Transcript Violent patient - Indiana University

The Combative Patient
Indiana 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. Organic
Functional
Organic
• Rarely present >45
years old
• All ages
• Alert and oriented
• Impaired orientation
• History of psychiatric
illness
• Situational factors
• Altered alertness
• 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 Delirium
Stratton 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%)
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–
–
–
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
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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