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Section Eight
THE PROBLEM PATIENT
CHAPTER 188
The Combative Patient
Jason D. Heiner and Gregory P. Moore
PERSPECTIVE
Background
Combative patients are among the most difficult patients emergency physicians encounter. Often brought in against their will,
they are agitated, confrontational, and nearly impossible to
examine, and they may physically harm themselves or others. The
emergency physician should seek to control the patient and the
situation, diagnose and treat reversible causes of violence, and
protect the patient and staff from harm.
Epidemiology
Violence is referred to as our nation’s shameful epidemic. Injury
is the leading cause of death in persons younger than 44 years, and
homicide is the second leading cause of death in persons aged 15
to 24 years.1,2 Rates of firearm violence and death from firearms
are higher in the United States than in any other industrialized
country.3-5 For each death there are an estimated 19 additional
injuries requiring hospitalization.6 The high lifetime cost of treating gunshot injuries and associated disabilities is a public health
issue as a large proportion of the expense is covered by U.S.
taxpayers.7-9
The emergency department (ED) is a volatile environment
because of high stress, illness, prolonged waiting times, and frequent lack of communication. The 24-hour open door policy,
availability of potential hostages, and widespread accessibility of
drugs and weapons compound the potential for violent behavior.
Among hospital workers, the majority of assaults occur in the ED,
psychiatric ward, waiting rooms, and geriatric units.10 In a survey
of 242 emergency care workers in five Midwestern hospitals, the
majority reported being verbally threatened, and 51% of physicians and 67% of nurses reported being physically assaulted at
least once in the past 6 months.11 Another survey of attending
physicians (n = 171) in Michigan EDs reported that 75% experienced a verbal assault and 28% a physical assault in the past 12
months; 82% were occasionally fearful of workplace violence.12 An
additional survey of 263 emergency medicine residents and
attending physicians found that 78% of participants experienced
a violent workplace act in the prior year and that workplace violence is experienced equally by men and women.13 An ED census
of at least 50,000 patients annually or an average waiting time of
at least 2 hours is significantly associated with an increased incidence of violence.14,15 The risk of workplace assault in the ED,
Disclaimer: The views expressed herein are solely those of the authors and do not
represent the official views of the Department of Defense or Army Medical
Department.
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however, exists across hospitals of all sizes and reflects the rate of
violence in the community.16 Despite these obvious risks, health
care providers are typically not trained in the identification and
management of combative patients.13
Patients armed with lethal weapons pose a serious threat to ED
staff. The carriage of weapons in the ED population is estimated
at approximately 4 to 8%.17,18 One large urban hospital ED with a
metal detector reported confiscation of an average of 5.4 weapons
a day.19 At this center, 27% of major trauma patients seen in the
ED during a 14-year period were initially armed with lethal
weapons (84% knives and 16% guns). The potential risk posed by
concealed weapons also exists in pediatric EDs.20 Unfortunately,
prediction of weapons carriage in any particular patient is impossible.21 Therefore, it is prudent to assume that all violent patients
are armed until it is proved otherwise, especially those presenting
with major trauma.
Identification of potentially violent patients is difficult; male
gender, prior history of violence, and drug or ethanol abuse are
the only positive predictors.22-26 Ethnicity, diagnosis, age, marital
status, and education are not reliable identifiers. A study conducted in an outpatient psychiatric setting found that the incidence of violent behavior occurring after psychiatric evaluation
does not vary with the experience of the psychiatrist.23 Actuarial
prediction of patient violence in a 6-month period by use of criteria such as age, drug use, and prior history of violence is substantially more accurate than prediction of future violence by
evaluating attending psychiatrists.27 The prediction, prevention,
and control of violent outbursts in the ED are difficult. Appreciation of the potential for violence, preparedness, and proper use of
verbal techniques and physical or chemical restraints assist the
patient while preventing injury.
PRINCIPLES OF DISEASE
Pathophysiology
The pathogenesis of violent behavior is conjectural. Potential
causes include environmental, historical, interpersonal, biochemical, genetic, hormonal, neurotransmitter, and substance abuse
disorders.28-30 Psychiatric illness is also a risk factor, with schizophrenia (paranoid and nonparanoid), personality disorders,
mania, and psychotic depression most frequently associated
with violence.26,29,31-33 Delusional schizophrenic patients become
violent, believing that others are attempting to harm them. They
may also have auditory hallucinations commanding harm to
others. Antisocial and borderline personality disorder patients
typically do not feel remorse for their violent actions. The patient
with acute mania is unpredictably dangerous because of emotional lability, a situation in which pleasantness can quickly turn
CHAPTER 188 / The Combative Patient
to aggression. Substance abuse disorders are consistently associated with violent behavior in both psychiatric and nonpsychiatric
populations.25,26,34-36 Biologically, the serotonin system controls
aggression and inhibition, with diminished serotonergic function
possibly disinhibiting aggression against self and others.37-43 Generalized brain dysfunction may predispose patients to violence by
disruption of the regulation of aggression, particularly in the prefrontal and temporal cortex.28,42-44 Cerebral imaging documents
both functional and structural impairments in violent criminals
and antisocial patients.42-46 Genetic and hormonal influences are
also implicated in the neurobiology of aggression.28,38,47
MANAGEMENT
Risk Assessment
Evaluation of the combative patient begins with risk assessment
and attention to safety measures. Violence often erupts after a
period of mounting tension. The astute practitioner may identify
verbal and nonverbal cues and subsequently have the opportunity
to defuse the situation.33,48-50 In a typical scenario, the patient first
becomes angry, then resists authority, and finally becomes confrontational and violent. When physicians have a “gut feeling” that
a dangerous situation may be developing, they should take appropriate precautions.49,50 Violent behavior may also erupt without
warning, especially in patients with an organic brain syndrome,
so clinicians should not feel overly confident in their ability to
sense impending danger.
An obviously angry ED patient should be considered potentially
violent. Provocative behavior, angry demeanor, pacing, loud or
pressured speech, tense posture, gripping arm rails intensely, frequently changing body position, pounding walls or throwing
things, and clenched fists are all symptoms and signs of impending
violence. To prevent escalation, the patient should be removed
from contact with other belligerent accomplices as well as from
other provocative patients. A quiet area with a window or direct
observation is optimal. Because increased waiting times correlate
positively with violent behavior, consider evaluating the potentially violent patient expeditiously to prevent escalation of aggression.10,14,15 Often, the perception of preferential treatment will
defuse the patient’s anger.
All patients should be screened for weapons before the interview. The use of metal detection is ideal before ED entry. Patients
brought to the ED by ambulance may bypass routine security
booths and metal detectors.51 The practice of undressing patients
and placing them in a gown is useful both as a nonconfrontational
search for weapons and for easy identification in the event of the
patient’s escape from the ED. Although screening and searching
of patients for weapons may appear to be a violation of privacy,
routine disarming of all ED patients results in an increased feeling
of safety for both patients and staff.18,52
The ideal setting for the patient interview should emphasize
privacy but not isolation.31,50 Some EDs have seclusion rooms
specifically designed for interview of potentially dangerous
patients.53 Security should be nearby and the door left open to
facilitate both intervention and escape for the provider. The
patient and interviewer may be seated roughly equidistant from
the door, or the interviewer may sit between the patient and the
door. Blocking of the door, however, poses a risk of harm to the
clinician if the patient feels the urge to escape. Two exits should
ideally be available, and doors should swing outward. The clinician should have unrestricted access to the door and never sit
behind a desk. The room should not contain heavy or potentially
dangerous objects that may be thrown. There ideally should be a
mechanism to alert others of danger, such as a panic button or a
code word or phrase that summons security (e.g., “I need Dr.
Armstrong in here.”). For personal protection, earrings, necklaces,
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and neckties should be removed. Personal accessories that may be
used against the caregiver, such as a stethoscope or scissors, should
be removed. The physician should be aware of any objects within
the room or on the patient’s body, such as pens, watches, or belts,
that may be used as weapons.48-50
Verbal Management Techniques
The patient should be made as comfortable as possible, and the
interviewer should adopt an honest and straightforward manner.
In some cases, an agitated patient may be aware of the impulse
control problem and welcome limit setting by the clinician (e.g.,
“I can help you with your problem, but I cannot allow you to
continue threatening me or the ED staff.”). The interviewer should
act as an advocate for the patient. Offering a soft chair or something to eat or drink (not a hot liquid, which may be used as a
weapon) may help establish trust. A significant percentage of
patients relax at this point because offering food or drink appeals
to their most basic human needs and builds trust. The interviewer
should adopt a nonconfrontational demeanor and be an attentive
and receptive listener without conveying weakness or vulnerability. The interviewer should respond verbally in a calm and soothing tone of voice. It is also important to stand at least an arm’s
length away and to avoid prolonged direct eye contact, approaching the patient from behind, or sudden movements.48-50
A key mistake in interviewing a potentially violent patient is
failing to address the issue of violence directly.23,48,49 The patient
should be asked relevant questions about suicidal or homicidal
ideations or plans, possession of weapons, history of violent
behavior, and current use of intoxicants. Acknowledgment of the
obvious (e.g., “You look angry.”) may help the patient to begin
sharing emotions. If the patient becomes more agitated, it is
important to speak in a conciliatory manner and to offer supportive statements, such as “You obviously have a lot of will power
and are good at controlling yourself,” to help defuse the situation.
If this is not successful, a respectful offer of medication or restraints
to the patient if another health care provider is close by may
prevent further escalation.
Counterproductive approaches to the combative patient
include argumentation, machismo, and condescension.48,49 These
inappropriate strategies challenge patients to “prove themselves.”
An open threat to call security personnel also invites aggression.
The clinician should be aware of her or his own reactions to the
patient and avoid transference of anger. The deception of a patient
(e.g., “I am sure you will be out of here in no time.”) only invites
violent consequences once the lie is uncovered. The unsuspecting
nurse or colleague who follows the interviewer may be victimized.
It is especially important not to deny or downplay threatening
behavior. If verbal techniques are unsuccessful and escalation
of violence occurs, the physician should leave the room and
summon help.
Physical Restraints
Physical restraint should be considered when verbal techniques
prove unsuccessful. The use of restraints can be humane and effective in facilitating diagnosis and treatment of the patient while
preventing injury to the patient or medical staff.48,54,55 The liability
one incurs for restraining a patient against his or her will is negligible compared with the potential liability for allowing a patient
to lose control and cause physical harm.50
Indications for emergency seclusion and restraint include the
prevention of imminent harm to the patient, others, or the immediate environment and as part of an ongoing behavior treatment
program.48-50,56,57 Seclusion or restraint may be contraindicated
because of the patient’s clinical or medical condition. Seclusion
should not be used in an unstable patient who requires close
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monitoring and should be avoided when the patient is suicidal,
self-abusive, or self-mutilating or has had an intentional ingestion
of drugs or poisons.33,57 Restraints should not be applied for convenience or as a punitive response for disruptive behavior. If one
is available, a colleague should document agreement with the
application of restraints, mentioning the specific indications (e.g.,
“I restrained Mr. Smith because he told me he was going to beat
me up and then took a swing at me.” is preferable to “I restrained
Mr. Smith because he was violent.”).
The implementation of restraints should be systematic, and an
ED protocol should be in place. This protocol begins when the
examiner leaves the room after verbal techniques are unsuccessful.
It may be helpful to consider the application of restraints as a
procedure analogous to running an advanced cardiac life support
code.49 The restraint team ideally consists of at least five people,
including a team leader. The leader, whether a physician, nurse, or
security officer, will be the only person giving orders and should
be the person with the most experience in implementing restraints.
Before entering the room, the leader outlines the restraint protocol
and warns of anticipated danger (e.g., the presence of objects that
may be used as weapons). All team members should remove personal objects that the patient could use against them. If the patient
is female, at least one member of the restraint team should be
female to potentially mitigate allegations of sexual assault.
The team enters the room in force and displays a professional
rather than threatening attitude. Many violent individuals calm
down at this point as a large show of force protects their ego (e.g.,
“I would have fought back but there were too many against me.”).
The leader speaks to the patient in a calm and organized manner,
explaining why restraints are needed and what the course of events
will be (e.g., “You require a medical and psychiatric examination
as well as treatment.”). The patient is instructed to cooperate and
to lie down to have restraints applied. Some patients are relieved
at the protection to self and others afforded by restraints when
they feel themselves losing control. Even if the patient suddenly
appears less dangerous, however, once the decision to restrain is
made, do not negotiate.
If physical force becomes necessary, one team member restrains
a preassigned extremity by controlling the major joint (knee or
elbow). The team leader controls the head. If the patient is armed,
two mattresses can be used to charge and immobilize or sandwich
the patient. Restraints are applied securely to each extremity and
tied to the solid frame of the bed (not side rails, as later repositioning of side rails also repositions the patient’s extremity). Leather
is the optimal type of restraint because it is a physically stronger
material and less constricting than typical soft restraints. For this
reason, gauze should not be used. Soft restraints may help restrict
extremity use in the semicooperative patient but are likely to be
less effective in the truly violent patient who is continuing to
struggle and attempt escape. If chest restraints are used, it is vital
that adequate chest expansion for ventilation is ensured. The
application of a soft Philadelphia collar to the patient’s neck minimizes head banging and biting. Whenever possible, the treating
physician should not actively participate in restraint application
to preserve the physician-patient relationship. The restraining of
patients on their sides helps prevent aspiration, although restraint
supine with the head elevated is more comfortable and allows a
more thorough medical examination while providing some protection against aspiration.33,58 Once the patient is immobilized,
announcing “the crisis is over” will have a calming effect on the
restraint team and the patient.
After restraints are successfully applied, the patient should be
monitored frequently and positions changed to prevent neurovascular sequelae such as circulatory obstruction, paresthesias, and
rhabdomyolysis associated with continued combativeness. A standardized form should be completed for physically restrained
patients. Documentation includes the specific indication for
restraint and, ideally, colleagues’ agreement that restraints are
necessary.
Sudden, unexpected deaths occur in restrained patients.59-64
Although healthy volunteers, when restrained and undergoing
physical exertion, do not appear to experience clinically significant
positional asphyxia,65-67 the combative ED patient often suffers
from other conditions that may predispose to increased morbidity.
Patients who are cocaine or stimulant intoxicated or restrained in
the prone position appear to be uniquely at risk.59-64 Increased
sympathetic tone and altered pain sensation allow exertion beyond
normal physiologic limits in these patients. Sympathetic-induced
vasoconstriction may impede clearance of metabolic waste products. Alteration of respiratory mechanics in an acidemic patient
resulting from the position of restraint can be a contributing
factor by impairment of respiratory compensation. As a general
guideline, the prone restraint position should be avoided when
possible and chemical sedation used when a patient continues to
struggle against physical restraints.
The Joint Commission on Accreditation of Health Care
Organizations has guidelines governing the use of restraint and
seclusion for behavioral health patients. Educational materials
and specific details about seclusion and restraint are available
at www.jointcommission.org/. Several general essential elements
to be provided in a restraint situation include the following:
Hospital policies and procedures guide appropriate and safe use
of restraint.
The implementation of restraint or seclusion is limited to
emergencies where imminent risk of harm exists to the
patient or others.
Staff is trained and competent to apply restraint safely.
Staff is trained to minimize the use of restraint.
Patients in restraint are timely and regularly monitored.
Time-limited orders for restraint use are provided by licensed
practitioners.
Medical records document that the use of restraint or seclusion
is consistent with organizational policy.
Chemical Restraints
Chemical restraints should be considered alone or in conjunction
with physical restraint in the management of an agitated or violent
patient in the ED. A struggling patient who is physically restrained
may have an increased risk of morbidity and mortality and may
benefit from the calming effect of these medications. Chemical
restraints subdue patients who may otherwise harm themselves or
others and facilitates their medical evaluation and treatment.
Clinical and administrative guidelines for their use are similar to
those for the use of physical restraints. The use of medication to
calm a patient may obscure the mental status examination and
clinical diagnosis. This should be weighed, however, against the
increased risk that both the patient and staff may face if such
medication is withheld.
Several pharmaceutical agents can quickly achieve safe behavioral control, or “rapid tranquilization,” of such a patient without
oversedation. The ideal agent should be effective, safe and well
tolerated, rapid in onset, titratable, and available through multiple
routes of administration. In the ED, benzodiazepines and antipsychotics (also known as neuroleptics) are commonly used either
alone or in combination for rapid tranquilization. The intramuscular route is often advantageous in the uncooperative and dangerous patient refusing an oral medication or an intravenous
catheter. A chemical restraint should ideally be taken voluntarily
by a patient as the offer of voluntary administration may restore
some feeling of control and ease escalating agitation.49,68-70 As with
physical restraints, it is imperative that these patients be evaluated
regularly for changes in their clinical status.
CHAPTER 188 / The Combative Patient
Benzodiazepines, particularly lorazepam (Ativan) and midazolam (Versed), are often used in the ED for rapid tranquilization
of an agitated or violent patient. Benzodiazepines enhance the
activity of the major inhibitory neurotransmitter γ-aminobutyric
acid to cause anxiolytic, anticonvulsant, and sedative effects. These
agents are particularly preferred for the management of agitation
caused by ethanol or sedative-hypnotic drug withdrawal as well as
cocaine and sympathomimetic drug ingestions.48,54 Although they
are generally well tolerated, side effects of benzodiazepines include
excessive sedation, ataxia, confusion, nausea, and respiratory
depression, which may be amplified in the presence of concurrent
alcohol and other depressant use.
Lorazepam is frequently preferred to other benzodiazepines
because of its rapid onset of action, short half-life, route of elimination with no active metabolites, and effectiveness by oral, intramuscular (IM), or intravenous (IV) route of administration.48,54,71
Recommended initial oral, IM, or IV doses of lorazepam range
from 0.5 to 4 mg. Typical doses for chemical restraint in the ED
begin at 1- to 2-mg increments intramuscularly or intravenously
with upward titration as needed.68,71 The onset of action after
administration of lorazepam is generally 5 to 20 minutes if it is
given intravenously or 15 to 30 minutes if it is given intramuscularly, with a duration of action of 6 to 8 hours.54,68,72
Midazolam is also an effective benzodiazepine for achievement
of mild sedation and has a more rapid onset of action and a
shorter duration of clinical effects than lorazepam. The intramuscular route is used widely to calm the agitated patient with a
typical initial dose of 5 mg IM.48,54 When it is administered
intramuscularly, the medication usually takes effect in about
15 minutes with a mean duration of 2 hours.48,54,73 In a comparison
of midazolam 5 mg IM to lorazepam 2 mg IM and to the antipsychotic haloperidol 5 mg IM to sedate violent and agitated
patients, all three showed similar efficacy, but midazolam demonstrated a more rapid onset of action and shorter duration of
activity than the other two medications.74 The choice of midazolam versus lorazepam should be determined by the duration
of sedation desired.
Antipsychotic medications also play a prominent role in the
chemical restraint of the violent ED patient. These medications
include the older “typical” (or “classic”) antipsychotics and the
newer “atypical” antipsychotics. The precise mechanisms of action
are unclear, but typical antipsychotics strongly block brain dopamine receptors, whereas the atypical antipsychotics less strongly
and more specifically antagonize dopamine as well as serotonin
receptors.48,75 Both classes of antipsychotics have variable effects
on other receptors, such as the adrenergic, cholinergic, and histaminic receptors.75 The typical antipsychotics can be categorized in
terms of their “potency,” a description referring to the relative
dosing of the medication and generally predictive of its side effect
profile. The incidence of sedation, hypotension, and anticholinergic side effects is higher with the low-potency antipsychotics,
whereas the incidence of extrapyramidal symptoms is greatest
with the high-potency antipsychotics. Low-potency antipsychotics
include chlorpromazine (Thorazine) and thioridazine (Mellaril),
medium-potency antipsychotics include loxapine (Loxitane) and
molindone (Moban), and high-potency antipsychotics include
haloperidol (Haldol) and droperidol (Inapsine).
Of the older typical antipsychotics, the butyrophenones haloperidol and droperidol have been widely used in the emergency
setting. Haloperidol is the most frequently administered antipsychotic to control the agitated patient in the ED.48,69,70,76 It is
available in oral, intramuscular, and intravenous preparations,
although the commonly used intravenous route of administration
is not approved by the Food and Drug Administration (FDA).
Haloperidol is generally given in 2.5- to 10-mg IM doses (often
5 mg IM for the average adult), with half doses administered to
the elderly and with repeated dosing every 20 to 60 minutes as
48,54,71,77-79
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needed.
Effects are usually seen by 30 minutes by the
intramuscular route; the average patient requires fewer than three
doses for the desired clinical effect.54,71,79
Droperidol has been commonly used at doses of 5 to 10 mg IM
and 2.5 to 5 mg IV in a manner similar to haloperidol to control
the agitated or combative patient.48,80-83 Compared with haloperidol, droperidol appears to more rapidly reduce agitation at equal
intramuscular dosing; it has a shorter duration of effect, more
sedation, a larger incidence of orthostatic hypotension, and a
lesser incidence of extrapyramidal symptoms.78,81,84 Compared
with midazolam 10 mg IM, droperidol 10 mg IM has an equally
rapid onset of action and requires fewer additional doses for sedation.85 The clinical use of droperidol decreased markedly after it
was given a controversial black box warning in 2001 by the FDA
for concern of QTc prolongation and torsades de pointes.86-89
Haloperidol is also associated with QTc prolongation and torsades de pointes.90-93 It is prudent to use caution when these medications are administered to patients with other identified risk
factors for or the known presence of existing QTc prolongation.
In 2007 an FDA alert recommended electrocardiographic monitoring of patients receiving haloperidol intravenously to further
minimize this risk.94 If it is possible to obtain an electrocardiogram
or to place the patient on a cardiac monitor before the administration of haloperidol, that should be done. If this is precluded by
poor cooperation of the patient, it should be accomplished as soon
as possible once the patient becomes more cooperative.
Common side effects of haloperidol and droperidol are sedation, orthostatic hypotension, and extrapyramidal symptoms.
Extrapyramidal symptoms are thought to be due to mesolimbic
dopamine receptor blockade, not dose related, and may occur
immediately or days after medication administration.78 Patients
can have akathisia (extreme restlessness) and uncoordinated
involuntary movements known as dystonia, including of the
muscles of the mouth (buccolingual), neck (torticollis), back
(opisthotonos), eyes (oculogyric crisis), and trunk (abdominopelvic). Treatment includes diphenhydramine 25 to 50 mg IV or
IM or benztropine 1 to 2 mg IV or IM acutely and extended for
3 days to minimize symptom recurrence. Both haloperidol and
droperidol have minimal anticholinergic properties and are often
coadministered with diphenhydramine or benztropine, so they
should not be used to control agitation in a patient with known
anticholinergic intoxication. The use of these medications in the
sympathomimetic-intoxicated patient is concerning because
some antipsychotics may lower the seizure threshold. Seizure
activity after administration of haloperidol or droperidol, however,
appears to be a rare event, and in the animal model haloperidol is
protective against seizures in cocaine intoxication and reduces
mortality in amphetamine intoxication.83,95,96
Neuroleptic malignant syndrome is a rare and potentially lethal
idiosyncratic reaction estimated to occur in 0.01 to 0.02% of
patients receiving antipsychotic medications.97 Characteristic
symptoms include autonomic instability, hyperthermia, lead-pipe
muscle rigidity, and altered mental status. If neuroleptic malignant
syndrome occurs, further antipsychotics should be withheld and
supportive treatment initiated. The role for any specific pharmacotherapy is uncertain.97
Chemical restraint with newer atypical antipsychotics is safe
and effective in the treatment of agitated and violent patients,
although their role in the treatment of the ED patient is still evolving.71,78,98 Compared with the typical antipsychotics such as haloperidol, these medications appear to provide more tranquilization
than sedation, have increased efficacy on both positive and negative symptoms in the outpatient, and have fewer extrapyramidal
side effects.71,78,99,100 Their use in the ED is facilitated by intramuscular and oral dissolving tablet formulations that may assist in a
smoother transition to oral dosing in those patients requiring
ongoing antipsychotic therapy.78,101-103 Atypical antipsychotics
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PART V ◆ Special Populations / Section Eight • The Problem Patient
such as olanzapine, ziprasidone, and aripiprazole are proving
useful in the ED. Although the clinical significance is uncertain,
all of these atypical antipsychotics carry a black box warning associating their use with an increased risk of death in elderly patients
with dementia-related psychosis.
Olanzapine (Zyprexa) is readily available in intramuscular, oral,
and oral dissolving tablet formulations and has a distinct calming
effect in clinical practice.104 It has FDA-approved indications for
the treatment of agitation associated with bipolar I mania and
schizophrenia. Intramuscular olanzapine has an onset of action of
15 to 45 minutes after the initial administration.54 The intramuscular form is typically administered as an initial dose of 2.5 to
10 mg with one or two subsequent doses every 2 to 4 hours for a
total maximum dose of 30 mg.105,106 Although it is generally well
tolerated, side effects include sedation, mild hypotension, and
anticholinergic properties that can exacerbate existing anticholinergic intoxication. Olanzapine has minimal QTc-prolonging
effects and a lesser occurrence of acute dystonia and akathisia
compared with haloperidol.107-109 Compared with lorazepam 2 mg
IM, olanzapine 10 mg IM demonstrates more rapid effectiveness
in reducing acute agitation in patients with bipolar mania.110 In
the acutely agitated schizophrenic patient, olanzapine IM at doses
of 5 mg, 7.5 mg, and 10 mg is more rapidly effective than haloperidol 7.5 mg IM.108,109 In acute dementia-related agitation, olanzapine IM at doses of 2.5 mg and 5 mg is well tolerated and as
effective as lorazepam 1 mg IM.111
Ziprasidone (Geodon) is FDA approved for treatment of the
agitated schizophrenic and bipolar manic patient, and IM doses
of 10 to 20 mg are effective in reducing acute agitation in patients
with underlying psychotic disorders.112,113 By the intramuscular
route, typical dosing is 10 mg every 2 hours or 20 mg every 4
hours (not to exceed 40 mg/day) with an onset of action of 15 to
30 minutes.69,76 Ziprasidone is generally well tolerated, although
side effects such as somnolence, dizziness, and headache are not
uncommon.112,114 Ziprasidone has more QTc-prolonging effects
than olanzapine, haloperidol, or risperidone and is associated with
torsades in polydrug exposures.71,115-117 This QTc-prolonging effect
may be clinically insignificant in most patients, but the use of
ziprasidone is not recommended in those patients with significant
risk for or known QTc prolongation.102,118-120 An observational
study of ziprasidone IM in a psychiatric ED reported rapid clinical
efficacy and decreased total time in restraints compared with historical controls who had received various doses of medications
including haloperidol and lorazepam.121 A randomized doubleblind trial comparing IM ziprasidone 20 mg, droperidol 5 mg,
and midazolam 5 mg to treat undifferentiated agitation in the ED
reported a relative delay of sedation onset with ziprasidone and a
more frequent need for rescue medication to achieve sedation
with midazolam-treated patients.122
Aripiprazole (Abilify) has FDA-approved indications for the
treatment of agitation associated with the schizophrenia or bipolar
disorders. Recommended doses for the acutely agitated emergency
patient are 5.25 to 15 mg IM (often 9.75 mg) every 2 hours as
needed (to a maximum daily dose of 30 mg).123 Compared with
haloperidol IM (6.5 or 7.5 mg) in the agitated schizophrenic
patient, aripiprazole 9.75 mg IM is equivalent and well tolerated
without oversedation and with a lower risk of extrapyramidal
symptoms.124-126 In the treatment of the agitated bipolar patient,
aripiprazole IM (9.75 and 15 mg) has comparable efficacy to
lorazepam 2 mg IM and a low risk of oversedation with the
9.75-mg dose.127
Benzodiazepines and typical antipsychotics are commonly
used in combination to chemically restrain the agitated or violent
patient. Lorazepam 2 mg and haloperidol 5 mg given together
are more rapidly sedating than either medication alone, have
fewer adverse effects such as extrapyramidal symptoms when
combined, and are compatible within the same syringe for up to
16 hours.70,128,129 This combination, given intramuscularly or intravenously and repeated every 30 minutes as needed, is often recommended to treat the combative patient with undifferentiated
agitation and no contraindications to either of these medications.70,71,76,78,102,130 Half doses should be administered to otherwise
appropriate elder patients.
Assault and Hostage Situations
Unfortunately, physical assault may occur despite appropriate precautions and interventions. When it happens, maintain a sideward
posture, keeping the arms ready for self-protection. If you are
faced with a punch or a kick, deflect with an arm or a leg. If
choking is attempted, tuck the chin in to protect the airway and
carotids. If bitten, do not pull away but rather push toward the
mouth and hold the nares shut to entice opening of the mouth. If
threatened with a weapon, try to appear calm and comply with
demands.50 Adopt a nonthreatening posture and avoid sudden
movements. Do not attempt to reach for the weapon. Avoid argument, despair, or whining. Attempt to establish a human connection with the hostage taker.31,131 Offering to administer aid to other
ill or injured hostages allows a hostage to appear less expendable.
Do not bargain or make promises, and do not lie, as the consequences could be disastrous. Reassure the hostage taker that
someone authorized to hear the complaint or demand should
arrive promptly.131 If a weapon is put down, do not reach for it
but rather attempt to verbally resolve the crisis while awaiting the
arrival of security personnel. Legal authorities can be called on to
provide a professional hostage negotiator if one is needed.
Each hospital should have a plan of action for cases of extreme
violence. The plan should include prevention and safety measures,
a means for rapid notification of security and police personnel,
evacuation plans, medical treatment, and crisis intervention.50,131,132
A novel approach uses a violence management team trained in the
preceding techniques to provide a mechanism for dealing with
aggressive patients and protecting the staff.133
CLINICAL FEATURES
History and Physical Examination
Once combative patients are controlled, they need to be evaluated
for organic causes of their agitated behavior. Separation of functional from organic disease is a challenging task complicated by
the fact that many patients with psychiatric disorders suffer from
organic medical disorders that may worsen their symptoms.
Patients who exhibit violent behavior that is caused or exacerbated
by an organic problem may rapidly deteriorate if the medical
issues are not addressed in a timely fashion. A focused history and
physical examination assist the physician in differentiating functional from organic illness.
Several historical features distinguish functional (psychiatric)
from organic (medical) illness. Patients older than 40 years who
have a new onset of psychiatric symptoms are more likely to have
an organic cause.134,135 Also, elders are at higher risk for organic
delirium from medical illness or adverse medication reactions.
Patients with a history of drug or ethanol abuse may exhibit
violent behavior as a manifestation of an intoxication or withdrawal syndrome. The acute onset of agitated behavior as well as
behavior that waxes and wanes over time suggests an organic
origin. Most psychiatric patients are alert and oriented and have
a past psychiatric history. Table 188-1 lists clues to distinguish
functional from organic causes of violent behavior.
The history should include psychiatric, medical, family, and
social information, including suicidal ideation, medication use,
and any recent changes to prescribed medications. Family and
friends can often provide valuable details as the agitated patient
CHAPTER 188 / The Combative Patient
may be unreliable. When they are available, they should be interviewed independently from the patient. Medical records may
detail medical and psychiatric history as well as prior history of
violence. Drug and ethanol use is an important part of the history
as substance abuse is highly correlated with violent behavior.
The patient should be asked for permission to perform a thorough physical examination to search for an organic cause of
violent behavior and to uncover any resulting injury. Restraint
of the patient may be necessary to accomplish even the most
rudimentary physical examination. The importance of obtaining
routine vital signs including temperature and performing a
thorough mental status and neurologic examination cannot be
overemphasized. Patients with persistently abnormal vital signs, a
clouding of consciousness, or focal neurologic findings are more
likely to suffer from organic disease and require further diagnostic
evaluation. A careful examination should focus on the patient’s
general appearance (e.g., hygiene, nourishment, tremors) and vital
signs, evidence of trauma or needle tracks, characteristic odors,
neurologic and mental status, and signs of a possible toxidrome
(Table 188-2).136
DIAGNOSTIC STRATEGIES
Although some authors advocate a standardized panel of laboratory and radiographic studies for patients with psychiatric symptoms, most recommend tailoring of diagnostic studies on the basis
of clinical findings.130,134,137-141
2419
A rapid blood glucose determination and pulse oximetry should
be obtained for all combative patients. Patients younger than
40 years with a prior psychiatric history, normal physical examination findings including vital signs, calm demeanor, normal orientation, and no physical complaints are likely to require no further
diagnostic testing.139 Additional studies that may be useful in
selected patients include serum electrolyte values, blood and urine
toxicology screening, serum ethanol level, thyroid function panel,
cranial imaging, and electroencephalography.29,32,50,134 A lumbar
puncture may be performed if a central nervous system infection
is suggested. Specific medication levels may be determined when
toxic levels would affect therapy. An electrocardiogram may be
useful in elders and in the setting of a suggested intentional
ingestion. Patients who may have intentionally ingested a toxic
substance should also have aspirin and acetaminophen level measurements as these potentially fatal ingestions may be difficult to
diagnose clinically.
An additional consideration in the diagnostic workup is the
concern of the psychiatrist who will ultimately evaluate the patient.
Although serum ethanol and toxicology screening may not significantly influence a patient’s ED treatment, the psychiatrist may
use them to assess the degree to which ethanol or drug use contributes to the patient’s behavioral issues.134,142-144 Ideally, an agreement on a diagnostic strategy should be reached between the
psychiatrist and emergency physician before referral. Unnecessary
diagnostic testing prolongs ED length of stay and delays definitive
psychiatric care.
DIFFERENTIAL CONSIDERATIONS
Distinguishing Organic from Functional
Table 188-1 Causes of Violent Behavior
Violent behavior often occurs in association with head trauma,
hypoxia, hypoglycemia, electrolyte imbalance, infections (particularly herpes encephalitis), drug intoxication or withdrawal or
adverse reaction, and metabolic and endocrine derangements.31,50
Uncommon organic causes include seizures (e.g., temporal lobe,
limbic), tumors (particularly those in the limbic system), limbic
encephalitis, multiple sclerosis, porphyria, Wilson’s disease, Huntington’s disease, sleep disorders, hyperparathyroidism, and
vitamin and mineral deficiencies (e.g., folate, vitamin B12, niacin,
and vitamin B6).145 In the ED setting, drug or ethanol intoxication
and withdrawal are the most common diagnoses in combative
patients.33,58 The mnemonic FIND ME (functional, infectious,
neurologic, drugs, metabolic, endocrine) helps organize a diagnostic search for the cause of violence (Box 188-1).
ORGANIC
CLINICAL
FEATURE
Delirium
Dementia
FUNCTIONAL
Onset
Acute
Gradual
Gradual
Age at onset
Any
>50 years
<40 years
Alertness
Altered
Normal
Normal or
hyperalert
Orientation
Impaired
Normal
Normal
Hallucinations
Common; can be
visual, auditory,
or tactile
None
Auditory in
schizophrenia,
otherwise
uncommon
Symptom picture
Fluctuating
Stable
Stable
Abnormal vital
signs
Common
Uncommon
Uncommon
Medical Clearance
Psychiatric
history
No
No
Yes
The emergency physician often provides “medical clearance” for
the psychiatric or combative patient, although medical clearance
is a misnomer and the patient is not “cleared” of all possible
Table 188-2 Vital Signs and Toxic Syndromes
TOXIN
BP
P
RR
T
PUPIL SIZE
SKIN
EXAMPLE
Sympathomimetic
↑
↑
↑
↑
↑
Wet
Cocaine
Anticholinergic
↑/↓
↑
↑/↓
↑
↑
Dry
Diphenhydramine
Cholinergic
↑/↓
↑/↓
—
—
↓
Wet
Pesticides
Opiates
↓
↓
↓
↓
↓
—
Morphine
Sedatives
↓
↓
↓
↓
↑/↓
—
Lorazepam
Withdrawal (ethanol, sedative-hypnotics)
↑
↑
↑
↑
↑
Wet
Benzodiazepine withdrawal
Modified from Olshaker JS, Browne B, Jerrard DA, Prendergast H, Stair TO: Medical clearance and screening of psychiatric patients in the emergency department. Ann Emerg Med
4:124, 1997.
BP, blood pressure; P, pulse; RR, respiratory rate; T, temperature; ↑, increased; ↓, decreased; —, no change.
2420
PART V ◆ Special Populations / Section Eight • The Problem Patient
BOX 188-1 Problems Associated with Violence
Psychiatric
Schizophrenia
Paranoid ideation
Catatonic excitement
Mania
Personality disorders
Borderline
Antisocial
Delusional depression
Post-traumatic stress disorder
Decompensating obsessive-compulsive disorders
Homosexual panic
Situational Frustration
Mutual hostility
Miscommunication
Fear of dependence or rejection
Fear of illness
Guilt about disease process
Antisocial Behavior
Violence with no associated medical or psychiatric explanation
(these patients may be managed by the police or security)
Organic
Diseases
Delirium
Dementia
Trauma
Central nervous system infection
Seizure
Neoplasm
Cerebrovascular accident
Vascular malformation
Hypoglycemia
Hypoxia
Acquired immunodeficiency syndrome (AIDS)
Electrolyte abnormality
Hypothermia or hyperthermia
Anemia
Vitamin deficiency
Endocrine disorder
Drugs
Unanticipated reaction to prescribed medication (especially
sedatives in brain-injured or elderly patients)
Alcohol (intoxication and withdrawal)
Amphetamines
Cocaine
Sedative-hypnotics (intoxication or withdrawal)
Phencyclidine (PCP)
Lysergic acid diethylamide (LSD)
Anticholinergics
Aromatic hydrocarbons (e.g., glue, paint, gasoline)
Steroids
medical conditions on completion of the ED evaluation.137,146 In
addition, there is no standard process for the provision of what
may be more accurately termed a focused medical assessment.130
The incidence of organic disease in patients presenting with
psychiatric complaints ranges from 24 to 80%.134,147,148 The more
relevant issue for the emergency physician is to detect medical
problems that are contributing to the patient’s violent behavior.
Misattribution of aberrant organic behavior in a patient with
known psychiatric disease is a common cause of litigation.149
Most psychiatrists rely on the emergency physician’s medical
assessment of the patient. Low-risk patients with functional illness
can be rapidly referred for psychiatric evaluation once they are
calm and cooperative with a therapeutic psychiatric interview.
Patients at higher risk for an acute organic illness require further
diagnostic studies.
Once the medical screening evaluation is completed, the findings should be communicated to the consulting psychiatrist. The
medical record should reflect that the evaluation shows no evidence that an acute medical condition is contributing to the
patient’s behavior. If the cause of the patient’s violent behavior
is drug or ethanol intoxication, the patient should be observed
until a therapeutic interview can be conducted by the psychiatrist.
Alternatively, the patient may be transported to a facility where
observation can occur until the effects of the intoxicants
have abated.
Preparing the Emergency Department
to Prevent Violence
The risk of violence in the ED should be minimized in a
cost-effective manner without creating a hostile or negative environment. The prevention of violence is best accomplished by
development of a system that includes ongoing staff education,
adequate personnel, and a well-designed physical structure.
Security Personnel
A well-trained and responsive security force is a key element of
any hospital security system. Such personnel are expensive, and
their expertise is often sacrificed quickly during budget curtailments, so decisions about the type and number of guards are often
made on an economic basis. The use of guns by hospital security
personnel is controversial, as is allowing other armed law enforcement officers into the ED. Other devices, such as the Taser, stun
gun, and mace, are suggested as less lethal alternatives to guns.
Patient Searches
Searching of patients for weapons as they enter the ED is permissible when it is performed in a nondiscriminatory manner.131
Warning signs should be prominently displayed, perhaps reading
“For the safety of patients and staff, individuals entering the ED
may be screened for weapons.” Almost all patients and families
will cooperate with searches and may actually feel safer as a result.52
Clear written policies about searches and disposal of contraband
should be distributed to the staff and closely followed.
Alarm Systems
The goal of any alarm system is to obtain rapid appropriate
response with a minimum of false alarms. A tiered alarm system
is usually best. Panic buttons in each room activate a central
buzzer in the department. Several designated ED personnel
respond initially and then judge the level of response needed.
Every ED should have at least one telephone with a direct line to
police or security in case additional personnel are deemed necessary. A verbal code (e.g., “Dr. Armstrong to room 9”) is also a
useful adjunct.50
Limited Access to the Emergency Department
Control of flow into the ED can be an effective method of preventing violent acts. High-risk departments should limit access to one
or two entrances, especially during the evening hours. Bulletproof
glass barriers and buzzer access systems are useful as well.
Use of a Designated Room
The American College of Emergency Physicians recommends that
most EDs contain at least one secure examination room with
CHAPTER 188 / The Combative Patient
shatterproof ceiling lights, solid ceiling, heavy indestructible
chairs, well-secured restraint bed, two doors that can be locked
from the outside, and emergency distress button that can be activated unobtrusively.131 If it is desired, this room can be set up for
video monitoring by security or ED staff. One large urban county
hospital with a high incidence of violent behavior in the ED is
equipped with a large security force, metal detectors, bulletproof
Plexiglas triage area, keypad security entry, controlled entryway
into the ED, and metal bars to prohibit cars from driving into the
department.19 This hospital reported no occurrence of weaponsrelated violence or injury in the ED after these measures were
implemented.
Prevention
The concepts of primary, secondary, and tertiary prevention of
violence can be applied to the ED environment.14 Primary prevention refers to trying to control those factors that encourage the
development of frustration and aggression. Long waiting times are
associated with development of violent behavior. Attempts to
shorten waiting times and to make the waiting room environment
as pleasant as possible may diminish previolent aggression. The
presence of surveillance cameras and a visible security force also
act as deterrents.
Secondary prevention of violence involves response to previolent agitation and aggression. Successful intervention involves
the recognition of risk and implementation of de-escalation
techniques. Staff should be trained to recognize previolent individuals who should be seen in a timely manner. The aura of
preferential treatment often defuses the situation.133 Training of
staff in techniques for management of violence leads to increased
staff confidence and comfort while decreasing the rate of aggressive incidents.150,151
Tertiary prevention refers to limitation of the actual act of violence itself once it has occurred. Physical and chemical restraints
are used, and security and police intervention are often needed.
2421
Protocols for dealing with the violent patient are important to
minimize risks to the patient and staff. Enhanced security measures may be indicated in an ED with substantial risk for
violence.
Violence is increasingly a major public health issue, with
increased focus on improving surveillance and universal preventive measures to target large populations.152-154 Physicians are
increasingly aware of their role in reducing violence, and the ED
is uniquely positioned to have an impact on at-risk populations.
Proposed agendas for violence prevention for emergency medicine
include improvements in medical education, research, and clinical
practice as well as involvement with public education and advocacy.155,156 Resources, particularly those aimed at youth violence
intervention and prevention in the medical setting, are available
to assist health care providers in the ED.154
KEY CONCEPTS
■ ED staff should be trained to recognize potentially violent
individuals and to intervene with de-escalation techniques.
■ The ED should have a written plan of action to deal with
violence that integrates the activities of ED staff, hospital
administration, security, and local authorities.
■ The emergency physician should be familiar with the use of
physical and chemical restraints.
■ The possibility of an organic (medical) cause of aggressive
behavior should be considered in all violent patients, even
those with known psychiatric disease.
■ ED leadership should be proactive in attempting to create an
environment that is safe and supportive for both patients
and staff.
The references for this chapter can be found online by
accessing the accompanying Expert Consult website.
CHAPTER 188 / The Combative Patient
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