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
Etiology
- Primary psychiatric problem:
- Most commonly psychosis or mania, but associated with many different diagnoses
- 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
- Neurologic:
- Seizure
- Stroke
- Head injury or bleed
- Brain lesion or mass
- Chronic primary medical problem:
- Dementia
- Intellectual disability
- Traumatic brain injury
- Criminal behavior or psychopathy
Diagnosis
Signs and Symptoms
- Early signs of impending violence risk (nonspecific):
- Loud speech
- Physical agitation or tension (pacing, clenching fists, darting eyes)
- 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
History
- 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
- Recent traumatic injury
Physical Exam
- 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
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, 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
Ed Treatment/Procedures
- 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
- Seclusion:
- If an appropriate room is available, this may obviate the need for restraint
- 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
- 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
- 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 PO
- Lorazepam: 1 " 2 mg IV, IM, or PO
- 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
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)