Emergency Department Management of Violent Patients

EXECUTIVE SUMMARY

• The two most common causes for a violent patient in the emergency department (ED) are psychiatric and toxidromes.
• Other potential causes that may be contributing also should be considered.
• The initial assessment of the violent patient should include a point-of-care glucose measurement.
• Verbal de-escalation should be the first management approach attempted in violent and agitated patients.
• First-line agents for chemical restraint are midazolam 5 mg to 10 mg intramuscular (IM), droperidol 5 mg to 10 mg IM, or olanzapine 10 mg IM in non-elderly adults.
• Ketamine has the most rapid onset of agents used for chemical restraint, but there is an increased risk of respiratory depression compared to other agents used for this purpose.
• In elderly patients, use lower doses of antipsychotics and avoid benzodiazepines because they may lead to increased delirium in this population.
• Monitor patients after chemical restraint until at least the initial half-life of the drugs used has passed.
• Physical restraints have increased risk for injury to both patients and staff, so use an organized protocol for their application and removal.

Definition of the Problem

A violent patient is someone under medical care who is a threat of danger to themselves, other patients, or hospital staff. Like many of the problems we face in the emergency department (ED), the management of a violent (or potentially violent) patient is not always straightforward. There is no one “gold standard” treatment and no simple algorithm to approach every patient. Each encounter will be influenced by the patient’s background, underlying health conditions, comorbid issues, psychiatric history, socioeconomic factors, and much more.¹

Some violent patients may need only verbal de-escalation, while others will require sedation and/or physical restraint. On rare occasions, patients who remain dangerous after all these measures may require intubation and deep sedation for the safety of the patient and staff. In addition to ensuring the immediate safety of patients and healthcare workers, emergency physicians must simultaneously investigate to rule out physiologic causes of the patient’s presentation.

Data remain limited since there is no global consensus on what defines a “violent patient.” Sources vary widely and often include terms like “delirium,” “violent,” “uncooperative,” “dangerous,” “hyperactive,” “bizarre,” “noncompliant,” “combative,” “agitated,” “paranoid,” “under the influence,” and more.² Further, confusing terminology like “excited delirium syndrome” often is used, ignoring the lack of standardization, implicit biases, and poor data to support this as a diagnosis. As a specialty, we have made great strides in the last few decades to better define this problem, develop best practices for management, and bring awareness and public attention to this important issue.

Relevancy

Violence is a worldwide problem. Child abuse, elder abuse, interpersonal and domestic violence, and workplace violence plague our societies daily. The United States currently is experiencing an unprecedented problem with gun-related violence occurring commonly. Violent acts regularly take place in schools, places of worship, mass gatherings, and practically any public space. Seemingly, no safe haven exists in this modern era of violence.

Unfortunately, the ED is no exception. In fact, the ED is one of the more likely places to experience acts of aggression and violence.^3-6 ED personnel often are the first line of contact for a potentially violent patient, and usually, the ED is the easiest 24-hour access point to any healthcare facility. Multiple studies from countries around the world have indicated that ED personnel face violence and aggression regularly, with the vast majority of workers reporting they had been victims of violence and abuse by patients.^7-9 Noting the aforementioned, the emergency physician is charged with not only ensuring the safety of their staff and other patients, but also creating an environment of safety for the patient and determining any potential dangerous underlying etiologies that may be giving rise to the aggression.

Background and Epidemiology

Considering violence in the ED, the problem can be broadly divided into two categories: violence or aggression in terms of patients and their underlying disease processes and workplace violence involving healthcare personnel.

Beginning with the latter, the US Occupational Safety and Health Administration defines workplace violence as “any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site.”¹⁰ Transitively, violence that occurs in the healthcare setting fits this description.

The global prevalence rates of workplace violence caused by patients and visitors against healthcare workers has been estimated in multiple reviews. One meta-analysis suggested the 12-month prevalence of workplace violence against ED healthcare workers was 31% (95% confidence interval [CI], 26% to 36%) for physical violence and 62.3% (95% CI, 53.7% to 70.8%) for nonphysical violence.¹¹ This includes actions from nonphysical actions like grumbling, shouting, and insulting to physical actions, such as holding, pinching, spitting, and hitting.¹²

In 1993, the American College of Emergency Physicians (ACEP) created a policy statement focused on the importance of protecting healthcare personnel from violence in the ED.¹³ The policy statement has been through multiple revisions through the years, most recently in 2016. In that same year, ACEP released the results of a survey of more than 3,500 emergency physicians, of whom: 47% reported they had been the victim of physical assault, 71% had witnessed another assault, and 77% reported they believed that “violence in the emergency department harms patient care.”¹⁴

Following this report, ACEP and the Emergency Nurses Association collaborated on an effort to meaningfully minimize the frequency of these attacks, protect emergency personnel, and bring awareness to this important issue. Launched in 2019, “No Silence on ED Violence” aims to support, empower, and provide the resources for emergency physicians, nurses, and other healthcare workers to enact safety improvements in their departments, while also educating state and federal policymakers, stakeholder organizations, and the public at large about this serious threat to safety and generate action to address this problem.

Although the safety of physicians and ED staff remains the highest priority, there has been a more recent shift to bring focus to patient safety and the need for further research on best practices in the evaluation and management.

Patients and their underlying disease processes present unique challenges. They have been difficult to study because of a lack of consensus on what constitutes a “violent” or aggressive patient, and some professionals and organizations use terms like “excited delirium” to describe a myriad of signs and symptoms with no standard definition. Of note, neither the American Psychological Association nor the World Health Organization recognizes excited delirium syndrome as a psychiatric or medical diagnosis, and in recent years, there has been increasing negative attention around the terminology because of the implicit biases and unexplainable morbidity and mortality that often result.² Some argue the terminology may be overused to explain preventable in-custody deaths among predominantly African-American men. When there is any chance for bias, there is opportunity for significant error, and in these high-risk scenarios, the error can be fatal. This topic will be explored further in the Additional Considerations section.

Because of this, emergency physicians and professional organizations have focused research toward better defining these presentations and developing best practices for the treatment of potentially violent patients in the ED. In 2010, the American Association for Emergency Psychiatry recruited a group of psychiatrists and emergency physicians with the challenge to create a patient-centered and safety-minded set of best practices for the evaluation and treatment of agitation. From this workgroup, Project BETA (Best Practices for the Evaluation and Treatment of Agitation) was created.^15-20

More recently, ACEP convened a task force to delineate best practices for emergency physicians, again with patient-centeredness and safety in mind.²¹ This task force developed a more standard definition and diagnosis for “hyperactive delirium with severe agitation” and provided evidence-based recommendations for the evaluation and management of these patients.

Clinical Features and Differential Etiologies

Violent patients come in all varieties, ranging the spectrum from stuporous to extremely hyperactive. Elderly patients with delirium may exhibit aggression or violence in near stuporous states, while the majority of aggravated and violent patients will present with more hyperactivity. Although no scale has been specifically developed for this population, there are several existing tools that can be used to help categorize these patients. These include the Richmond Agitation Sedation Scale (RASS), the Altered Mental Status Score (AMSS), and the Behavioral Activity Rating Scale (BARS), among others.^22-24

Patients may present with a variety of signs and symptoms, including: agitation, thrashing, bizarre behavior, inappropriate nudity, imperviousness to pain, hypervigilance, lack of tiring, abnormal strength, combativeness, noncompliance, stupor, fear, and panic.²

When considering the violent patient with (or without) hyperactive delirium, the overwhelming majority of patients will fall under one of two categories: psychiatric diagnoses or acute toxidromes. Psychiatric diagnoses, including schizophrenia, schizoaffective disorder, bipolar disorder, and others, can give rise to acute psychosis and violent or aggressive actions.²⁵ Acute sympathomimetic toxicity also can lead to a hyperactive and violent state, seen often in patients who abuse cocaine, methamphetamines, methylenedioxy-methylamphetamine (MDMA), lysergic acid diethylamide (LSD), and other drugs of abuse.²⁶ Although one typically thinks of acute sympathomimetic toxicity in these patients, remember to consider withdrawal from sedative-hypnotic agents like benzodiazepines, barbiturates, alcohol, and others.

While the overwhelming majority of patients will fall under the two categories described earlier, emergency physicians should rule out other organic causes of hyperactive delirium or other violent presentations. See Table 1 for a listing of many potential etiologies of hyperactive delirium that could lead to an agitated, aggressive, or violent state.

Emergency physicians should rely on their history and physical exam information to lead to the probable underlying issue. When the patient is uncooperative or the physician is otherwise unable to elicit a thorough history, then the physical exam, outside information from relatives, police, or emergency medical services, and adjunct testing are other valuable sources of information. Vitals are vital! If they are abnormal, they should be explained and can help guide the physician to potential underlying etiologies of the patient’s symptoms.

Situational factors also should be recognized and considered in the differential, such as mutual hostility, miscommunication, fear of rejection, fear of illness, and lack of trust. These may be more fleeting concerns and not related to the initial reason for arrival to the ED, so always consider the possible need for both a medical clearance and de-escalation of a potentially violent situation.

Although hyperactive delirium with agitation may result from any of the predisposing conditions included in Table 1, not every patient with these conditions will present in a violent state. It is most important for emergency physicians to remember that just because a patient may have a psychiatric illness or acute toxidrome, that does NOT rule out the potential for other concomitant underlying processes that also may be contributing to symptoms.

Pathophysiology

The majority of violent patients presenting to the ED are in some state of agitated delirium, usually hyperactive. Delirium is associated with imbalances of important neurotransmitters like acetylcholine, dopamine, gamma-aminobutyric acid (GABA), and serotonin.²¹ These imbalances may result from underlying medical conditions or exposure to toxicants. Most importantly, the pathophysiology will vary widely based on the underlying etiology leading to the hyperactive delirium state.

Diagnostic Studies

Other than a complete set of vital signs (including temperature) and blood glucose level, there are no required diagnostic studies to perform in every patient presenting with agitated delirium or aggression/violence. ED diagnostics should serve as an adjunct to historical and physical exam information. These supplemental diagnostic studies should be ordered based on presenting symptoms and presumed underlying etiologies.

Common tests may include an electrocardiogram, chemistry panel, pregnancy test, arterial blood gas, urinalysis, urine drug screen, toxicology panel including levels for acetaminophen, alcohol, and salicylates, cerebrospinal fluid studies, chest radiography, or computed tomography of the brain. These tests and others, ordered at the discretion of the emergency physician, can help to provide insight for potential underlying causes of the patient’s presenting symptoms.

Management

Immediate stabilization of a violent patient is similar to other undifferentiated patients who present to the ED, with one caveat: the clinician must quickly assess for the threat of violence or harm prior to proceeding with the primary survey. If there are weapons or potential for danger to self or staff, the need for a safe environment supersedes resuscitation. After ensuring staff safety, proceed as normal with assessment of airway, breathing, and circulation. After ensuring the aforementioned are intact, attempt to get a complete set of vital signs (including temperature) and a point-of-care glucose level to help rule out hypoglycemia or hyperglycemia causes of agitation and violence.

Following initial stabilization measures, the general consensus for management is to proceed with step-wise de-escalation techniques, beginning with verbal de-escalation, followed by chemical restraint, and finally physical restraint as a last resort. When a situation is deemed safe and the patient appears hemodynamically stable, the emergency physician should first attempt to verbally de-escalate the patient. Project BETA proposes using 10 key concepts in verbal de-escalation attempts.^18,28 These concepts are summarized in Table 2 and detailed in the following section.

1. Respect personal space.

Agitated and potentially violent patients require additional precautions when it comes to respecting personal space. Ensure that you and other staff members maintain a safe distance of at least two arm-lengths from the patient and keep an exit clear and safe. Recall that many of these patients have experienced traumatic events and may be more protective of their space and belongings.

2. Do not be provocative.

Demonstrate through your words and actions that your priority is to keep the patient and staff safe. Emergency personnel should be cautious to keep hands clearly visible and avoid clenching the fists (as it could be perceived as aggressive or concealing a weapon). Best practice is to present at an angle to the patient, rather than directly in front of them. Be aware of your body language and ensure that it is congruent with your intentions. Most importantly for the ED, remember that humiliation can be aggressive: do not challenge the patient, insult them, or allow staff members to do anything else that can be perceived as humiliating.

3. Establish verbal contact.

Ideally, only one person should engage the patient at time, preferably the emergency physician first. This is particularly important in cases of hyperactive delirium, where multiple people talking can be confusing and potentially appear threatening. Maintain a steady, low, and slow tone with the patient, and maintain a calm and soothing manner. It is important to introduce yourself and your role in leading the care and ensuring the safety of the patient.

4. Be concise.

Agitated and delirious patients are, by definition, impaired in their ability to process sensory input, specifically verbal information. To aid in ensuring the patient understands, use short phrases and basic vocabulary. You may be required to repeat the same thing several times to ensure comprehension.

5. Identify wants and feelings.

As always, the emergency physician should serve as the patient’s advocate. Offering to assist with simple needs can quickly establish respect and trust. For example, providing some food, small amounts of water, or warm blankets can lead to calming and credence in your claim to be their advocate. You should ask every patient exactly what they want out of this visit; further, you should reassure them that even if you are unable to address everything, you will benefit from understanding their feelings and it will help you come to a common goal.

6. Listen closely to the patient.

It also is important to use active listening skills. Best practice is to repeat what is heard using paraphrasing and clarifying statements. Clarifying statements can be as simple as ‘‘Tell me if I have this right …’’ or “So what I am hearing you say is ….” These skills are invaluable in reiterating to the patient that you are on their side, are genuinely concerned, and are advocating for their best interest.

7. Agree (or agree to disagree).

It may seem like a dichotomous picture, but there are actually multiple ways we can “agree” with a patient. First, you can agree with the truth. For example, you could agree with the facts surrounding their presentation: “Yes, the police have placed you under an involuntary hold, and I can imagine how terrible that may feel. How can we work together to get to a solution?” Second, you can agree with the principle. For example, if a patient feels like they are being mistreated by police and seeking your validation, instead of agreeing they were mistreated, you can say “I believe that everyone should be respected.” Third, you can agree with the odds. For example, “I have not been in your position, but I can certainly understand how others in your position might feel the same way.” Lastly, if a patient’s demands are completely unreasonable, you can agree to disagree — never lie to them.

8. Set clear limits with consequences.

As previously mentioned, you should always be honest with the patient. While it is important to empathize with their condition and show you genuinely care about their well-being, it also is important to set clear limits and explain that violence or aggression in any form will not be tolerated. Consequences also should be clearly communicated. You can further establish trust and rapport by offering to help the patient stay calm. Indicate that you and other staff members are uncomfortable when they are being aggressive, and you feel like it is impeding your ability to give the best care. You can offer to assist them in calming down so that you can provide the highest level of care.

9. Offer choices and optimism.

As mentioned earlier, little things can go a long way. Offer the patient choices. Offer them kindness. Perhaps go out of your way to get them food or a warm blanket. If you are considering medications, attempting to involve patients in the decision of which agent to use can improve outcomes.²⁹ Inquiring what medications may have helped in the past invites the patient to offer medication ideas. Offer optimism too. Reassure patients they are going to get better.

10. Debrief the patient and staff.

Finally, if you must engage in physical restraint and/or chemical sedation, you must debrief. Debrief staff through a discussion of what went well and what can be improved for the future, and allow the entire staff to make suggestions. Most importantly, however, you must debrief the patient. After any involuntary intervention, it is the physician’s responsibility to restore the doctor-patient relationship and work to mitigate the risk for additional violence or aggression. Calmly explain why the intervention was necessary, solicit the patient’s perspective, and discuss together how you can prevent the need for future interventions.

If verbal de-escalation fails to improve the patient’s agitation and/or the patient continues to represent a danger to themselves or others, chemical restraint should be considered. The emergency physician must be cognizant of the purpose of chemical sedation: to improve agitation, calm the patient, and allow them to meaningfully participate in their care. The purpose is NOT to induce sleep or “knock them out.”

Chemical sedation in the ED frequently is achieved through the use of benzodiazepines, antipsychotics, benzodiazepines plus antipsychotics, and ketamine. In very rare circumstances, a patient might require intubation for chemical sedation and paralysis.

Pharmacotherapy should be approached according to the level of agitation. In a patient with mild agitation who is cooperative, oral medications can be considered. As an example, consider a patient who arrives to the ED restless, yelling loudly at staff, but who remains redirectable. After attempting verbal de-escalation, the patient remains agitated, but can recognize their condition and is agreeable to medications. In this case, a medication like oral lorazepam or sublingual olanzapine can be considered.

Unfortunately, many of the violent and aggressive patients presenting to the ED will not have this insight or ability to cooperate in medical decision-making. In these instances, intramuscular injections are the mainstay of pharmacotherapy.

Benzodiazepines for chemical sedation are common options since they are available in oral, intramuscular, and intravenous formulations. These agents work through activation of inhibitory neurotransmitters in the central nervous system, by binding GABA receptors. (See Figure 1.) Several studies have directly compared different medications within this class, most notably midazolam and lorazepam.

Figure 1. Mechanism of Action for Benzodiazepines

Many others have compared benzodiazepines to multiple other agents, including first- and second-generation antipsychotics as well as ketamine. The current evidence suggests that intramuscular midazolam (5 mg to 10 mg) is superior to intramuscular lorazepam (2 mg) in time to reach adequate sedation endpoints.^30-31 When assessing time to adequate sedation, midazolam ranges from 8.5 to 30 minutes, with the majority of studies falling somewhere between 10 to 20 minutes. In comparison, lorazepam ranges from 30 to 60 minutes.

When comparing adverse effects and reactions, it is important to remember that all benzodiazepines produce respiratory depression at higher doses. Often the degree of sedation is unpredictable, so any use of benzodiazepines should be followed by close patient monitoring. Given the equivalency of safety profiles, midazolam should be considered first-line over lorazepam because of its rapidity in achieving adequate sedation.

Antipsychotics are another important medication class to consider in the management of acute agitation, including presentations of hyperactive delirium. By extension, these may be useful in other undifferentiated violent patients as well. Antipsychotics fall into two broad categories: first-generation (or typical) and second-generation (or atypical). Agents from both generations work by inhibiting dopamine effects in the central nervous system, leading to sedation and calming. (See Figures 2 and 3.) Extrapyramidal side effects, more common in first-generation agents, occur due to this action on dopaminergic neurons. However, these side effects and more serious adverse reactions, like neuroleptic malignant syndrome, are exceedingly rare in studies of acute administration for agitation.²¹

Figure 2. Selected First- and Second-Generation Antipsychotics

Figure 3. Mechanism of Action for Antipsychotics

When treating severe agitation with intramuscular injections, haloperidol and droperidol have been studied among the first-generation agents, and olanzapine and ziprasidone have been studied among the second-generation agents. When directly comparing antipsychotic agents, multiple studies have been published, leading to high-quality, evidence-based recommendations. For first-generation medications, droperidol (5 mg to 10 mg) was found to be equivalent or superior to haloperidol (5 mg to 10 mg) in numerous studies. Among second-generation agents, olanzapine (10 mg) was found to be superior to ziprasidone (20 mg) in reaching adequate sedation at 15 minutes. In summary, droperidol (5 mg to 10 mg) or olanzapine (10 mg) may both be considered first-line agents when selecting an antipsychotic in the management of violent agitation in the ED.^32-38

Many of the more experienced emergency physicians may recall the widespread abandonment of droperidol when it was issued a U.S. Food and Drug Administration (FDA) black box warning in 2001 because of concern for QT interval prolongation and the development of torsades de pointes. However, over the last 20 years, this warning has been refuted and “debunked.” In fact, ACEP even created a policy statement supporting the use of droperidol in the ED. Droperidol has been studied widely during the past two decades, proving to be a very safe and effective option in the treatment of many common complaints, including nausea, headache, and acute agitation.³⁹ Going further, research has indicated that even an electrocardiogram is unnecessary prior to administration of droperidol in the prehospital or ED setting.¹³

Finally, ketamine has emerged as another viable treatment option for acute agitation and is growing in popularity both in the ED and prehospital setting. The mechanism of action for ketamine is not completely understood, but it seems to act mainly as an N-methyl-D aspartate (NMDA)-receptor antagonist. The first human trials of ketamine began in 1965, and researchers observed that “sensory input may reach cortical receiving areas but fail to be perceived.”^40-41 Although still not completely understood, ketamine seems to act in both excitatory and inhibitory pathways on various areas of the brain related to the perception and memory of painful stimuli, helping it earn the term “dissociative anesthetic.”^42,43

The growing popularity of ketamine likely is due to its main advantages: rapid onset and reliable achievement of sedation in the form of intramuscular injection. In terms of its quick onset of action, even early studies revealed that ketamine given intravenously could achieve sedation “adequate to perform procedures” within 20 seconds, and intramuscular ketamine could reach similar levels of sedation within three minutes.^40,42,44

Unfortunately, although the rapid onset of action makes ketamine an appealing first choice, there is increased risk of respiratory depression when compared to other agents from different drug classes. Consensus seems to be that the intramuscular dose of ketamine in acute agitation and hyperactive delirium is 4 mg/kg. But it is prudent to understand that this dose was developed retrospectively from studies in pediatric anesthesiology. Nonetheless, many more recent studies have used variable dosages with no significant difference in rates of intubation, so ketamine remains a viable first-line option for this group.^45-52 The only contraindication to the use of ketamine in this population are those in who a significant elevation in blood pressure would constitute a serious hazard.⁵³ Ketamine causes psychoperceptual symptoms in all patients. These symptoms may be controlled with benzodiazepines and do resolve without specific treatment.”⁵³

To put it all together, current evidence supports the use of a few key medications from each of the classes described. (See Table 3.) Although research surrounding ketamine has been ongoing since the 1960s, there is a continued need for further prospective research studies regarding its use in this population. Ketamine seems to be the fastest working agent, reaching adequate sedation within two to three minutes in many cases. Unfortunately, its use can be associated with increased rates of respiratory depression and the need for endotracheal intubation. Further, it is contraindicated in patients with schizophrenia.

Midazolam has similar rates of respiratory depression compared to ketamine, but it has emerged as the drug of choice when using benzodiazepines for sedation because of its rapid onset (10-20 minutes).

When considering antipsychotic medications, droperidol (first-generation) and olanzapine (second-generation) have emerged as the medications of choice for the treatment of aggression and agitation. Droperidol, in particular, has been safely documented in multiple prospective studies over the last two decades. In retrospect, the FDA black box warning likely is unwarranted and it can be used safely in the ED for the management of acute agitation without concern for torsades. Both droperidol and olanzapine have demonstrated fewer adverse effects, including respiratory depression, when compared to ketamine or midazolam.

Given the available data, it is impossible to determine a clearly superior single agent for the treatment of acute agitation, but current evidence supports the use of all these agents and offers enough variety within each drug class to give several options for initial management. Table 3 summarizes these first-line agents for the treatment of agitation.

Finally, physical restraint should be used as a last resort, after verbal de-escalation and chemical sedation have failed or in situations where rapid restraint is necessary to prevent harm to the patient or staff members. Unfortunately, many physicians view physical restraint as the safest and most efficient intervention for the agitated patient. This view is contradicted by studies finding that these restrictive interventions actually are associated with an increased incidence of injury to both patients and staff, physically and psychologically.²¹

Most hospitals and regulating bodies have strict rules and requirements in place regarding the initiation and monitoring of physical restraints. Straightjackets, hogties, neck restraint, and prone positioning have been repeatedly associated with bad outcomes and should not be used under any circumstances.⁵⁴

Safety is the primary objective when applying physical restraints. Best practice is to have a minimum team of five staff members, at least one for each extremity and one to administer additional medications if needed. If the patient is thrashing or banging their head, a staff member assigned to control the head and neck to minimize self-harm sometimes is needed. Each member of the team should be assigned an extremity to restrain and should immobilize with one hand above and one below each joint, such as an elbow or knee.

Soft restraints are preferred, should immobilize each extremity tied to the frame of the bed (not the guardrails), and the patient should remain in supine position at all times. Frequent repeat neurovascular assessments of each restrained extremity are indicated, and the restraints should be discontinued as soon as it is safe to do so. Follow the section detailing restraint removal practice in your hospital restraint policy.

Monitoring Recommendations

After sedation and/or restraint, patients should be monitored on telemetry, with continuous pulse oximetry and end-tidal carbon dioxide measurements for at least the half-life of the agent used for sedation and until the patient returns to baseline level of alertness without agitation requiring an additional sedating medication. The half-life of ketamine has an alpha time of 10-15 minutes and beta of 2.4 hours with recovery time of three to four hours.⁵³ Droperidol has a peak action of 30 minutes and can last up to four hours.²⁷ Olanzapine has been noted to have continued effects for up to two hours when administered intramuscularly with a half-life of 30 hours.⁵⁵ Midazolam has a peak effect of 30-60 minutes with a duration of up to six hours and half-life of three hours, on average, in adults.⁵⁶

Ketamine specifically is a medication that has been reported to cause apnea, but in a retrospective review it was found that the dosing was not significantly different between intubated patients vs. non-intubated patients.⁵⁰

In respect to physical restraints, the patient should be monitored continuously with a dedicated chaperone (or “sitter”) until physical restraints no longer are required. Additionally, physicians should perform frequent face-to-face examinations and focused neurovascular assessments of the restrained extremities according to hospital protocol, at minimum every hour for children and every two hours for adults.

Special Considerations

In certain populations, such as pregnant or elderly patients, there are additional considerations in the approach to management. Specifically, pregnant patients with mild agitation may be treated with oral diphenhydramine, one of the only indications for this medication in the initial treatment of agitation. In moderate to severe agitation, use medications from the classes described earlier, depending on the suspected underlying etiology of symptoms. While there are associated risks to the fetus with these medications, the risk-benefit scale is tipped in favor of ensuring the safety of the parent.

In elderly patients, it is most important to rule out easily reversible causes of agitation, such as hypoglycemia. It is appropriate to use lower starting doses of medications, and antipsychotics are preferred to benzodiazepines, as the latter lead to increased delirium in elderly patients.⁵⁷

Additional Considerations

As mentioned earlier, there has been growing controversy over the “diagnosis” of excited delirium. Some have voiced concerns that the term is frequently being applied incorrectly to justify the need for physical or chemical restraint and explain away preventable deaths as inevitable outcomes. In fact, in a study of “combative” patients in law enforcement custody who required an emergency medical services response, verbal de-escalation techniques were all that was required in more than 80% of the cases.²¹

Another growing concern is the rapid expansion of ketamine use in the prehospital arena. A recent CBS News article brought attention to this growing concern, noting that the use of ketamine has increased 3,000% since 2010, and that increase has “led to mistakes.”⁵⁸ In one reported case, paramedics were quick to administer ketamine for mild agitation, when all evidence pointed to hypoglycemic seizure and a postictal state as the cause of this patient’s symptoms. In a retrospective review of the prehospital administration of ketamine, researchers discovered that approximately 17% of those cases resulted in complications, mostly hypoxia, with apnea reported in more than 2% of these patients.⁵⁹

One method to mitigate these concerns and improve outcomes is to develop evidence-based protocols to guide medication selection and use in the prehospital setting. One such example is depicted in Table 4. In this simplified example protocol, there are clear algorithms, specific medication options with dosing and route included, restraint methods to avoid (being “hog-tied”), and the direction to contact medical control when there is a perceived need to divert from the protocol.

Another important consideration in the management of hyperactive delirium with severe agitation is the iatrogenic sequelae that can follow. First, consider medication side effects, such as variable depths of sedation and respiratory depression, that have been discussed previously. Exceedingly rare adverse effects range from minor extrapyramidal symptoms to major concerns like neuroleptic malignant syndrome (NMS) and serotonin syndrome (SS).

Recall that NMS may present with hyperthermia, “lead-pipe” rigidity, altered mental status, and other abnormal vital signs. Treatment is with intravenous (IV) dantrolene. Serotonin syndrome may present with hyperthermia and clonus, as well as other vital sign abnormalities. Treatment for SS consists of benzodiazepines or cyproheptadine. Given these concerns, continuous cardiac and pulse oximetry monitoring are required after administration of any sedating medication.

Also consider the potential sequelae of physical restraint. These can range from minor injuries and trauma, to dehydration and rhabdomyolysis, to apnea and death.

Further, all medical conditions and concerns should be fully addressed before disposition, including any abnormal vital signs.⁶⁰

Disposition

The patient’s ultimate disposition will vary widely and depend heavily upon the initial reason for the visit, the emergency department course, underlying conditions and comorbidities, and psychosocial aspects of care. Some patients will have mild agitation, easily corrected with non-coercive interventions. Some will have acute intoxication and recover completely after a short period of observation in the ED.²⁷ Others may require medical clearance and psychiatric evaluation. Still others will require hospital admission across all levels of care, even including the intensive care unit.

More important than the ultimate disposition is to reinforce the need for a trained emergency physician to be leading this disposition decision. Any patient who requires chemical sedation in the prehospital setting should not be released into law enforcement custody or another non-medical setting without further evaluation. As we have discussed, there are many causes of hyperactive delirium with severe agitation, many of which are life-threatening. These conditions may go unrecognized and untreated if patients elect to forego evaluation or are taken into custody. This further reiterates the need for proper and complete evaluation and management, best performed by a trained emergency physician.

Summary

In summary, the approach to management of a violent patient in the ED is multifaceted and complex, considering a wide range of underlying etiologies, differential considerations, and external factors influencing their presentation and management. Most often, violent patients are agitated, hyperactive, and in an altered state of consciousness.

In recent years, emergency medicine physicians and researchers have made significant progress in better defining hyperactive delirium with severe agitation and using evidence-based treatment approaches. The most important initial steps are to: ensure safety, preventing harm to the patient and to staff; rapidly control the behavior through verbal de-escalation or chemical sedation, with physical restraint used in rare instances when those measures fail, or as a temporizing measure to safely administer medications; and lastly to recognize and appropriately target treatment to the most likely underlying cause.

As discussed at length earlier, verbal de-escalation techniques should be attempted first, using the 10 domains described in Project BETA. Some mildly agitated patients will be agreeable to oral medications and can benefit from these interventions. For the majority of patients requiring chemical sedation, intramuscular ketamine, midazolam, droperidol, and olanzapine all are appropriate initial treatment options.

After chemical sedation or physical restraint, ensure the patient is appropriately monitored with continuous cardiac and pulse oximetry monitoring as well as frequent reassessments. Ensure that all vital signs (including temperature) are checked and a point-of-care blood glucose level is within normal limits. Other diagnostic studies should be ordered on a case-by-case basis to assist the emergency physician in ruling out dangerous underlying etiologies of symptoms. Remember that the ultimate disposition plan will be affected by ED course, underlying pathology, comorbid conditions, and several other factors. Importantly, only a trained emergency physician should be making these disposition decisions.

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