see: [Dunn Violence](x-devonthink-item://64407D91-FE6B-4913-8120-87A4EAABFCFF), [RMH occupational violence and aggression (OVA)](https://www.health.vic.gov.au/worker-health-wellbeing/occupational-violence-and-aggression-resources) [Dunn - staff protection and safety](x-devonthink-item://4F43B97B-9FDF-48E8-8AF1-C3DF4A23DD01) - [ACEM Violence in ED guideline](x-devonthink-item://0DD8BC77-E483-4F61-917D-4A25FEF190C9) - [ACEM restrictive practices guideline](x-devonthink-item://9B62F4F9-32DB-47B5-8EF7-C7BC868FBC3A) [MHWA principles for restrictive interventions (bear)](bear://x-callback-url/open-note?id=D3A5380B-A720-4352-8E12-9748DA872991-43360-0000148CA046510B&header=MHWA%20principles%20for%20restrictive%20interventions%20%28RMH%29) see also: [[Domestic violence|intimate partner violence]], [[Delirium vs psychosis]], [[Sedation and restraint]], [[Agitation]], [[Capacity and consent]], [[Sedation and restraint#Decision-making principles for restrictive treatment and intervention]] ![[Sedation and restraint#Decision-making principles for restrictive treatment and intervention]] ## Risk factors - violence in previous 72 hours - substance abuse - psychosis - personality disorder - childhood abuse - male sex ## DDx - substance abuse (EtOH, amphetamine, benzo/opiate withdrawl) - schiziphrenia or mania - personality disorders - hypoglycaemia - hypoxia - head injury - dementia with acute delirium - post-ictal state - CNS infection ## Risk factors for organic cause - age > 40 w/ no prior psych history - disorientation - ALOC - abnormal vital signs - visual hallucinations - illusions - unconcerned regarding personal privacy ## Ix none or many depending on situation # Management of violence in ED **prevention** - train staff in aggression de-escalation techniques - alert system to advise of previous violent behaviour ; may need security to attend **ED design** - seclusion rooms away from high traffic areas - quiet area for disturbed patients - waiting area not visible from street - control of ED access, duress alarms **Preparation** - strip search all potentially violent patients ## Clinical management - see agitated patients as soon as possible - alert security before incident occurs - separate them fro other staff - remove items that could be used to harm (necklass, stethoscopes, pins) - always have an escape route - keep hands visible **communication** - one person as primary communicator - acknowledge patient's feelings (eg frustration, anger) - try and give the patient choices - always draw the line regarding acceptable behaviour "I would like to help you but I will not stay if you threaten me" - offer patient restraint ## De-escalation - many agitated pts are terrified of losing control ; welcome efforts to prevent them from acting out - less effective in pts with drug induced psychosis, command hallucinations, and severe paranoia **anger diffusion techniques** - introduce self and address the patient formally to convey respect - ask why angry , try and address issue and be honest - ask simple questions about pts age, occupation, interest, etc - empathetic verbal intervention - express your concern for your safety when appropriate - ask non threatening questions - direct conversation towards problem solving - offer comforts - always give patient choices *do not* - appear judgemental - negate the pts right to feel angry - counter attack (threaten to take away privileges) - react to baited comments - adopt a defensive body position - ask them why they are behaving this way *take time out* whenever you feel you may be losing control of your own emotions *set limits* -- use only if other diffusing techniques have been ineffective - describe unacceptable behaviour - request behaviour change - describe consequences if violence continues - outline choices available **AGRO technique** - **A**ngry -- find out why they are angry - **G**auge your own feelings - **R**espond openly to engage pt in conversation - **O**bserve pts non-verbal behaviours *TADA* approach: tolerate, anticipate, do not agitate (usually for delirium) ## Restraint see also [[Delirium vs psychosis#treatment for geriatric delirium and agitation]], [[Sedation and restraint]], [Bear - Geriatric sedation](bear://x-callback-url/open-note?id=9E5A56AB-8311-482F-AD97-2B40637F765B-94035-00001093D8490E17) [[Capacity and consent]] **aims** - to prevent harm to self or others, property damage - to allow appropriate assessment (physical exam, investigations) ### Chemical restraint **oral** - lorazepam 1-2 mg - olanzapine 5-10 mg - rispiridone 0.25 - 0.5mg (delirium in elderly) - quetiapine 12.5 - 25mg in pts with PKD or lewy body dementia **IM and IV** IM slower but may be necessary if unable to get IV access - midazolam 5-10mg IM/ IV ; repeat Q 15 min if required - olanzapine or haloperidol 5-10mg IM ; repeat in 30 min if required - max dose 20 mg/ 24 hours - droperidol 5-10 mg IM or IV - avoid in elderly due to falls and NMS - max 20 mg in 24 hours ### physical restraint - last resort if de-escalation techniques have failed