The Combative PatientIndiana University Emergency Medicine

Case• 28 yo male brought into ED by

police after fighting at a local fast food restaurant

• Bystanders report history of drug and alcohol abuse

• Sustained several lacerations and abrasions while resisting arrest

Physical Examination• Belligerent and spitting• Strong odor of ETOH• HEENT: PERRL with nystagmus • Forehead laceration• Many contusions and abrasions• Demanding release from the ED

What do you do now?• He wants to leave - Can he?• Should you sedate him? Restrain

him? Wouldn’t that be assault? • What is the standard of care in the

diagnosis and treatment of this patient?

• How can you protect yourself and your ED staff from harm?

Another scenario• You see a patient in the ED who is

loudly unhappy with their care• Security is summoned to escort the

patient out of the ED• The patient threatens to wait for

you after your shift

ED is Prone to Violence• Duty to see and treat everyone• 24 hour open door • High stress• Waiting times• Availability of hostages• Limited security

Violence in healthcare is common• ~50% of providers become victims of

violence– ED, Psych, Geriatric units most prevalent

• 1992 survey of ED residents– 62% concerned about personal safety – 50% feel security measures inadequate

• 1997 survey of psychiatry residents– 73% threatened, 36% assaulted – 66% not trained to manage violent pts

Violence against ED workers• Gates DM J Emerg Med 2005; 31(3): 331-7• Survey of ED workers in 5 Cincinnati

hospitals (n =242)• In the previous 6 months:

– 96% of physicians reported verbal harassment or threats

– 51% of physicians reported physical violence

– 8% had had violence management training in the previous year

Weapons carriage in the ED• Estimated 4-8% of ED patients• Major trauma victims often

armed• Rapid escalation

Is there a way to predict who will become violent?

Risk assessment• Positive predictors of violent behavior

– Male gender– Prior history of violent behavior– Drug or alcohol abuse

• NOT predictive: age, ethnicity, education, diagnosis, marital status

• Clinicians are notoriously poor at predicting who will become violent

Verbal and nonverbal cues“Pre-violent agitation”• Provocative behavior• Angry demeanor• Pacing, gripping arm rails• Clenched fists• Tense posture, loud speech

What is the #1 patient characteristic that predicts violent behavior?

Intoxication

ED Evaluation the Violent

Patient

Goals of ED Evaluation• Ensure provider and patient safety• Functional vs. organic disease

– Organic disease may be reversible (hypoxia, hypoglycemia)

– Rapid deterioration possible with organic disease

• Appropriate disposition

Disarm all patients• Prior to interview• Weapons detectors at the

door• Undressing and placing in a

gown is a non-confrontational search

• Routine disarming results in increased feeling of safety for patients and staff

Setting of Interview• Privacy but not isolation• Seclusion room

– Ideally two exits available– No heavy objects or potential weapons– Heavy furniture, bolted down

• Easy access to security– Security button, or verbal code such as

“I need Dr Armstrong in here.”

Setting of Interview• Examiner sits closest to door or

equidistant from door• Remove personal accessories

– Glasses, watch, ties, necklaces, pocketknives

• Be aware of objects on pt’s body which can be used as weapons

Verbal Techniques• Be honest and straightforward• Non-confrontational demeanor

– Avoid direct eye contact– No sudden movements

• Act as a patient advocate– Offer food or drink (cold)

Verbal Techniques• Be attentive and listen• Address violence directly

– “You seem angry”– “I want to help you, but I cannot allow you to threaten

me or the ED staff”• Do not challenge the patient’s ego• Do not lie to the patient• Never downplay threatening behavior• Excuse yourself if escalation occurs

Functional vs. OrganicFunctional• Rarely present >45

years old• Alert and oriented• History of

psychiatric illness• Situational factors

Organic• All ages• Altered alertness• Impaired

orientation• Abnormal vital

signs• Acute onset

Functional vs. Organic• Unrecognized medical emergencies

admitted to psychiatric units. Am J EM 2000; 18(4): 390-3.

• 64 psychiatric pts transferred to medical floor w/i 24 hours of admission

• Most common eventual diagnoses:– Drug/alcohol toxicity/withdrawal (66%)– Metabolic (14%)– Infection (9%)

• Documentation very poor

Organic Disorders• Hypoxia• Hypoglycemia• Intoxication or withdrawal• CNS infection• Endocrine disorders• Medication reaction• Many others

History• Psychiatric, medical, social history• Drug/alcohol use• Prior episodes of violence• Medication use and changes• Interview family and friends, as

patient may not be a reliable historian

Physical Examination• Vital signs including temp, pulse ox• Neurologic and mental status exam• Signs of drug or alcohol use

– Nystagmus, ataxia, pupils, needle tracks• Toxic syndrome identification

– Anticholinergic, sympathomimetic

Diagnostic Studies• Studies guided by clinical findings• Laboratory

– Rapid glucose– Electrolytes, medication levels– “Tox screens” of limited benefit– CSF analysis

• Radiology/Other– CT/MRI, EEG, EKG

Disposition• Who needs to be admitted/observed?

– Suicidal/homicidal ideation– Psychotic– Organic etiology– Intoxicated

• Consider psychiatric consultation prior to discharge

• Specific follow up is mandatory

Restraining the violent patient

Physical Restraints• Humane and effective • Facilitate diagnosis and treatment• Legal issues

– Documentation, agreement of others• Courts have supported physicians

who restrain patients for safety

Physical Restraints• Indications:

– Prevent harm to patient/others– Prevent significant disruption or

damage to surroundings• NOT indications:

– Convenience– Punitive response

Type of Restraints Used• Leather restraints are strongest• Soft restraints most commonly used• Posey vest• C-collar• NOT bandage gauze• Facemask if spitting

How to restrain a patient• Assemble a restraint team

– At least five persons including team leader– One female if patient is female

• Leader outlines restraint protocol• Enter the room in force with professional

attitude• Do not negotiate• Restrain to solid frame of bed

The patient has been successfully restrained

Monitoring• Frequent monitoring• Standardized form• Complications: circulatory

obstruction, pressure sores, paresthesias

• Rhabdomyolysis, acidosis, and death are reported in pts struggling against restraints

Physical Restraints• Factors Associated with Sudden Death for

Individuals Requiring Restraint for Excited DeliriumStratton SJ et al. J Emerg Med 2001: 19:187.

• Case series of 18 patient deaths• Factors most associated:

– Hobble/hogtie position– Continued struggling in restraints– Stimulant drug use

• Do not place patients in the Hobble Position!

Physical Restraints

• Do NOT allow a patient to struggle in restraints!

• Sedation and monitoring are very important

Chemical Restraints

Ideal chemical restraint• Effective & rapid acting• IV/IM/PO• No addiction• No tolerance• No adverse effects• Does not exist!

Haloperidol• Commonly used• 2.5 - 10 mg IM/IV q 30-60 min • Maximum 6 doses/24 hours• Effective within 10-30 min

Haloperidol: Adverse Effects• Dystonic reaction, akathisia

– May treat with diphenhydramine or benztropine

• Neuroleptic malignant syndrome (<1%)– Autonomic instability– Hyperthermia– Lead-pipe rigidity– Idiosyncratic reaction

• QT prolongation

Benzodiazepines• Used alone or with haloperidol• Lorazepam (Ativan®)• 2-4 mg IV/IM q 15-30 minutes• Titrate to effect• Side effects: Sedation, respiratory

depression• Bonus: Treats ETOH and benzo

withdrawal

Haloperidol, Lorazepam, or Both?• Am J Emerg Med 1997;15:335-40.• Prospective double-blind RCT of 98

agitated pts• IM haloperidol (5mg) vs. IM lorazepam

(2mg) vs. both• Similar rate of adverse events• Tranquilization achieved more rapidly with

combination treatment

Newer (atypical) antipsychotics• Olanzapine (Zyprexa®)• Ziprasidone (Geodon®)• Risperidone (Risperdal®)• Aripiprazole (Abilify®)

Newer (atypical) antipsychotics• Oral or IM dosing

– Rapidly dissolving oral tablets– Oral dosing requires patient cooperation

• Fewer movement disorders than typical antipsychotics

• A number of studies demonstrate utility in acute agitation

• Reasonable alternative to traditional agents, but role in ED not fully defined

What if you are assaulted?

Assault• Immediately summon help• Defend yourself without attacking

– Deflect rather than inflict– If bitten, push toward the mouth and

hold nares– If choking attempted, tuck in chin to

protect airway/carotids

If the assailant is armed

• Comply with demands• Try to remain calm• Do not argue, lie, or bargain• Attempt to establish a human

connection, tend to injured hostages

Assault• Each hospital should have a plan of

action to be utilized in case of extreme violence– Prevention and safety measures– Notification of security and police– Evacuation– Medical treatment– Crisis intervention

Medicolegal Considerations

Consent• Voluntary agreement by competent

individual to undergo medical care• Competent individual may refuse care• If competency is in question

– Substituted consent from family/guardian– Assistance from colleagues, psychiatry, legal– Err on the side of treatment– Document thoroughly

Standard of Care• Defined by professional literature

and practice standards• In a combative patient:

– Diagnose and treat organic etiology– Use physical and chemical restraints

to permit evaluation and treatment while preventing harm

– Arrange appropriate disposition

Duty to warn• Tarasoff v. U of California

– Patient told of intent to kill a woman– Psychologist called police, pt questioned– Patient killed victim 2 months later and her

parents successfully sued psychologist• Warn intended victim and authorities if a

violent patient communicates intent to harm a “foreseeable” victim

Restraint of patients• Youngberg v Romeo 1982• A young man with repeated episodes of

violence was allowed to be restrained and involuntarily committed

• Supreme Court supports the use of restraints to protect patients and others

• Assumes best interest according to reasonable medical judgment

“Involuntary hold”• If a patient is a danger to self or

others, they can be held for a predetermined length of time for evaluation (24-72 hours)

• Document the need, have others corroborate

• Specific forms available

Medicolegal Summary• Be aware of the above concepts• The best defense is the best

practice of medicine• Act in the best interest of the

patient while maintaining a a safe ED environment

Back to our patient• Verbal techniques unsuccessful• Restrained, sedated with haloperidol and

lorazepam• Evaluated per ATLS protocol

– C-spine series, head CT are negative• Laboratory values

– Chem-7 & EKG wnl, ETOH 320 mg/dL• Admitted for alcohol detoxification

Take Home Points• Safety first• Know your resources• Rule out organic etiology of violence• Risk assessment and verbal techniques• Physical/chemical restraints

– Frequent monitoring• Act in the best interest of the patient• Document thoroughly