Management Of Violent Patient

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Management Of Violent Patient

  1. 1. Management of The Violent Patient Dr. Varalee Aphinives Bhumibol Adulyadej Hospital
  2. 2. Is violence a problem in the ED?  Yes  Acts of violence resulting in death have occurred in 7% of major teaching hospitals.
  3. 3. The patient become violent in the first place  Acute intoxication  Acute withdrawal  Metabolic disorder  Trauma  Infectious disease  Environmental injury  Cardiovascular  Psychiatric disorder disorders  Intracranial disorder  Hypoxia
  4. 4. What can be done preempt a violent episode?  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 their persons.  3.Do not leave any instruments that can be used as weapons near a potentially violent patient
  5. 5. 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 descalation.  The physician should remind the patient is in a safe environment.  Improving the patient’s comfort.  Stationing security officers may dissuade further inappropriate behavior.  Most important, care providers must check their own emotion.  Yelling back or exchanging threats with the patient only further escalates the situation
  6. 6. What if doesn’t work?  Multiple different restraint techniques -Two-point restraint -Four-point restraint Precaution: Physical restraints often may increase patients’ agitation  Chemical restraint -depends on what is cuasing the agitation.  Sometime both are neccessary
  7. 7. Chemical restraint  Two class of drugs  1.Butyrophenones such as halaperidol and droperidol  2.Benzodiazepine such as larazepam and diazepam
  8. 8. Butyrophenones  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 days after.
  9. 9. Benzodiazepine  Sympathomimetic-induced(e.g.,amphetamine, PCP, and cocaine)  Preferred suppectd anticholinergic toxicity because they reduce CNS production of catecholamines  Initial dose :Diazepam 5 to 10 mg iv and repeated dosed of 2 to 10 mg every 20 to 30 minutes as need
  10. 10. 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 weapons.
  11. 11. 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 for weapons.  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 operator.  5.Responding police or security officers should be trained and equipped appropriately.  6.Clear documentation in the medical record.  7.A comprehensive program patterned after the critical incident stress debriefing model provide immediate and long-term psychological support.
  12. 12. Reference Emergency Medicine Secrets third edition Vincent j.Markovchick,MD, Facep Peter T. Pons,MD, Facep

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