Approach to AGGRESIVE Patients

Approach to AGGRESIVE Patients

Healthcare workers, especially staff in emergency departments, are likely to encounter aggression and violence every day. These problems can occur in combination. It is important that a diagnosis is made, to assess and manage these patients properly, with-out biases, and with the same thoroughness that you assess every patient with. Practice design and policies as well as staff training can help to reduce the risk of violence.

Aggression and violence may be a manifestation of underlying psychiatric disorders. These include drug psychosis, delusional states, mania and personality disorder. Some patients try to use aggression as means of achieving a particular goal, such as being seen earlier or obtaining drugs.

ABC of assessing the potentially violent patient

A= Assessment:

• Primary Survey
• Appearance
• Current medical status
• Psychiatric History (history of violence)
• Current medication
• Oriented (time, place, person)

Physiological indications for impending aggression

• Flushing of skin
• Dilated pupils
• Shallow rapid respirations
• Excessive perspiration

B= Behavioural indications:

• Observation of behaviour
• General behaviour (intoxicated, anxious, hyperactive)
• Irritability
• Hostility, anger
• Impulsivity
• Restlessness, pacing
• Agitation
• Suspiciousness
• Property damage
• Rage (especially children)
• Intimidating physical behaviour (clenched fist, shaping up)

C= Conversation

• Patient self-report
• Admits to weapon
• Admits to history of violence
• Thoughts about harm to others
• Threats to harm
• Admits to substance use/abuse
• Command hallucinations to harm other
• Admits extreme anger

Medical causes of violence and aggression in patients

Risk factors for sudden related violence:

• Younger age
• Male gender
• Lower income
• History of violence
• Past juvenile detention
• History of physical abuse by parent or guardian
• Substance dependence only
• Comorbid mental health and substance disorder
• Victimization in past year
• Unemployed and looking for work in the past

ED management for violence and aggression

General Consideration  

• Early recognition and use of de-escalation strategies aimed at diffusing a volatile situation is the preferred approach.
• Consider personal safety at all times
• Consider the safety of other patients and their visitors at all times
• Place the person in a quiet and secure area and let staff know what is happening and why
• Never turn your back on the individual
• Don’t walk ahead of the individual and ensure adequate personal space
• Provide continuous observation and record behaviour changes in patient notes
• Wear personal duress alarm if available
• Let the person talk (everyone has a story to tell, let them tell it)
• Never block off exits and ensure you have a safe escape route

Non-pharmacological Management

Physical/Mechanical Management - Restraints

• Clinicians should beware of local policies, laws and acts before restraining patients
• Applying physical restraint’s is a team sport, 1 for each limb and 1 to lead the restraint and manage the airway.
• Physical restraint should always be followed up with chemical and mechanical restraints.
• Physical restraints need to be secure enough to restrain the patient, but able to be easily removed if the patient begins to vomit, seizure, or loose’s control of their airway.
• Restraints must be applied in the least restrictive maner and for the shortest period of time.
• Padding should be applied between restraints and the patients to prevent neurovascular injury, and regular neurovascular observations should be perform every 15-30mins whilst patient is physically restrained.
• The clinician ordering the restraints should document the reason for restraints, what limbs are restrained, how frequent neurovascular observations are needed, and when the restraints need reviewed, generally every 2 hours restraints should be reviewed by treating clinician.

Indications for restraint

• Other methods to control the behaviour have failed such as de-escalation techniques; and
• The patient displays aggressive or combative behaviour which arises from a medical or psychiatric condition (including intoxication); and
• The patient requires urgent medical or psychiatric care; and
• The behaviour involves a proximate risk of harm to the patient or others, or risk of significant destruction of property.

Chemical / Pharmacological Management

• Remember you are generally treating the undifferentiated patient, with limited access to past medical history.
• These patients are generally reluctant to take oral medications, IV access needs to be obtained, or IM or SL sedation can be given while attempting IV canulation,
• Once you choose to start chemical sedation, you have full responsibility to maintain the patient’s airway, breathing, circulation, provide bladder care, hydration, and general nursing care to that patient.
• Benzodiazepines are preferred in the ED, as have prompt onset of action, and a good safety profile.
• Antipsychotics have a role when patient is not responding to benzodiazepines, and as an adjunct to the benzodiazepines to achieve sedation

Post-sedation management

In almost all circumstances the patient will need to be transferred for further medical and then psychiatric assessment as soon as possible. After sedation the patient must be closely observed and monitored. They should be managed in a safe position with a clear airway and if possible supplemental oxygen given. The degree of sedation (for example as assessed by the Glasgow Coma Score), pulse, temperature, blood pressure, respiratory rate and pupils should be checked. If equipment is available check the blood glucose (or give glucose if hypoglycaemia is possible but glucose cannot be checked), ECG rhythm and oxygen saturation. A physical examination looking for possible organic medical illness should be performed.

Arranging urgent transfer and managing a patient post-sedation is critical. An awareness of the potential adverse effects and possibility of overdosage is essential. Documentation including recorded observations is required.

Cautions and contraindications to physical restraint and emergency sedation:

• A patient who is 'acting out' and who does not need acute medical or psychiatric care should be discharged from the hospital to a safe environment (home, police, DHS) rather than be restrained.
• Be aware of previous medications and possible substance use.
• Safe containment is possible via alternative means (including voluntary, collaborative oral sedation).
• Inadequate personnel/unsafe setting/inadequate equipment.
• Situation judged as too dangerous e.g. patient has a weapon (call a Code Black)

Complications of sedation and restraining patients:

• Respiratory depression and pulmonary aspiration
• Sudden cardiac death/Excited delirium
• Hypotension
• Deep venous thrombosis & pulmonary embolus
• Rhabdomyolysis
• Dystonic reactions
• Neuroleptic malignant syndrome
• Anticholinergic effects
• Delirium
• Lactic acidosis
• Lowered seizure threshold
• Special problems in the elderly

Conclusion

Preparedness involves a level of awareness and some planning for the possibility of aggression and violence, in particular facility design, policies and procedures and staff training. It should always be remembered that organic illness can mimic or coexist with psychiatric illness and that both may cause behaviour disturbance. Verbal de-escalation is a useful technique.

In the uncommon situation that sedation is needed in a non-hospital setting, an early call for police and ambulance assistance should be made. Oral sedation can be effective, but intramuscular or intravenous medication is needed in some cases. Post-sedation physical assessment and monitoring is essential. A review of practice preparedness and staff debriefing should be undertaken after an event.

Source : 

1. www.lifeinthefastlane.com

2. www.australianprescriber.com

3www.rch.org.au