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HandlingHandling violentviolent oror aggressiveaggressive patients:patients: aa planplan forfor youryour
HandlingHandling violentviolent oror aggressiveaggressive
patients:patients:
aa planplan forfor youryour hospital.hospital.
DRDR HH VV KING.KING.
HURDLESHURDLES ININ DEALINGDEALING WITHWITH VIOLENTVIOLENT OROR AGGRESSIVEAGGRESSIVE PATIENTS:PATIENTS: ••
HURDLESHURDLES ININ DEALINGDEALING WITHWITH VIOLENTVIOLENT OROR
AGGRESSIVEAGGRESSIVE PATIENTS:PATIENTS:
•• StaffStaff lacklack experienceexperience inin dealingdealing withwith suchsuch
individuals.individuals.
•• HospitalsHospitals lacklack “safe“safe rooms”rooms” wherewhere aa patientpatient cancan bebe
keptkept withoutwithout dangerdanger toto himhim oror herselfherself oror others.others.
•• LackLack ofof adequateadequate securitysecurity personnel,personnel, esp.esp. duringduring
eveningevening andand nightnight hours.hours.
•• DistancesDistances toto specialisedspecialised unitsunits areare far.far.
•• LackLack ofof clearclear referralreferral pathspaths toto psychiatrists,psychiatrists, whowho
areare notnot inin oversupply.oversupply.
AA successfulsuccessful planplan forfor preparingpreparing staffstaff toto dealdeal withwith thesethese casescases
AA successfulsuccessful planplan forfor preparingpreparing staffstaff toto dealdeal withwith
thesethese casescases involves:involves:
•• TeachingTeaching staffstaff howhow toto anticipateanticipate whenwhen violentviolent oror
aggressiveaggressive behaviourbehaviour maymay occur.occur.
•• WhereWhere inin thethe casualtycasualty toto placeplace aa potentiallypotentially violentviolent
patient.patient.
•• WhenWhen toto requestrequest moremore assistance.assistance.
•• ProperProper bodybody languagelanguage toto employ.employ.
•• TheThe preparationpreparation ofof aa protocolprotocol forfor utilisingutilising
emergencyemergency restraintsrestraints eithereither physical,physical, mechanicalmechanical
oror chemical.chemical.
•• AlthoughAlthough aggressiveaggressive behaviourbehaviour cancan bebe aa symptomsymptom ofof medicalmedical oror
•• AlthoughAlthough aggressiveaggressive behaviourbehaviour cancan bebe aa symptomsymptom
ofof medicalmedical oror psychiatricpsychiatric illness,illness, mostmost violentviolent
behaviourbehaviour inin ourour societysociety isis simplesimple criminality,criminality,
unrelatedunrelated toto illness,illness, whichwhich isis oftenoften betterbetter handledhandled
byby thethe police,police, thethe prisonsprisons andand thethe courts.courts.
•• However,However, decidingdeciding ifif suchsuch behaviourbehaviour isis thethe resultresult
ofof diseasedisease requiresrequires aa medicalmedical andand mentalmental statusstatus
evaluation.evaluation.
•• TheThe vastvast majoritymajority ofof patientspatients withwith psychiatricpsychiatric diseasedisease areare
•• TheThe vastvast majoritymajority ofof patientspatients withwith psychiatricpsychiatric
diseasedisease areare nevernever aggressive,aggressive, dangerousdangerous oror violent.violent.
•• CausesCauses ofof aggressiveaggressive andand violentviolent behaviourbehaviour inin
casualtycasualty areare manymany andand includeinclude 44 broadbroad categories:categories:
A.A. PsychiatricPsychiatric diseases.diseases.
B.B. OrganicOrganic brainbrain syndromes.syndromes.
C.C. DrugDrug andand alcoholalcohol abuse.abuse.
D.D. PersonalityPersonality oror behaviouralbehavioural disorders.disorders.
A.A. PsychiatricPsychiatric diseases:diseases: •• AcuteAcute Mania:Mania: AA relativelyrelatively commoncommon
A.A. PsychiatricPsychiatric diseases:diseases:
•• AcuteAcute Mania:Mania:
AA relativelyrelatively commoncommon psychiatricpsychiatric cause.cause.
CanCan bebe deceptivedeceptive becausebecause thethe personperson maymay bebe outwardlyoutwardly
quitequite pleasantpleasant andand jovialjovial------untiluntil angered!angered!
•• Schizophrenia:Schizophrenia:
Esp.Esp. thethe paranoidparanoid variety.variety.
OftenOften quotedquoted asas beingbeing aa commoncommon causecause ofof casualtycasualty
departmentdepartment violenceviolence inin thethe literature,literature, butbut lessless commoncommon
thanthan mania.mania.
B.B. OrganicOrganic brainbrain syndromes:syndromes: •• ByBy thisthis termterm isis meantmeant confusedconfused
B.B. OrganicOrganic brainbrain syndromes:syndromes:
••
ByBy thisthis termterm isis meantmeant confusedconfused andand occasionallyoccasionally aggressiveaggressive behavbehaviouriour
whenwhen thethe brain’sbrain’s functioningfunctioning isis disturbeddisturbed by:by:
••
Illness.Illness.
HeadHead injury.injury.
DisturbedDisturbed metabolism.metabolism.
TheThe hallmarkshallmarks ofof thisthis are:are:
••
••
DisorientationDisorientation
AA fluctuatingfluctuating levellevel ofof consciousness.consciousness.
AbnormalAbnormal vitalvital signs.signs.
MoreMore ofof aa problemproblem ofof thethe older,older, inin--patientpatient thanthan thethe casualtycasualty dept.dept.
patient.patient.
MentalMental retardationretardation // Dementia:Dementia:
DiagnosisDiagnosis isis usuallyusually wellwell knownknown toto thethe caregiverscaregivers andand isis oftenoften
obviousobvious toto thethe medicalmedical personnel.personnel.
•• MetabolicMetabolic causes:causes: DiabetesDiabetes Mellitus.Mellitus. DehydrationDehydration RenalRenal
•• MetabolicMetabolic causes:causes:
DiabetesDiabetes Mellitus.Mellitus.
DehydrationDehydration
RenalRenal impairment.impairment.
HepaticHepatic impairment.impairment.
ElectrolyteElectrolyte disturbances.disturbances.
•• CVSCVS causes:causes:
Anoxia.Anoxia.
CCF.CCF.
SBE.SBE.
DissectingDissecting aneurysm.aneurysm.
MI.MI.
CardiacCardiac Tamponade.Tamponade.
•• InfectiveInfective causes:causes: Meningitis.Meningitis. ViralViral infections.infections. UTI’sUTI’s
••
InfectiveInfective causes:causes:
Meningitis.Meningitis.
ViralViral infections.infections.
UTI’sUTI’s
Syphilis.Syphilis.
HIVHIV--related.related.
Malaria.Malaria.
••
NutritionalNutritional causes:causes:
Pellagra.Pellagra.
Hypoglycaemia.Hypoglycaemia.
••
IntracranialIntracranial causes:causes:
Tumours.Tumours.
Haemorrhages.Haemorrhages.
Epilepsy.Epilepsy.
CVA’s.CVA’s.
Injuries.Injuries.
•• RespiratoryRespiratory causes:causes: TB.TB. Pneumonia.Pneumonia. Pneumothorax.Pneumothorax.
••
RespiratoryRespiratory causes:causes:
TB.TB.
Pneumonia.Pneumonia.
Pneumothorax.Pneumothorax.
PleuralPleural effusion.effusion.
••
SurgicalSurgical causes:causes:
ParalyticParalytic ileus.ileus.
AcuteAcute abdomen.abdomen.
FullFull bladder.bladder.
Sepsis.Sepsis.
Fractures.Fractures.
••
CauseCause ofof postpost--operativeoperative andand postpost--traumatictraumatic confusionconfusion isis
hardlyhardly everever psychiatric.psychiatric.
C.C. DrugDrug andand alcoholalcohol abuse:abuse: •• •• CommonCommon cause.cause. Alcohol:Alcohol: ••
C.C. DrugDrug andand alcoholalcohol abuse:abuse:
••
••
CommonCommon cause.cause.
Alcohol:Alcohol:
••
••
••
••
••
••
IntoxicationIntoxication withwith oror withoutwithout Delirium.Delirium.
WithdrawlWithdrawl DeliriumDelirium (DT’s).(DT’s).
Cannabis.Cannabis.
Amphetamines.Amphetamines.
Cocaine.Cocaine.
BenzeneBenzene andand glues.glues.
MethaqualoneMethaqualone // Mandrax.Mandrax.
Sedatives,Sedatives, hypnoticshypnotics && anxiolytics.anxiolytics.
•• Anticholinergics.Anticholinergics.
Steroids.Steroids.
PolypharmacyPolypharmacy andand overdosage:overdosage: commoncommon inin thethe elderly.elderly.
••
••
D.D. PersonalityPersonality oror behaviouralbehavioural disorders:disorders: •• •• •• •• ••
D.D. PersonalityPersonality oror behaviouralbehavioural
disorders:disorders:
••
••
••
••
••
ThoseThose withwith antisocial,antisocial, narcissisticnarcissistic oror borderlineborderline
personalitiespersonalities cancan bebe quitequite noisynoisy andand aggressive.aggressive.
TheseThese areare usuallyusually notnot classifiedclassified asas havinghaving psychiatricpsychiatric
illnesses.illnesses.
DifficultDifficult toto handlehandle becausebecause theythey cannotcannot bebe “talked“talked down”.down”.
MoreMore properlyproperly handledhandled byby hospitalhospital securitysecurity oror thethe police.police.
‘ACTING‘ACTING OUT”OUT” oror Hysteria,Hysteria, esp.esp. inin adolescentsadolescents——thesethese
cancan getget quitequite aggressive.aggressive.
WhenWhen toto bebe onon thethe alertalert forfor thethe possibilitypossibility ofof aggressiveaggressive oror
WhenWhen toto bebe onon thethe alertalert forfor thethe possibilitypossibility ofof
aggressiveaggressive oror violentviolent behaviour:behaviour:
••
••
••
AsAs inin anyany problem,problem, forewarnedforewarned isis forearmed.forearmed.
ImportantImportant toto knowknow whenwhen aggressiveaggressive oror violentviolent behaviourbehaviour isis
likelylikely toto occur.occur.
ConsiderConsider thethe followingfollowing scenarios:scenarios:
FamilyFamily oror friendsfriends useuse wordswords suchsuch asas “out“out ofof control”,control”,
“wild”,“wild”, “crazy”“crazy” oror “angry”“angry” toto describedescribe thethe patient.patient.
PatientPatient isis broughtbrought toto thethe casualtycasualty restrainedrestrained byby friends,friends,
thethe policepolice oror thethe ambulanceambulance attendants.attendants.
PatientPatient isis underunder thethe influenceinfluence ofof drugsdrugs oror alcohol’alcohol’
PatientPatient hashas beenbeen knownknown toto havehave indulgedindulged inin violentviolent
behaviourbehaviour inin thethe past,past, eithereither towardstowards othersothers (e.g.(e.g. spouse)spouse)
oror hashas behavedbehaved violentlyviolently inin thethe casualty.casualty.
•• HighHigh--riskrisk factorsfactors associatedassociated withwith violenceviolence inin thethe emergencyemergency
•• HighHigh--riskrisk factorsfactors associatedassociated withwith violenceviolence inin
thethe emergencyemergency departmentdepartment include:include:
AlcoholAlcohol oror drugdrug abuse.abuse.
MaleMale gender.gender.
NightNight timetime------possiblypossibly relatedrelated toto longerlonger waitingwaiting
timestimes oror toto moremore prevalentprevalent alcoholalcohol andand drugdrug
abuseabuse duringduring thesethese times.times.
PastPast historyhistory ofof violenceviolence inin CasualtyCasualty Dept.Dept.
WhoWho youyou shouldshould callcall forfor help:help: •• A.A. OnOn callcall MedicalMedical Officer.Officer. ••
WhoWho youyou shouldshould callcall forfor help:help:
•• A.A. OnOn callcall MedicalMedical Officer.Officer.
•• B.B. SecuritySecurity staff.staff.
•• C.C. Police.Police.
•• D.D. AmbulanceAmbulance attendants.attendants.
•• E.E. HospitalHospital Manager.Manager.
A.A. OnOn callcall MedicalMedical Officer:Officer: •• •• •• NeededNeeded forfor physicalphysical andand
A.A. OnOn callcall MedicalMedical Officer:Officer:
••
••
••
NeededNeeded forfor physicalphysical andand mentalmental statestate evaluation.evaluation.
TakesTakes controlcontrol ofof situation.situation.
RequiresRequires trainingtraining inin calmingcalming andand restraintrestraint ofof patient.patient.
B.B. SecuritySecurity staff:staff: •• AlsoAlso requirerequire trainingtraining inin calmingcalming andand
B.B. SecuritySecurity staff:staff:
••
AlsoAlso requirerequire trainingtraining inin calmingcalming andand restraintrestraint ofof patients,patients,
especiallyespecially inin absenceabsence ofof police.police.
C.C. Police:Police: •• •• Remember,Remember, mostmost violentviolent andand aggressiveaggressive
C.C. Police:Police:
••
••
Remember,Remember, mostmost violentviolent andand aggressiveaggressive behaviourbehaviour isis
criminalcriminal inin nature,nature, andand thereforetherefore shouldshould notnot bebe dealtdealt withwith
viavia thethe heathheath carecare system.system.
CallCall thethe policepolice immediatelyimmediately ifif thethe patient:patient:
MakesMakes anyany threats,threats, verbalverbal oror physical.physical.
ActsActs destructivelydestructively (e.g.(e.g. hitshits thethe walls,walls, destroysdestroys
equipment,equipment, hitshits someone).someone).
IsIs noisy,noisy, hyperactivehyperactive andand won’twon’t quietquiet downdown afterafter 11 oror 22
requests.requests.
IsIs armedarmed (e.g.(e.g. gun,gun, knifeknife oror brokenbroken bottle.)bottle.)
•• DoDo notnot informinform thethe patientpatient thatthat youyou havehave calledcalled thethe policepolice——
••
DoDo notnot informinform thethe patientpatient thatthat youyou havehave calledcalled thethe policepolice——
thisthis maymay makemake himhim eveneven moremore aggressiveaggressive
allall on”.on”.
“I’ll“I’ll taketake themthem
••
••
••
••
DoDo notnot trytry toto negotiatenegotiate withwith aa personperson displayingdisplaying thisthis levellevel ofof
aggressionaggression
IfIf afterafter youyou havehave calledcalled thethe police,police, thethe patientpatient seemsseems toto
quietquiet downdown onon hishis own,own, dodo notnot callcall offoff thethe police.police.
AllowAllow thethe policepolice toto comecome andand evaluateevaluate thethe situationsituation
TheThe medicalmedical officerofficer shouldshould evaluateevaluate whetherwhether itit isis safesafe toto
allowallow thethe policepolice toto leave leave
D.D. AmbulanceAmbulance attendants:attendants: •• •• IfIf thethe patientpatient requiresrequires moremore
D.D. AmbulanceAmbulance attendants:attendants:
••
••
IfIf thethe patientpatient requiresrequires moremore securitysecurity thanthan cancan bebe offeredoffered byby
thethe nursingnursing staffstaff andand securitysecurity onon duty,duty, oror ifif helphelp isis neededneeded
toto applyapply oror adjustadjust restraints.restraints.
Note:Note: needneed toto arrangearrange anan agreementagreement withwith EMRSEMRS toto provideprovide
thisthis service.service.
E.E. HospitalHospital Manager:Manager: •• IfIf thethe police’spolice’s assistanceassistance hashas beenbeen
E.E. HospitalHospital Manager:Manager:
••
IfIf thethe police’spolice’s assistanceassistance hashas beenbeen summoned,summoned, needneed toto
informinform thethe HospitalHospital Manager.Manager.
Triage:Triage: wherewhere toto placeplace anan aggressiveaggressive oror potentiallypotentially violentviolent
Triage:Triage: wherewhere toto placeplace anan aggressiveaggressive oror
potentiallypotentially violentviolent patient:patient:
•• A.A. PatientPatient alreadyalready inin restraints.restraints.
•• B.B. PatientPatient notnot inin restraints,restraints, butbut highhigh--risk.risk.
•• C.C. LowLow--riskrisk patient.patient.
A.A. PatientPatient alreadyalready inin restraints:restraints: •• •• •• •• •• •• ••
A.A. PatientPatient alreadyalready inin restraints:restraints:
••
••
••
••
••
••
••
WhenWhen thethe patientpatient arrivesarrives alreadyalready inin restraintsrestraints placedplaced byby thethe
ambulanceambulance attendantsattendants oror thethe police,police, movemove himhim intointo aa
“Crash“Crash Room”Room”
ThisThis shouldshould bebe thethe largestlargest treatmenttreatment roomroom inin thethe casualtycasualty
dept.dept.
LargeLarge enoughenough toto accommodateaccommodate severalseveral personspersons withoutwithout
crowdingcrowding thethe patient.patient.
LargeLarge enoughenough toto allowallow staffstaff toto manoeuvremanoeuvre eveneven whenwhen thethe
patientpatient isis onon aa stretcher.stretcher.
ThisThis allowsallows forfor anyany medicalmedical oror monitoringmonitoring equipmentequipment toto bebe
nearby,nearby, inin casecase needed.needed.
AskAsk anyany accompanyingaccompanying relativesrelatives oror friendsfriends toto remainremain untiluntil aa
completecomplete assessmentassessment hashas beenbeen done.done.
Initially,Initially, dodo notnot removeremove thethe restraintsrestraints——thisthis maymay makemake thethe
patientpatient moremore aggressive.aggressive.
B.B. PatientPatient notnot inin restraints,restraints, butbut highhigh--risk:risk: •• •• •• ••
B.B. PatientPatient notnot inin restraints,restraints, butbut highhigh--risk:risk:
••
••
••
••
WhenWhen thethe patientpatient isis notnot inin restraints,restraints, butbut isis noisy,noisy, onon
alcohol,alcohol, bigbig oror “scary”“scary” andand thethe MOMO isis notnot immediatelyimmediately
available,available, thethe nursingnursing staffstaff shouldshould askask thethe patientpatient toto waitwait inin
thethe waitingwaiting areaarea inin frontfront ofof thethe nursingnursing station.station.
InIn thisthis large,large, openopen area,area, thethe patientpatient cancan easilyeasily bebe observed,observed,
hashas lessless accessaccess toto hospitalhospital equipment,equipment, andand itit isis moremore
difficultdifficult forfor himhim toto “sneak“sneak up”up” onon staff.staff.
TryTry toto keepkeep thethe patientpatient awayaway fromfrom otherother waitingwaiting patientspatients
andand fromfrom hishis friendsfriends oror relativesrelatives------ifif youyou feelfeel thatthat theythey areare
worseningworsening thethe situation.situation.
OnOn arrival,arrival, thethe MOMO cancan decidedecide whetherwhether toto examineexamine thethe
patientpatient inin thethe “Crash“Crash Room”Room” (( highhigh risk)risk) oror treatmenttreatment roomroom
(low(low risk).risk).
C.C. LowLow--riskrisk patient:patient: •• IfIf youyou feelfeel thatthat thethe patientpatient isis lowlow--riskrisk
C.C. LowLow--riskrisk patient:patient:
•• IfIf youyou feelfeel thatthat thethe patientpatient isis lowlow--riskrisk (i.e.(i.e. quietquiet onon
arrival,arrival, notnot onon alcoholalcohol oror isis older),older), hehe maymay bebe takentaken
toto oneone ofof thethe examiningexamining roomsrooms inin thethe OPOP dept.dept.
•• RoomsRooms thatthat havehave exitsexits atat bothboth endsends areare preferablepreferable
soso thatthat nono oneone feelsfeels trapped.trapped.
•• RemoveRemove anyany sharpsharp objectsobjects fromfrom thethe roomroom
beforehand.beforehand.
•• LeaveLeave atat leastleast oneone ofof thethe doorsdoors open,open, ifif possible.possible.
HowHow toto actact inin thethe presencepresence ofof aggression:aggression: •• A.A. Two’sTwo’s company.company.
HowHow toto actact inin thethe presencepresence ofof aggression:aggression:
•• A.A. Two’sTwo’s company.company.
•• B.B. StayStay calm.calm.
•• C.C. PositionPosition yourselfyourself carefully.carefully.
•• D.D. BodyBody language.language.
•• E.E. OfferOffer aa snacksnack oror drink.drink.
•• F.F. CheckCheck forfor weapons.weapons.
•• G.G. TooToo hothot toto handle.handle.
A.A. Two’sTwo’s company:company: •• IfIf youyou areare frightenedfrightened oror mademade nervousnervous byby aa
A.A. Two’sTwo’s company:company:
•• IfIf youyou areare frightenedfrightened oror mademade nervousnervous byby aa
patient,patient, ifif possible,possible, havehave anotheranother staffstaff staystay
withwith youyou whenwhen youyou talktalk toto him.him.
•• YouYou willwill feelfeel calmercalmer andand moremore reassuredreassured andand
thisthis willwill havehave aa calmingcalming effecteffect onon thethe patient.patient.
B.B. StayStay calm:calm: •• •• •• •• •• IfIf thethe patientpatient isis angryangry andand
B.B. StayStay calm:calm:
••
••
••
••
••
IfIf thethe patientpatient isis angryangry andand aggressive,aggressive, speakspeak slowlyslowly andand
politely.politely.
TryTry notnot toto showshow angeranger yourselfyourself——thisthis isis difficultdifficult toto do,do, butbut
showingshowing youryour angeranger onlyonly worsensworsens thethe situation.situation.
IntroduceIntroduce yourselfyourself andand askask whywhy hehe isis angryangry oror simplysimply askask
himhim toto telltell youyou aboutabout himselfhimself——antisocialantisocial personspersons us.us. lovelove toto
bragbrag aboutabout themselves.themselves.
Don’tDon’t argueargue backback andand don’tdon’t agreeagree withwith thethe patientpatient ifif hehe hashas
anyany delusionsdelusions oror bizarrebizarre ideas.ideas.
AllowAllow thethe patientpatient toto ““ ventilate”ventilate” aa bit,bit, withoutwithout becomingbecoming
judgmentaljudgmental——often,often, afterafter aa fewfew minutesminutes thethe patientpatient doesdoes
calmcalm down.down.
•• IfIf thethe patientpatient isis simplysimply angry,angry, rememberremember thatthat sometimessometimes hehe maymay
•• IfIf thethe patientpatient isis simplysimply angry,angry, rememberremember thatthat
sometimessometimes hehe maymay havehave reasonsreasons forfor thatthat anger:anger: hehe
maymay bebe inin pain,pain, maymay havehave waitedwaited hourshours inin aa
crowdedcrowded waitingwaiting room,room, maymay bebe stressedstressed becausebecause ofof
aa sicksick spousespouse oror child.child.
•• EvenEven aa simplesimple statementstatement suchsuch as:as: ““ II knowknow thatthat
youyou areare angryangry aboutabout thethe 22 hourhour wait,wait, butbut it’sit’s hardhard
forfor meme ifif youyou areare yelling.yelling. WhyWhy don’tdon’t youyou telltell meme
whatwhat II cancan dodo forfor you,you, andand I’llI’ll trytry toto helphelp youyou out?”out?”
maymay helphelp tremendously.tremendously.
•• RememberRemember thatthat aa littlelittle empathyempathy sometimessometimes goesgoes aa
longlong way!way!
C.C. PositionPosition yourselfyourself carefully:carefully: •• HowHow farfar awayaway fromfrom thethe patientpatient
C.C. PositionPosition yourselfyourself carefully:carefully:
•• HowHow farfar awayaway fromfrom thethe patientpatient shouldshould youyou stand?stand?
•• StandStand aboutabout 1.51.5 metresmetres inin frontfront ofof him,him, butbut aa bitbit offoff
toto thethe sideside——dodo notnot faceface himhim directly.directly.
•• ThisThis isis closeclose enoughenough toto allowallow youyou toto developdevelop aa
rapport,rapport, butbut farfar enoughenough awayaway soso thatthat youyou dodo notnot
threatenthreaten hishis personalpersonal spacespace andand hehe can’tcan’t easilyeasily
touchtouch oror hithit you.you.
•• Don’tDon’t turnturn youryour backback onon him.him.
•• AlwaysAlways approachapproach thethe patientpatient fromfrom thethe front.front.
D.D. BodyBody language:language: •• AdoptAdopt aa submissivesubmissive pose:pose: armsarms relaxedrelaxed andand
D.D. BodyBody language:language:
•• AdoptAdopt aa submissivesubmissive pose:pose: armsarms relaxedrelaxed andand
hanginghanging downdown atat thethe side,side, palmspalms openopen belowbelow youryour
waistwaist andand facingfacing thethe person,person, shouldersshoulders drooping,drooping,
legslegs relaxed.relaxed.
•• Don’tDon’t looklook directlydirectly intointo thethe patient’spatient’s eyeseyes becausebecause
thisthis isis threateningthreatening toto mostmost peoplepeople——focusfocus youryour eyeseyes
onon hishis chin.chin.
•• ThisThis isis perceivedperceived asas lessless threatening,threatening, andand hishis
handshands cancan bebe easilyeasily seen.seen.
E.E. OfferOffer aa snacksnack oror drink:drink: •• •• •• •• •• OfferOffer thethe patientpatient
E.E. OfferOffer aa snacksnack oror drink:drink:
••
••
••
••
••
OfferOffer thethe patientpatient juice,juice, biscuits,biscuits, aa softsoft drink,drink, andand maybemaybe
havehave somesome yourself.yourself.
SharingSharing foodfood isis aa naturalnatural bondbond betw.betw. people,people, andand peoplepeople
aren’taren’t asas likelylikely toto argueargue ifif theythey areare eating.eating.
IfIf thethe patientpatient isis reallyreally insistentinsistent onon aa coffee,coffee, givegive itit toto him,him,
butbut bebe awareaware thatthat hehe cancan throwthrow aa hothot drinkdrink atat you.you.
SittingSitting downdown togethertogether andand talkingtalking oror eatingeating alsoalso formsforms aa
bond,bond, butbut dodo notnot sitsit downdown ifif thethe patientpatient refusesrefuses toto sitsit down.down.
Don’tDon’t sitsit inin aa corner,corner, wherewhere youyou cancan bebe trapped.trapped.
F.F. CheckCheck forfor weapons:weapons: •• CheckCheck aa pursepurse oror pocketspockets forfor weapons,weapons,
F.F. CheckCheck forfor weapons:weapons:
•• CheckCheck aa pursepurse oror pocketspockets forfor weapons,weapons, esp.esp.
ifif thethe patientpatient isis beingbeing admitted.admitted.
G.G. TooToo hothot toto handle:handle: •• AlthoughAlthough violenceviolence cancan occuroccur quicklyquickly andand
G.G. TooToo hothot toto handle:handle:
••
AlthoughAlthough violenceviolence cancan occuroccur quicklyquickly andand randomly,randomly, inin mostmost
casescases therethere isis somesome advanceadvance warning:warning:
Anger.Anger.
Agitation.Agitation.
AA clenchedclenched--fistsfists posture.posture.
LoudLoud behaviour.behaviour.
Yelling.Yelling.
••
••
AnAn importantimportant rulerule forfor nursingnursing staffstaff isis thatthat ifif thethe patientpatient
suddenlysuddenly standsstands upup andand startsstarts toto yellyell oror wagswags oror pointspoints hishis
fingerfinger atat you,you, GETGET OUTOUT OFOF THETHE WAYWAY ASAS QUICKLYQUICKLY ASAS
POSSIBLE!POSSIBLE!——thisthis patientpatient isis tootoo hothot toto handle.handle.
NoNo heroics!heroics!------backback outout ofof thethe roomroom quicklyquickly------runrun ifif youyou
havehave to!to!
•• •• •• •• •• •• IfIf therethere areare 22 ofof youyou onon duty,duty, runrun
••
••
••
••
••
••
IfIf therethere areare 22 ofof youyou onon duty,duty, runrun offoff inin oppositeopposite
directionsdirections——hehe can’tcan’t chasechase both!both!
IfIf youyou areare reallyreally scared,scared, locklock yourselfyourself inin aa bathroombathroom oror runrun
outout ofof thethe building.building.
CarryingCarrying aa portableportable phonephone isis aa goodgood ideaidea——youyou cancan callcall forfor
help.help.
AA violentviolent patientpatient isis unlikelyunlikely toto hurthurt otherother patientspatients------thethe staffstaff
isis moremore atat risk.risk.
IfIf thethe patientpatient runsruns outout ofof thethe hospitalhospital------letlet himhim go.go.
TheThe MOMO cancan decidedecide whetherwhether oror notnot toto callcall thethe police.police.
UseUse ofof restraints:restraints: •• A.A. PhysicalPhysical restraint.restraint. •• B.B. MechanicalMechanical
UseUse ofof restraints:restraints:
•• A.A. PhysicalPhysical restraint.restraint.
•• B.B. MechanicalMechanical restraint.restraint.
•• C.C. ChemicalChemical restraint.restraint.
•• NOTE:NOTE: TheThe useuse ofof allall typestypes ofof restraintsrestraints areare
forfor protectiveprotective purposes,purposes, andand NOTNOT toto bebe usedused
asas aa punitivepunitive measure.measure.
A.A. PhysicalPhysical restraint:restraint: •• •• •• •• •• •• UsedUsed forfor thethe
A.A. PhysicalPhysical restraint:restraint:
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UsedUsed forfor thethe purposepurpose ofof eithereither applyingapplying mechanicalmechanical
restraintsrestraints oror forfor thethe administrationadministration ofof sedation.sedation.
TheThe appropriateappropriate drugdrug shouldshould bebe drawndrawn upup
BEFOREHAND,BEFOREHAND, whilewhile youyou assembleassemble enoughenough people.people.
ApproachApproach thethe patientpatient inin aa nonnon--threateningthreatening manner,manner, thenthen
overwhelmoverwhelm himhim quicklyquickly andand efficiently.efficiently.
EachEach membermember mustmust havehave aa jobjob------ AA grabsgrabs thethe rightright arm,arm, BB
thethe leftleft arm,arm, CC thethe rightright leg,leg, DD thethe leftleft leg,leg, EE thethe head,head,
whilewhile thethe 66 thth personperson eithereither appliesapplies thethe mechanicalmechanical restraintsrestraints
oror administersadministers thethe sedation.sedation.
AsAs soonsoon asas hehe isis sedated,sedated, makemake aa notenote ofof anyany injuriesinjuries andand
examineexamine carefullycarefully toto excludeexclude aa treatabletreatable condition.condition.
CheckCheck thatthat thethe patientpatient isis fullyfully sedatedsedated beforebefore releasingreleasing thethe
physicalphysical holdhold onon him.him.
B.B. MechanicalMechanical restraints:restraints: •• •• •• •• •• •• •• IfIf youyou
B.B. MechanicalMechanical restraints:restraints:
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IfIf youyou areare concernedconcerned forfor thethe safetysafety ofof thethe patientspatients oror staff,staff, itit
isis permissiblepermissible inin anan emergencyemergency toto applyapply restraintsrestraints priorprior toto
thethe arrivalarrival ofof thethe MOMO onon dutyduty
ViewView thethe applicationapplication ofof restraintsrestraints asas aa procedure.procedure.
KnowKnow whenwhen itit isis necessarynecessary andand workwork accordingaccording toto aa plan,plan,
withwith teamworkteamwork andand aa clearclear teamteam leader.leader.
InformInform thethe patient:patient: ““ WeWe areare goinggoing toto havehave toto putput youyou inin
restraintsrestraints toto helphelp usus protectprotect you”you” (.or,(.or, ““ toto protectprotect
ourselves”).ourselves”).
IfIf thethe patientpatient appearsappears toto consent,consent, fine,fine, butbut onceonce you’veyou’ve
decideddecided toto applyapply restraints,restraints, don’tdon’t discussdiscuss oror negotiatenegotiate
further.further.
ApplyApply thethe restraintsrestraints asas quicklyquickly andand humanelyhumanely asas possible.possible.
EvenEven ifif thethe patientpatient calmscalms down,down, thethe nursesnurses shouldshould notnot
removeremove them.them.
•• •• •• •• •• •• •• •• •• TheThe MOMO shouldshould decidedecide whenwhen
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TheThe MOMO shouldshould decidedecide whenwhen itit isis safesafe toto removeremove thethe
restraints.restraints.
ItIt maymay bebe safersafer toto leaveleave thethe patientpatient inin aa laterallateral positionposition
becausebecause aspirationaspiration maymay occur.occur.
AA softsoft neckneck collarcollar maymay alsoalso protectprotect thethe patientpatient andand itit makesmakes
itit moremore difficultdifficult forfor himhim toto bitebite someone.someone.
ObtainObtain aa writtenwritten medicalmedical orderorder forfor thethe restraintsrestraints asas soonsoon asas
possible.possible.
Don’tDon’t leaveleave aa restrainedrestrained patientpatient alonealone inin thethe room.room.
MakeMake suresure therethere isis somesome kindkind ofof monitoringmonitoring regimenregimen inin
place.place.
WatchWatch thethe patient’spatient’s headhead ------ hehe cancan stillstill bite!bite!
RestraintsRestraints shouldshould bebe removedremoved afterafter everyevery 3030 minutes,minutes, afterafter
patientpatient hashas beenbeen sedated.sedated.
TheseThese restraintsrestraints shouldshould bebe paddedpadded leatherleather straps.straps.
C.C. ChemicalChemical restraint:restraint: •• •• •• •• •• DrugDrug TherapyTherapy hashas toto
C.C. ChemicalChemical restraint:restraint:
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DrugDrug TherapyTherapy hashas toto bebe partpart ofof thethe overalloverall plan.plan.
NoNo sedativesedative isis idealideal forfor allall situations.situations.
KnowKnow aa fewfew well,well, includingincluding sideside effectseffects andand precautions.precautions.
DrugsDrugs usedused toto controlcontrol agitationagitation taketake timetime toto work,work, thereforetherefore
givegive earlierearlier ratherrather thanthan later.later.
DrugsDrugs commonlycommonly used:used:
LorazepamLorazepam (Ativan).(Ativan).
HaloperidolHaloperidol (Serenace).(Serenace).
ClothiapineClothiapine (Etomine).(Etomine).
ZuclopenthixolZuclopenthixol acetateacetate (Clopixol(Clopixol Acuphase).Acuphase).
ChlorpromazineChlorpromazine (Largactil).(Largactil).
OlanzapineOlanzapine (Zyprexa).(Zyprexa).
•• •• BeforeBefore administeringadministering sedationsedation IMIM oror IV,IV, offeroffer oraloral
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BeforeBefore administeringadministering sedationsedation IMIM oror IV,IV, offeroffer oraloral
medicationmedication suchsuch asas ChlorpromazineChlorpromazine (Largactil)(Largactil) atat aa dosedose ofof
50mg50mg toto 100mg100mg p.o.p.o. stat,stat, unlessunless contraindicated.contraindicated.
ResortResort toto IMIM oror IVIV sedationsedation ONLYONLY if:if:
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PatientPatient isis potentiallypotentially aa dangerdanger toto selfself andand // oror others.others.
PatientPatient refusesrefuses oraloral medication.medication.
PatientPatient requiresrequires rapidrapid controlcontrol ofof behaviour.behaviour.
FollowingFollowing administrationadministration ofof sedation,sedation, itit isis imperativeimperative toto
monitormonitor vitalvital signssigns asas oftenoften andand regularregular asas possible,possible, e.g.e.g.
everyevery 1515 minutesminutes forfor 44 hourshours andand thenthen tapertaper asas necessary.necessary.
LorazepamLorazepam (Ativan.):(Ativan.): •• •• •• •• NotNot asas effectiveeffective ifif givengiven
LorazepamLorazepam (Ativan.):(Ativan.):
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NotNot asas effectiveeffective ifif givengiven orally.orally.
2mg2mg toto 44 mgmg IMIM oror IVIV slowly.slowly.
Max.Max. 6mg6mg inin 2424 hours.hours.
GoodGood choicechoice inin patientspatients with:with:
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SuspectedSuspected drugdrug--inducedinduced disorder.disorder.
“Organic“Organic brainbrain syndrome”syndrome”
Mania.Mania.
EfficacyEfficacy enhancedenhanced byby coco--administrationadministration withwith HaloperidolHaloperidol
IMIM oror IV.IV.
AdverseAdverse effect:effect: watchwatch forfor respiratoryrespiratory depression,depression,
hypotensionhypotension andand behaviouralbehavioural disinhibition,disinhibition, esp.esp. inin thethe
elderly.elderly.
HaloperidolHaloperidol (Serenace.):(Serenace.): •• •• •• •• •• •• 5mg5mg IMIM oror IV.IV.
HaloperidolHaloperidol (Serenace.):(Serenace.):
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5mg5mg IMIM oror IV.IV.
CanCan repeatrepeat withinwithin 11 toto 22 hours.hours.
Max.Max. 33 dosesdoses inin 2424 hours.hours.
UseUse halfhalf dosesdoses inin thethe elderly.elderly.
RelativelyRelatively safe,safe, effectiveeffective andand cheap.cheap.
AdverseAdverse effects:effects:
SomeSome EPSEPS reactions:reactions: dystonias,dystonias, akathisia,akathisia, motormotor restlessness.restlessness.
Rarely:Rarely:
SuddenSudden death.death.
NeurolepticNeuroleptic MalignantMalignant Syndrome.Syndrome.
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Rx:Rx:
AdministerAdminister BiperidenBiperiden (Akineton)(Akineton) 55 mgmg IM;IM; changechange toto anan “atypical”“atypical”
oror decreasedecrease dose.dose.
ClothiapineClothiapine (Etomine.):(Etomine.): •• •• •• 120mg120mg toto 160mg/day160mg/day po,po, IMIM oror
ClothiapineClothiapine (Etomine.):(Etomine.):
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120mg120mg toto 160mg/day160mg/day po,po, IMIM oror IVIV inin 22 toto 33 divideddivided dosesdoses
initially.initially.
Max.Max. 360mg/day.360mg/day.
AdverseAdverse effects:effects:
Sedation.Sedation.
OrthostaticOrthostatic hypotension.hypotension.
Arrhythmias.Arrhythmias.
Epileptogenic.Epileptogenic.
TissueTissue necrosis.necrosis.
ArterialArterial thrombosisthrombosis withwith gangrene.gangrene.
ZuclopenthixolZuclopenthixol acetateacetate (Clopixol(Clopixol Acuphase.):Acuphase.): •• •• •• ••
ZuclopenthixolZuclopenthixol acetateacetate (Clopixol(Clopixol
Acuphase.):Acuphase.):
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50mg50mg toto 150mg150mg IM,IM, maymay bebe repeated,repeated, ifif necessary,necessary, afterafter 22 toto
33 days.days.
VeryVery effectiveeffective inin belligerentbelligerent aandnd aggressiveaggressive patientspatients withwith nono
responseresponse toto earlierearlier measures.measures.
UseUse onlyonly ifif nono responseresponse toto LorazepamLorazepam andand // oror
Haloperidol.Haloperidol.
UseUse withwith caution:caution:
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RecentRecent excessiveexcessive useuse ofof alcohol.alcohol.
Dehydration.Dehydration.
ElectrolyteElectrolyte imbalance.imbalance.
AdverseAdverse effects:effects:
SedationSedation whichwhich lastslasts forfor days.days.
HypotensionHypotension andand circulatorycirculatory collapse.collapse.
ChlorpromazineChlorpromazine (Largactil.):(Largactil.): •• •• 50mg50mg toto 100mg100mg popo statstat oror
ChlorpromazineChlorpromazine (Largactil.):(Largactil.):
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50mg50mg toto 100mg100mg popo statstat oror 25mg25mg toto 50mg50mg IM.IM.
AdverseAdverse effects:effects:
VeryVery sedating.sedating.
Hypotension.Hypotension.
PainfulPainful injection.injection.
•• Contraindications:Contraindications:
Epilepsy.Epilepsy.
RecentRecent excessiveexcessive useuse ofof alcohol.alcohol.
ChronicChronic hepatichepatic disease.disease.
Elderly.Elderly.
RecentRecent historyhistory oror evidenceevidence ofof headhead injury.injury.
PrePre--existingexisting cardiaccardiac disease.disease.
OlanzapineOlanzapine (Zyprexa):(Zyprexa): •• •• •• •• •• •• •• •• ••
OlanzapineOlanzapine (Zyprexa):(Zyprexa):
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10mg10mg IMIM stat.stat.
MayMay havehave specificspecific antianti--maniamania effect.effect.
10mg10mg roughlyroughly == 7.57.5 mgmg Haloperidol.Haloperidol.
VirtuallyVirtually nono EPS.EPS.
OccasionalOccasional hypotension.hypotension.
LittleLittle sedatingsedating effect,effect, thereforetherefore advantageadvantage inin elderly.elderly.
PatientPatient remainsremains alert,alert, orientedoriented andand cooperative.cooperative.
HasHas delayeddelayed onsetonset ofof action,action, maymay taketake days.days.
VeryVery expensive.expensive.
PointsPoints toto note:note: •• •• •• •• •• •• •• TheThe timetime toto makemake
PointsPoints toto note:note:
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TheThe timetime toto makemake youryour hospitalhospital planplan isis nownow atat 11001100 AM,AM,
NOTNOT atat 0300AM0300AM whenwhen someonesomeone isis tearingtearing upup youryour casualtycasualty
dept.dept.
SpecifySpecify wherewhere toto putput thethe patient,patient, whowho toto inform,inform, rulesrules forfor
restraints,restraints, etc.etc.
TrainTrain youryour staff.staff.
GoGo overover thethe planplan withwith them.them. WhyWhy notnot holdhold aa practicepractice
session?session? WithWith aa simulatedsimulated ““ patient”patient” onon howhow toto handlehandle anan
“agitated“agitated patient.”patient.”
BuildBuild aa hospitalhospital ““ securesecure room”room”
HaveHave aa contractcontract withwith aa securitysecurity firm.firm.
UnderstandUnderstand thethe rolerole ofof youryour locallocal policepolice andand ambulanceambulance
attendants.attendants.
Summary:Summary: •• •• BeBe suresure youryour hospitalhospital hashas aa properproper planplan forfor
Summary:Summary:
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BeBe suresure youryour hospitalhospital hashas aa properproper planplan forfor handlinghandling thethe
violentviolent oror aggressiveaggressive patient.patient.
ThisThis planplan shouldshould specify:specify:
ResourcesResources availableavailable
WhoWho shouldshould bebe calledcalled
WhereWhere toto putput thethe patientpatient
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TrainTrain youryour staffstaff inin properproper procedureprocedure andand bodybody languagelanguage forfor
dealingdealing withwith thisthis difficultdifficult clientele.clientele.
DebriefDebrief youryour staffstaff afterafter anan incident.incident.
DiscussDiscuss howhow thethe situationsituation went,went, whatwhat waswas donedone wellwell andand
whatwhat couldcould bebe improvedimproved onon thethe nextnext time.time.
THANKTHANK YOUYOU ForFor youryour attention……… attention………
THANKTHANK YOUYOU
ForFor youryour attention……… attention………