt stressor (marital conflict, real or symbolic loss)

Assessing and Predicting Violent Behavior:

Signs of Impending Violence: Recent acts of violence including property violence Verbal or physical threats Carrying weapons/objects that may be used as weapons Progressive motor agitation Alcohol/other substance intoxication Paranoid features in psychotic patient

Assessing and Predicting Violent Behavior:

Signs of Impending Violence: Command from violent auditory hallucinations Brain diseases Catatonic excitement Manic episodes Agitated depressive episodes Personality disorders (rage, poor impulse control)

Assessing and Predicting Violent Behavior:

Other Significant Markers Present MSE Tension/Agitation Poor Impulse Control Contradictory Judgment (+) Command hallucinations (+) Delusional thinking Physicians Feeling

Pointers in Handling Violent Patients

In defusing situation, it is best to be alone with the patient in a closed room Physical techniques to prevent attacks by unarmed patient- non-threatening protective posture Avoid crowding or sudden movements

Options in Talking with the Patient

Door Closed : Alone with Patient Door Open : Alone with Patient Aides outside the room : Alone with patient Aides inside the room Patient in restraints

Options in Talking with the Patient

Appear calm and in control. Speak in a non-provocative manner.

Preferably, both of you should be sitting; do not tower over the patient. Allow enough space between you.

Options in Talking with the Patient

Avoid direct eye contact Project passivity yet with a sense of control Listen when patient starts to talk Appear empathic and concerned.

If Patient is armed:
Do not appear frightened, play for time Initially, comply with patients demands Take special care to avoid upsetting the patient Do not attempt to reach for the weapon; rather, suggest that he place the weapon on a table or safe place

If Patient is armed:
If he complies, do not reach for the weapon, rather, continue talking with the patient If the patient conceals the weapon, make an excuse to leave the room; notify security right away. A warning system should be devised (panic button, messages).

In a Hostage Situation:
Most Dangerous Do exactly as the hostage-taker says Do not speak unless spoken to Avoid an open display of despair Remain observant Do not attempt to escape or overpower the patient unless during rescue attempts, expect a lot of noise and confusion, go down on the floor until the confusion is resolved.

Remember!
Most patients who are violent do so out of fear. In recognizing this fact, ER staff diminishes the danger of violence by acting to allay the patients fears.

Intervention:

Initial Intervention:
Verbal intervention Use of significant others Show of force

Other options
Restraints-use of force Seclusion Medications

Restraining Procedures:

Preferably 4-5 persons with one person per limb. Leather restraints are safest and surest type. No display of humiliation of the patient or threatening the patient. Physician should remain calm, professional and in control. Explain to the patient why he is to be restrained. You may give few and clear behavioral options without threatening the patient. Tell the patient that his behavior is out of control.

Restraining Procedures:
Staff personnel should be visible and reassuring patient who is being restrained. Reassurance helps alleviate patients fear of helplessness, impotence and loss of control. Patient should be restrained with legs spread-eagled, one arm to one side and one arm over the patients head.

Restraining Procedures:
Restraints should be placed so that IVF can be given if necessary The patients head is slightly raised to decrease the patients feeling of vulnerability and to reduce the possibility of aspiration The restraints should be checked periodically for safety and comfort

Restraining Procedures:
After the patient is in restraints, the physician begins treatment using verbal intervention Even when restrained, majority of patients still take antipsychotic medications

Restraining Procedures:
After the patient is under control, one restraint at a time should be removed at 5-minute intervals until the patient has only two restraints on. Both of the remaining restraints should be removed at the same time, because it is inadvisable to keep a patient in only one restraint. Always thoroughly document the reason for the restraints, the course of treatment, and the patient's response to treatment while in restraints

Remember!
Restraints and seclusion as a punitive response is contraindicated for pure staff comfort

Potential Problems with Restraints:

Circulatory Obstruction Aspiration

Contraindications for Restraints:

Medical problem Self-abuse types Over-dosages

Removal from Seclusion/Restraints:

Patient is under control No threat

Debriefing (tension release)

see patient within an hour telephone notification minimum of 2 visits/day, 12h apart order not valid >12h

Indications for Psychotropic Medications:

Violent, assaultive behavior

Massive anxiety or panic EPS - dystonia, akathisia (diphenhydramine) Laryngospasm- establish airway

Pharmacotherapy

Violent outburst haloperidol benzo, B-blockers, carbamazepine, lithium, Seizure disorder anticonvulsant therapy Recreational drugs benzo than haloperidol Allergic response to

Pharmacotherapy
Remember! Do not overmedicate. Interview during violent episode may provide a glimpse to the reason behind the violence.

Pharmacotherapy:
Rapid tranquilization: Haloperidol 5-10mg q30min until patient is calm Chlorpromazine 25mg IM Olanzapine - 10 mg powder for injection Risperidone - orally disintegrating tablets Anxiety: Lorazepam 2-4mg IV or IM prn BACK q30mins