# Management of the Aggressive/Violent Patient

## Overview

This module describes the procedure of managing an aggressive or violent patient using physical or pharmacological containment. This approach pertains to the

aggressive

aggressive

Aggressive patients may display

1. Potential violence (thoughts of suicide or homicide without action). Goal is prevention.
2. Imminent violence (restless, irritable, abusive, hostile, threatening imminent action). Goal is de-escalation.
3. Emergent violence (physically forceful, assaultive, destructive patient endangering others). Goal is containment and safety.

rather than the

agitated

agitated

Usually displaying non-specific psychological and motor hyperactivity impairing function and caregiving. Might become a risk to the safety of others.

or

angry

angry

Normal emotions may become pathological when the patient cannot control extreme emotions due to psychiatric or medical illness or substance intoxication.

patient.

## Indications

Patients displaying potential, imminent or emergent violence caused by:

1. Non-medical causes such as criminal behaviour

2. Personality disorders such as antisocial personality disorder

3. Substance use — intoxication and withdrawal

4. Mental illness

5. Medical conditions such as head injury

## Contraindications

1. Do not restrain or sedate patients unless absolutely necessary for patients’ and healthcare providers’ safety

## Patient information and consent

Stay calm and speak to the patient in a low voice. Never insult the patient or make promises or commitments you cannot keep. Avoid direct body contact and prolonged eye contact. While it may seem counterintuitive in the heat of the moment, try to engage the patient and caregivers, reassuring them that you want to help.

### How do I explain this procedure?

“I want to help you and make you more comfortable. I want to protect you from hurting yourself or others. If you can cooperate with me, we may not need the help of the nursing staff or the security.”

### What can my patient expect?

“To help you, I need to ask you some questions about your health, your medications, or other problems. Some of these questions might annoy or upset you, but are necessary for me to help you. After that I will examine you to check for any injuries or illness that might cause you to feel this way. I might have to give you an injection to help with your frustration. You will experience a small prick, after which you will feel very relaxed and sleepy.”

### What is my patient’s role?

“Try to relax and work with me. Tell me if you need a break from the questions or examinations.”

## Preparation

### Documentation

1. Patient notes

2. Relevant Mental Health Care Act documents, if certifying a patient

### Equipment if sedation is indicated

1. Non-sterile gloves

2. Alcohol swab

3. IV cannula

4. Short extension set (J loop) primed with normal saline or water for injection

5. Syringes
   Syringes

   These must be labelled. The situation can deteriorate quickly leading to incorrect medications being administered.

   containing the necessary medications

6. Transparent film dressing

## Site & Positioning

1. Stay calm

2. Alert security officers
   Alert security officers

   Familiarise yourself with the location of the panic buttons/alarm. It is a good idea to also carry a whistle with you.

   to provide monitoring, backup, or assistance with restraining.

3. Once they arrive,

   close down the space
   close down the space

   Ensure that you have a clear exit path.

   and relocate the patient if needed.

## Procedure

1. Avoid physical confrontation. Instead, contain the patient with reassurances and try to elicit their cooperation.

2. Offer

   sublingual or oral
   sublingual or oral

   Sublingual and oral routes are preferred by patients and are safer, but take longer to work.

   medication.

3. If this fails, immobilise the patient using four point immobilisation in order to tranquillise the patient:

   - Restrain the patient on a trolley, bed, or floor by having four male staff members each holding onto the patient’s hips and shoulders and respective limbs.
   - Apply the minimum degree of force, attempting to calm rather than provoke.
   - Proceed by removing the patient’s shoes or boots, checking for concealed weapons or potentially dangerous objects. Be aware of biting and spitting.

4. If the patient is not willing to take the oral route and resuscitation equipment is not available, use intramuscular injections.

5. If resuscitation equipment and monitoring is available, you and your staff are familiar with the medication and rapid tranquilisation is needed, use an intravenous injection.

6. Administer the following medications via the route chosen above:

   - Benzodiazepine such as lorazepam (2 - 4 mg) AND antipsychotic such as haloperidol (5 - 10 mg). Lorazepam is the drug of choice as it is rapid in onset, has a short half life and is relatively safe.
   - Substitute for lorazepam: midazolam (7.5 - 15 mg)
   - Substitute for haloperidol: risperidone (1 - 2 mg PO) OR olanzapine (10 mg). Risperidone is a good option if the family or caregiver is content and able to take the patient home, to return for a consultation the next day. Never give olanzapine with benzodiazepines, as it is potentially fatal.

7. Assessment: Look for underlying causes of aggressive behaviour such as

   delirium, organic disease, mental illness
   delirium, organic disease, mental illness

   Note that delirium is a medical emergency and must be treated immediately.

   When investigating organic disease, exclude focal neurological signs, pyrexia, neck stiffness, and dehydration. Exclude a post-ictal state associated with epilepsy.

   When excluding mental illness, a history from relatives is imperative.

   , and substance use. Exclude head injury, especially in inebriated patients.

8. Complete the patient notes as well as any required Mental Health Care Act Forms.

9. Monitor
   Monitor

   Do not abandon a sedated patient to a back room; deterioration of the underlying cause is easily missed.

   vital signs as well as neurological observations for as long as the patient is sedated.

## Troubleshooting

The restraints are causing bruising or abrasions.

Assess the need for physical restraints, which should be unnecessary if the patient is sufficiently sedated. Restlessness and agitation can be caused by physical discomfort. Check for thirst, loosen tight clothing, ensure they are warm or cool enough, make a bedpan or urinal available. If the patient is at risk of falling off the bed or trolley, rather place a mattress on the floor. If physical restraints are absolutely required, place a sponge between the patient’s skin and the restraint.

The sedation is not working or is wearing off.

The combination of lorazepam and haloperidol can be repeated up to twice at 30-60 minute intervals as required. If a second dose does not work, consult a senior.

## Risks

1. Injury to the patient

2. Injury to other people

3. Damage to property

4. Risks of sedation include: obscuring signs of underlying illness, loss of protective reflexes, respiratory depression, adverse cardiovascular events such as hypotension and arrhythmias

5. Intervention seen as ‘medical assault’ by the patient with the risk of

   legal implications
   legal implications

   Make detailed notes including monitoring and prescriptions, complete adverse incident reports if necessary, and report the event to a senior and/or the police if necessary. If the Mental Health Care Act forms need to be completed, ensure meticulous notes.

## References

1. Swingler D. The agitated or violent patient. In: Baumann S. Primary Health Care South Africa: A practical guide for Southern Africa. 3rd ed. Kenwyn: Juta and Co Publishers; 2008: 123-132

2. Wyatt J.P. General Approach. In: Oxford Handbook of Accident and Emergency Medicine. 2nd ed. New York: Oxford University Press; 2005: 28-29

3. Mash B. An approach to the aggressive patient. In: Oxford Handbook of Family Medicine. 4th Ed. Cape Town: Oxford University Press South Africa; 2017: 146