Management of The
Dr. Varalee Aphinives
Bhumibol Adulyadej Hospital
Is violence a problem in the ED?
Acts of violence resulting in death have
occurred in 7% of major teaching
The patient become violent in
the first place
Acute intoxication Acute withdrawal
Metabolic disorder Trauma
Infectious disease Environmental injury
Intracranial disorder Hypoxia
What can be done preempt a
1. Be aware of early sighs of impending violent
behavior, such as agitation, abusive language,
and challenges to authority.
2.Completely undress major trauma victims as
soon as possible, removing any weapons on
3.Do not leave any instruments that can be
used as weapons near a potentially violent
What is the initial approach a physician can
take to control an agitated or violent patient?
First approach to any agitated patient should be verbal
The physician should remind the patient is in a safe environment.
Improving the patient’s comfort.
Stationing security officers may dissuade further inappropriate
Most important, care providers must check their own emotion.
Yelling back or exchanging threats with the patient only further
escalates the situation
What if doesn’t work?
Multiple different restraint techniques
Precaution: Physical restraints often may
increase patients’ agitation
-depends on what is cuasing the agitation.
Sometime both are neccessary
Two class of drugs
1.Butyrophenones such as halaperidol
2.Benzodiazepine such as larazepam and
Haloperidol 5-10 mg iv (about two dose)
don’t give three dose( avoid toxicity)
Switch to benzodiazepine
Side effect is extrapyramidal or other
dystonic reaction.hypotension is rare.
Prophylaxis with diphenhydramine or
benztropine mesylate (Cogentin) for 2 to 3
PCP, and cocaine)
Preferred suppectd anticholinergic toxicity
because they reduce CNS production of
Initial dose :Diazepam 5 to 10 mg iv and
repeated dosed of 2 to 10 mg every 20 to 30
minutes as need
Do I have any alternatives to
restraining a patient?
Ideally, an ED should have isolation room
which agitated patients can be placed
This room should be monitored
easily(e.g.,through windows or video camera)
Emptied of any objects that can be used as
What can hospital do to
decrease the risk of violence?
1.All unnecessary doors should be locked and access into the
hospital limited to a few patrolled entrances.
2.Metal detectors should be used to screen patients and visitors
3.Continuous-surveillance, closed-circuit television monitors help
to ensure safety in the parking areas and the immediate grounds
of the hospital.
4.Multiple methods of sommoning police or security must be
available to the ED without having to go through the hospital
5.Responding police or security officers should be trained and
6.Clear documentation in the medical record.
7.A comprehensive program patterned after the critical incident
stress debriefing model provide immediate and long-term
Emergency Medicine Secrets third edition
Facep Peter T. Pons,MD, Facep