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Violence, Management of, Emergency Medicine

Basics

Description

- EDs and waiting rooms are areas of high prevalence for violence - Higher risk associated with busier EDs - Patients with primary psychiatric complaints are likely to be boarding >24 hr and may not be receiving psychiatric care - Risk factors for violence in the ED: - Prior history of violence OR being a victim of violence - Patient arriving in police custody - Substance abuse history/intoxication - Poor impulse control - Male gender - Psychiatric illness (complex relationship to risk)

- No clear difference in risk associated with: - Ethnicity - Language - Education - Medical diagnosis

- Acute primary medical problem: - Infection - Metabolic: - Hypoglycemia - Hypoxia - Hypothermia or hyperthermia

- Toxicologic: - Alcohol intoxication or withdrawal - Illicit drug intoxication or withdrawal - Sedatives - Pain medications - Anticholinergics - Steroids

- Chronic primary medical problem: - Dementia - Intellectual disability - Traumatic brain injury

- Later signs of impending violence risk: - Abusive or provocative language - Behaving irrationally; unable to comply with reasonable limit setting - Invading personal space - Eliciting anger in staff

- Prior history: - Violent behavior - Self-injurious behavior - Medical and psychiatric histories - Substance use history - Legal or criminal history

- Current HPI: - Recent substance use - Potential head injury - Pain or discomfort from medical or psychiatric symptoms or environment - Plan or threat of violence

- Indicators of a higher likelihood of medical etiology: - Age >40 without a history of similar symptoms or behaviors - Concurrently emerging medical complaints - Comorbid medical conditions commonly associated with mental status changes: - Neurologic problems (including seizure disorders, CNS infections) - Chronic cognitive impairment - Vascular or cardiovascular disease - Diabetes mellitus - Chronic pain treated with opiates - Inflammatory disorders treated with steroids - Cancer - HIV/AIDS

- Exam signs suggesting a medical cause for the mental status change: - Abnormal vital signs - Focal neurologic findings - Seizure activity - Speech or gait deficits without evidence of alcohol or substance abuse

- Prevention: - Environmental: - Control access to ED: Secured doors, protected entrances, metal detectors, cameras - Visible security staff - Post visible rules stating clearly that weapons are not allowed - Exam room exits clear of obstruction

- Procedural: - Identify high-risk patients at triage - Shorter ED wait times are helpful - Search/derobe patients after triage; if involuntary, ensure careful documentation of reasons in terms of risk to patient and providers - See to patients ' comfort quickly - Alleviate pain - Online alerts for patients with past history of violence in ED - Clear ED protocols for managing violence and documenting interventions - Enlist family support when possible; if not, remove family to safe place - Train all clinical staff to recognize and manage potentially violent situations

- Approaching the potentially violent patient: - Do not go alone - Remove your own personal articles that could be used as weapons (neckties, jewelry, trauma shears, etc.) - Keep 2 arms lengths between you and patient; open stance - Introduce yourself and try to address the patient's concerns as soon as possible - Maintain open exit for patient and staff - Leave immediately and initiate seclusion or restraint if there is an open threat of violence or imminent violence seems likely

- Verbal de-escalation: - Attempt to clarify and validate patients immediate concerns - Calmly explain potential need for a restraint if de-escalation is not successful - Offer patient choices when possible

- Physical restraint: - Follow your institutional protocol - Must document appropriate reason for restraint, attempts to verbally de-escalate, and plans for appropriate monitoring and reassessments - Whenever possible, treating physician should not be part of restraint team - Use leather restraints for combative patients; soft restraints for patients who are unlikely to be combative or try to elope - 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

- Chemical restraint: - Offer voluntary PO or 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, 1st attempt to treat the underlying cause - Consider benzodiazepines for hyperadrenergic (including cocaine) state 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 to neuroleptics: - Knowledge of or suspicion for Parkinson disease, dementia with Lewy bodies or frontotemporal dementia - Neuroleptic malignant syndrome, dystonic reaction, or catatonia - Prolonged QT - Anticholinergic overdose

- Second line: - Droperidol: 2.5 " 5 mg IV or IM; watch QTc - Olanzapine: 5 " 10 mg IM or PO; if IM, do not give with IM/IV benzodiazepines due to risk of respiratory depression - Risperidone: 0.5 " 1 mg PO - Ziprasidone: 10 mg IM every 2 hr, not to exceed 40 mg IM per day

  • EDs and waiting rooms are areas of high prevalence for violence
  • Higher risk associated with busier EDs
  • Patients with primary psychiatric complaints are likely to be boarding >24 hr and may not be receiving psychiatric care
  • Risk factors for violence in the ED:Prior history of violence OR being a victim of violencePatient arriving in police custodySubstance abuse history/intoxicationPoor impulse controlMale genderPsychiatric illness (complex relationship to risk)
  • No clear difference in risk associated with:EthnicityLanguageEducationMedical diagnosis

Etiology

  • Primary psychiatric problem:Most commonly psychosis or mania, but associated with many different diagnoses
  • Acute primary medical problem:InfectionMetabolic:HypoglycemiaHypoxiaHypothermia or hyperthermiaToxicologic:Alcohol intoxication or withdrawalIllicit drug intoxication or withdrawalSedativesPain medicationsAnticholinergicsSteroidsNeurologic:SeizureStrokeHead injury or bleedBrain lesion or mass
  • Chronic primary medical problem:DementiaIntellectual disabilityTraumatic brain injury
  • Criminal behavior or psychopathy

Diagnosis

Signs and Symptoms

  • Early signs of impending violence risk (nonspecific):Loud speechPhysical agitation or tension (pacing, clenching fists, darting eyes)
  • Later signs of impending violence risk:Abusive or provocative languageBehaving irrationally; unable to comply with reasonable limit settingInvading personal spaceEliciting anger in staff

History

  • Prior history:Violent behaviorSelf-injurious behaviorMedical and psychiatric historiesSubstance use historyLegal or criminal history
  • Current HPI:Recent substance usePotential head injuryPain or discomfort from medical or psychiatric symptoms or environmentPlan or threat of violence
  • Indicators of a higher likelihood of medical etiology:Age >40 without a history of similar symptoms or behaviorsConcurrently emerging medical complaintsComorbid medical conditions commonly associated with mental status changes:Neurologic problems (including seizure disorders, CNS infections)Chronic cognitive impairmentVascular or cardiovascular diseaseDiabetes mellitusChronic pain treated with opiatesInflammatory disorders treated with steroidsCancerHIV/AIDSRecent traumatic injury

Physical Exam

  • Exam signs suggesting a medical cause for the mental status change:Abnormal vital signsFocal neurologic findingsSeizure activitySpeech or gait deficits without evidence of alcohol or substance abuse

Essential Workup

  • Identify early warning signs
  • Pay careful attention to findings during neurologic and mental status exams and note vital signs
  • May be performed with the patient in restraints in an emergency

Diagnosis Tests & Interpretation

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

Lab

  • CBC, electrolytes, BUN, creatinine, and glucose if medical cause is suspected or if psychiatric admission or chemical restraint use is likely
  • Consider LFTs, Ca, Mg, and Ph if chronically medically ill or pursuing delirium
  • Drug screen if ingestion is likely

Imaging

CT head if bleed or stroke suspected

Diagnostic Procedures/Surgery

Obtain ECG if chemical restraint use is likely

Treatment

  • Medical workup is important, but in an emergency you may need to restrain potentially violent patients 1st to reduce risk of harm to self or others
  • Involve security or police as needed

Pre-Hospital

  • Physically restrain violent patients and seek police assistance if necessary
  • Keep weapons and other dangerous items (sharp objects, medications, cords, etc.) out of the patients reach

Initial Stabilization/Therapy

  • Prevention:Environmental:Control access to ED: Secured doors, protected entrances, metal detectors, camerasVisible security staffPost visible rules stating clearly that weapons are not allowedExam room exits clear of obstructionProcedural:Identify high-risk patients at triageShorter ED wait times are helpfulSearch/derobe patients after triage; if involuntary, ensure careful documentation of reasons in terms of risk to patient and providersSee to patients ' comfort quicklyAlleviate painOnline alerts for patients with past history of violence in EDClear ED protocols for managing violence and documenting interventionsEnlist family support when possible; if not, remove family to safe placeTrain all clinical staff to recognize and manage potentially violent situations
  • Approaching the potentially violent patient:Do not go aloneRemove your own personal articles that could be used as weapons (neckties, jewelry, trauma shears, etc.)Keep 2 arms lengths between you and patient; open stanceIntroduce yourself and try to address the patient's concerns as soon as possibleMaintain open exit for patient and staffLeave immediately and initiate seclusion or restraint if there is an open threat of violence or imminent violence seems likely

Ed Treatment/Procedures

  • Verbal de-escalation:Attempt to clarify and validate patients immediate concernsCalmly explain potential need for a restraint if de-escalation is not successfulOffer patient choices when possible
  • Seclusion:If an appropriate room is available, this may obviate the need for restraint
  • Physical restraint:Follow your institutional protocolMust document appropriate reason for restraint, attempts to verbally de-escalate, and plans for appropriate monitoring and reassessmentsWhenever possible, treating physician should not be part of restraint teamUse leather restraints for combative patients; soft restraints for patients who are unlikely to be combative or try to elopeSupine position if patient needs to be examined; side position if aspiration risk is significantIf restraint in prone position is needed, ensure adequate airway is maintained
  • Chemical restraint:Offer voluntary PO or IM sedative medication prior to initiating involuntary restraintAvoid PO medications for involuntary restraint due to bite riskChoice 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, 1st attempt to treat the underlying causeConsider benzodiazepines for hyperadrenergic (including cocaine) state or if there is a contraindication to neurolepticsConsider neuroleptics for most primary medical or psychiatric causes, sedative intoxication, or primary behavioral causeOften used in combinationContraindications to neuroleptics:Knowledge of or suspicion for Parkinson disease, dementia with Lewy bodies or frontotemporal dementiaNeuroleptic malignant syndrome, dystonic reaction, or catatoniaProlonged QTAnticholinergic overdosePotential adverse effects:Dystonia: Treat with IM benztropine 1 mg or IM diphenhydramine 50 mgQTc prolongation and/or torsades de pointes (rare)Neuroleptic malignant syndrome (rare): Stop all antipsychotics; begin intensive monitoring and supportive care

Medication

  • Patients who are elderly, have medical or neurologic illness, or have cognitive impairment are more vulnerable to adverse effects and may respond to lower doses (e.g., haloperidol 0.5 mg)
  • If 1st dose of IM haloperidol is ineffective, may be repeated after 30 " 60 min.
  • First line:Haloperidol: 5 " 10 mg IV, IM, or POLorazepam: 1 " 2 mg IV, IM, or PO
  • Second line:Droperidol: 2.5 " 5 mg IV or IM; watch QTcOlanzapine: 5 " 10 mg IM or PO; if IM, do not give with IM/IV benzodiazepines due to risk of respiratory depressionRisperidone: 0.5 " 1 mg POZiprasidone: 10 mg IM every 2 hr, not to exceed 40 mg IM per day

Follow-Up

Disposition

Admission Criteria

  • Medical admission for medical conditions not temporary or reversible in the ED
  • Medical admission if further medical workup needed for which ED setting is not optimal
  • Psychiatric admission if patient has a treatable psychiatric illness appropriate for inpatient level of care
  • Involuntary admission for safety may be necessary according to criteria defined by individual state laws

Discharge Criteria

  • Underlying medical or psychiatric causes have been stabilized
  • Appropriate follow-up is in place
  • Access to weapons has been assessed
  • If intoxication played a role in presentation, sober re-evaluation should occur prior to discharge
  • Discharge to police custody may be appropriate if no psychiatric or medical issues remain
  • If patient elopes, must consider imminent danger to self or others; notify police if risk is high or if safety evaluation not complete
  • Duty to warn or protect 3rd parties from risk of harm: "Tarasoff " laws vary among states, so know yours

Additional Treatment

Issues for Referral

  • Psychiatric consultation in the ED can be helpful, especially if primary mental illness suspected
  • Other consultation may be indicated based on the underlying etiology

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

Pearls and Pitfalls

  • Do not assume that patients with violent behavior have only psychiatric problems
  • Patients who have been restrained require appropriate monitoring, including regular nursing checks and VS, and labs/ECG if chemical restraints are used
  • "Distracting staff " is annoying and may interfere with the care of other patients, but this is not an indication for restraints
  • Document need for restraints and renewal of restraints per your hospitals protocol

Additional Reading

  • Coburn VA, Mycyk MB. Physical and chemical restraints. Emerg Med Clin North Am. 2009;27:655 " 667.
  • Lukens TW, Wolf SJ, Edlow JA, et al. Clinical policy: Critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med. 2006;47(1):79 " 99.
  • Richmond JS, Berlin JS, Fishkind AB, 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(1):17 " 25.
  • Rossi J, Swan MC, Isaacs ED. The violent or agitated patient. Emerg Med Clin North Am. 2010;28:235 " 256.
  • Tishler CL, Reiss NS, Dundas J. The assessment and management of the violent patient in critical hospital settings. Gen Hosp Psychiatry. 2013;35:181 " 185.
  • Wilson MP, Pepper D, Currier GW, et al. The psychopharmacology of agitation: Consensus statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup. West J Emerg Med. 2012;13(1):26 " 34.
  • Zun LS. Pitfalls in the care of the psychiatric patient in the emergency department. J Emerg Med. 2012;43(5):829 " 835.

See Also (Topic, Algorithm, Electronic Media Element)

Codes

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)