Emergency Medicine

VIOLENT PATIENT

440 Psychiatric Emergencies

(iii) Withdrawal syndromes from alcohol or barbiturates.

(iv) Hypoglycaemia, including as the patient recovers from a

hypoglycaemic episode after i.v. dextrose administration.

(v) Post-ictal state.

(vi) Hypoxia.

(vii) Other organic confusional state (see p. 81).

MANAGEMENT

1 Explain what is happening at all times, keep reassuring the patient, and

avoid confrontation including averting your eyes or looking away.

(i) Never turn your back on a patient or allow them between you

and the cubicle door.

(ii) Call the police immediately if a weapon is involved. Await their

arrival before proceeding.

2 Attempt verbal restraint by defining acceptable and unacceptable behaviour

and their likely consequences. Speak firmly with courtesy and respect.

3 Consider physical restraint if verbal restraint fails.

(i) Call the hospital security guards, and await adequate numbers,

ideally five or six people, as a ‘show of force’.

(ii) Never try to restrain a patient single-handedly.

(iii) Conversely, never remove physical restraints until a full

evaluation has been made and help is at hand.

4 Consider chemical restraint if physical restraint fails.

(i) Give diazepam 5–10 mg i.v. or midazolam 5–10 mg i.v. for

rapid control. This may be supplemented with haloperidol or

droperidol 5–10 mg i.m. or slowly i.v.

(ii) Such treatment may be given without consent under common

law in an emergency if the patient is a danger to others or

themselves.

5 Monitor every patient once sedated in a resuscitation area until the risks of

respiratory depression and hypotension have passed.

(i) Complete a full physical examination, looking for evidence of

organic disease including abnormal vital signs.

6 Record exact details of events and the necessary action taken in the notes.

7 Admit the patient under the medical or psychiatric team if further treatment

is indicated.

8 Debrief staff in the emergency department, and consider immediate support

for staff injury or intimidation.

(i) Plan future team strategies for violence prevention and

management.