violence in the er edited

8/8/2019 Violence in the ER Edited

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VIOLENCE IN THEEMERGENCY

DEPARTMENT Adapted from source


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A plan for our hospitals.

Management of violent/aggressivepatients

Objectives.


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HURDLES

Staff lack experience

Hospitals safe rooms

Security personnel

Specialised units

Referral to Psychiatrists


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A successful plan for preparing staff to deal with

these cases involves: E ducate staff to anticipate violent or

aggressive behaviour. Where in the ED to place a potentially violent

patient. When to request more assistance. Proper body language to employ.

The preparation of a protocol for utilisingemergency restraints either physical,mechanical or chemical.


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Mo st vi ol ent behavi our in our so ciety is simp le c r imina l ity

H ow eve r

R eq u ir es a medica l and menta l stat u s

eva lu ati o n exc lu sio n.


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T he vast maj or ity of patients w ith psychiat r icdisease ar e neve r agg r essive, dange rou s or viol ent .

Cau ses of agg r essive and vi ol ent behavi our inED a r e many and inc lu de 4 b ro ad categ or ies :

A. D ru g and a lco hol ab u se.

B. Pe r so na lity or behavi our al dis or de r s.

C. Psychiat r ic diseases

D. O r ganic b r ain synd ro mes


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A. Drug and alcohol abuse: Common cause.

A lco hol :Int o xicati o n w ith or w ith ou t De l ir iu m.

Withd r a w a l De l ir iu m (D T s).Cannabis.

Amphetamines.Co caine.Benzene and g lu es.M ethaq u a lo ne / M and r ax.Sedatives, hypn o tics & anxi ol ytics.

Antich ol ine r gics.

Ste ro ids.Pol ypha r macy and o ver do sage: co mm o n inthe e lde rl y.


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B . Personality or behavioural

disorders: pe r so na lity dis or de r s

no psychiat r ic i ll ness

cann o t be ta lk ed d ow n

BES T

handl

ed by:ho spita l sec ur ity or pol ice

AC T ING OU T


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C. Psychiatric diseases:

A cute Mania:commondeceptive!

Schizophrenia:NB paranoid

? common


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D. Organic brain syndromes:Co n fu sed and o ccasi o na ll y agg r essive behavi our w hen the

b r ain s fu ncti o ning is dist ur bed by:I ll ness.Head inj ur y.Dist ur bed metab ol ism.

Ha ll ma rk s:Dis or ientati o nF lu ct u ating level of co nsci ou sness.Vita l signs abn or ma l .

Co mm o n - ol de r , in-patient.M enta l r eta r dati o n / dementia:

Kn ow n to ca r egive r s - of ten


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Metabolic causes:D iabetes Mellitus.D ehydrationRenal impairment.Hepatic impairment.E lectrolyte disturbances.

CVS causes:A noxia.CCF.D issecting aneurysm.MI.Cardiac Tamponade.

Infective causes:Meningitis.Viral infections.UTIsSyphilis.HIV-related.Malaria.

Nutritional causes:Pellagra.Hypoglycaemia.

Intracranial causes :Tumours.Haemorrhages.E pilepsy.CVA s.Injuries.


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R espi r at or y ca u ses: T B.

Pneu

mo

nia.Pne u m o th or ax.P leur a l effu sio n.

Sur gica l ca u ses:Pa r a l ytic i leu s.

Acu te abd o men.Full b ladde r .Sepsis.Fr act ur es.

Ca u se of po st- o pe r ative and p o st-t r au matic c o n fu sio n isha r d l y eve r psychiat r ic.


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W hen to be on the alert for the possibility of

aggressive or violent behaviour:For e w ar ned is for ea r med

Scena r io s:

Fami l y or fr iends: ou t of co nt rol , w ild, c r azy, ang r y

R est r ained: fr iends, p ol ice or QAS

Unde r the in flu ence: d ru gs and/ or alco hol

P r ior hist or y of viol ent behavi our


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High- r isk f act or s ass o ciated w ith vi ol ence inthe eme r gency depa r tment inc lu de:

A lco hol or d ru g ab u se.

M ale gende r???

Night time- lo nge r w aiting times or p r eva lent a lco hol and d ru g ab u se.

Past hist or y of viol ence in ED.


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W ho should you call for help: A . Security staff/ Wardies.

B. Police.

C. A mbulance attendants.

D

. On call Senior Medical Officer.

E . Hospital Manager, A dministrators.


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Police:R emembe r , m o st viol ent and agg r essive behavi our is

cr imina l in nat ur e, and the r efor e sh oul d n o t be dea lt w ith or viathe heath ca r e system.

Call the p ol ice immediate l y if the patient:

M ak es any th r eats, ve r ba l or physica l .

Acts dest ru ctive l y (e.g. hits the w all s, dest ro yseq u ipment, hits s o me o ne).

Is n o isy, hype r active and wo n t q u iet d ow n a f te r 1 or 2r eq u ests.

Is armed (e.g. g

un,

k ni

f e

orb

rok en b

ott

le.)


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Do

no

t infor

m the patient that you

have call

ed the pol

ice this may ma k e him even m or e agg r essive I ll ta k e thema ll o n.

D o no t t r y to neg o tiate w ith a pe r so n disp laying this leve l of

agg r essi o n

I f af te r you have ca ll ed the p ol ice, the patient seems t oca lm d ow n o n his ow n, do no t ca ll off the p ol ice .

A llow the p ol ice t o co me and eva lu ate the sit u ati o n

T he medica l off ice r sh oul d evalu ate w hethe r it is sa f e t oa llow the p ol ice t o leave, or no t


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Triage:

patient in r est r aints - C r ash Roo m

lar gest t r eatment roo m in ED

Sta ff man o eu v r abi lity

m o nit or ing and r esu s eq u ipment

r elatives or fr iends

R est r aints do no t r em o ve.


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How to act in the presence of AGGRESSION:

A. T wo s c o mpany.

B. Stay ca lm.

C. P o siti o n your se lf ca r efull y.

D. B o dy lang u age.

E. O ff er a snac k or d r ink .

F. Chec k for w eap o ns.

G. T oo ho t to hand le.


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A. Twos company:

F r ightened !!!

Be ca lm and m or e r eass ur ed


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B . Stay calm:

Spea k slowl y and p ol ite l y.

T r y no t t o sh ow ange r

Int ro du ce your se lf and as k w hy he is ang r y

Do n t a r gu e bac k and do n t ag r ee w ith the patient if hehas any de lu sio ns or biza rr e ideas .

A llow the patient t o venti late a bit , w ith ou t bec o mingju dgmenta l


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He may have r eas o ns for that ange r

R emembe r

A litt le empathy s o metimes g o es a

lo ng w ay!


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C. Position yourself carefully:H ow f ar a w ay fro m the patient sh oul d you stand ?

Stand ab ou t 1.5 met r es in fro nt of him, b u t a bit off to the sided o no t f ace him di r ect l y.

T his is c lo se en ou gh t o allow you to deve lo p ar app or t, b u t f ar en ou gh a w ay s o that y ou do no tth r eaten his pe r so na l space and he can t easi l y

tou ch or hit y ou .

Do n t t ur n your bac k o n him.

A lw ays app ro ach the patient fro m the fro nt .


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D. B ody language: Ad o pt a su bmissive p o se

fo cu s your eyeso n his chin.

pe r ceived as less th r eatening , and hishands can be easi l y seen .


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E. Offer a snack or drink:O ff er the patient j u ice, bisc u its, a s of t d r ink , and maybe

have s o me y our se lf .

Sha r ing foo d is a nat ur al bo ndbet w een pe o p le

ho t d r ink s

Sitting d ow n t o gethe rbu t do no t sit d ow n i f the patient r efu ses t o sit d ow n.

Do n t sit in a c or ne r , w he r e you can be t r apped.


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G. Too HOT to handle:


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G. Too HOT to handle: A lth ou gh vi ol ence can o ccur qu ickl y and r and o m l y, in m o st

cases the r e is s o me advance w ar ning : Ange r .

Agitati o n. A c lenched- f ists p o st ur e.

Lou d behavi our . Ye ll ing.

N o he ro ics !---bac k ou t of the roo m q u ickl y---ru n i f youhave t o !


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A viol ent patient is u n lik el y to hur t o the r patients ---the sta ff

is mor

e atris

k .

I f the patient ru ns ou t of the h o spita l---let him g o .

Pol ice ????? .

I f the r e a r e 2 of you in roo m, ru n off in o pp o sitedi r ecti o nshe can t chase b o th!


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Restraints available: A. Physica l r est r aint.

B. M echanica l r est r aint.

C. Chemica l r est r aint.

NO T E:P ro tective

NO T pu nitive!!!


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B . Mechanical restraints:Q ueensland F CHSD Policy & Procedure manual.

G ive verbal/written order sooner than later

App l y qu ickl y and h u mane l y as p o ssib le.

Even i f the patient ca lms d ow n, the n ur ses sh oul d n o tr

emo

ve them.


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M O sh oul d decide

Latera

lp

ositi

on

A sof t nec k coll ar - p ro tect -di ff icul t for him t o bite s o me o ne

ImportantDo n t leave a r est r ained patient a lo ne in the roo m.

M ak e s ur e the r e is s o me k ind of m o nit or ing r egimen in p lace.

R est r aints sh oul d be r em o ved a f te r ever y 30 min u tes , a f te r patient has been sedated.


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C. Chemical restraint:Pa r t of the o ver all p lan.N o idea l d ru g for all sit u ati o ns.

Know a f e w w ell , inc lu ding side e ff ects and p r eca u tio ns.D ru gs u sed t o co nt rol agitati o n ta k e time t o work , the r efor e

give ea rl ie r r athe r than late r .

D ru gs c o mm o n l y u sed:

O lanzapine (Zyp r exa). T AB/Wa f er s/I M 10mg/1m l Lor azepam (Ativan): I M 2mg/1m lCh lor p ro mazine (La r gacti l): I M /IV 5mg/1m lHa lo pe r idol (Se r enace): I M /IV 5mg/1m l


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Olanzapine (Zyprexa):10mg I M / or al/SL.

M ay have speci f ic anti-mania e ff ect.

10mgrou

ghl y = 7.5 mg Ha

lo pe

rid

ol. Ver y f e w side e ff ects:

Vi r tu all y no EPS.Occasi o na l hyp o tensi o n

Litt le sedating e ff ect- e lde rl y.

Patient r emains a ler t, or iented and c oo pe r ative .Has de layed o nset of acti o n, may ta k e days.

Ver y expensive.


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Lorazepam (Ativan.):N o t as e ff ective i f given or a ll y.2mg t o 4 mg I M or IV s lowl y.

M ax. 6mg in 24 h our s.

Goo d ch o ice in patients w ith:Su spected d ru g-ind u ced dis or de r .

O r ganic b r ain synd ro meM ania.

E ff icacy enhanced by c o -administ r ati o n w ith Ha lo pe r id olIM or IV.

Adve r se e ff ect: w atch for r espi r at or y dep r essi o n,

hyp o tensi o n and behavi our al disinhibiti o n, esp. in theelde rl y.


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Chlorpromazine (Largactil.):50mg t o 100mg PO stat or 25mg t o 50mg I M .

Adve r se e ff ects: Ver y sedating.Hyp o tensi o n.

Pain ful injecti o n.

Co nt r aindicati o ns:

Epi lepsy.R ecent excessive u se of a lco hol .Ch ro nic hepatic disease.

E lde rl y.R ecent hist or y or evidence of head inj ur y.

P r e-existing ca r diac disease.


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Haloperidol (Serenace.):5mg I M or IV.

Can r epeat w ithin 1 t o 2 hour s.M ax. 3 d o ses in 24 h our s.

Use ha lf do ses in the e lde rl y.

R elative l y sa f e, e ff ective and cheap.Mul tip le adve r se e ff ects:

So me EPS r eacti o ns: dyst o nias, a k athisia, m o tor r est lessness.R ar el y:

Su dden death.Ne urol eptic M alignant Synd ro me.


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Summary:H o spita l p lan for viol ent or agg r essive patient.

Know r esour ces Wh o sh oul d be ca ll ed Whe r e t o pu t the patient

Know your r est r aintsPhysica lM echanica l

Chemica l

Deb r ie f your sta ff .

violence in the er edited

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