Agitated or combative patient: Difference between revisions

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==Background==
==Background==
 
*'''Violence may occur without warning'''
*Positive predictors of violence
*Positive predictors of violence
**Male gender
**Male gender
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**Substance abuse
**Substance abuse
**Psychiatric illness
**Psychiatric illness
***Schizophrenia, Psychotic depression
***[[Schizophrenia]], Psychotic [[depression]]
***Personality disorders - lack remorse for violent actions
***[[Personality disorders]] - (e.g. antisocial personality disorder patients may lack remorse for violent actions_
***Mania - unpredictable because of emotional lability
***[[bipolar disorder|Mania]] - unpredictable because of emotional lability
**Increased wait times
**Increased '''waiting''' duration (for evaluation, results, treatment, etc)
*Factors that '''do not''' predict violence
*Factors that '''do not''' predict violence
**Ethnicity, diagnosis, age, marital status, and education
**Ethnicity, diagnosis, age, marital status, and education
**Evaluation by psychiatrist, regardless of experience
**Evaluation by psychiatrist, '''regardless of experience'''


==Clinical Features==
==Clinical Features==
 
*Escalation behaviors may include progression through:
**Anger, resistance, aggression, hostility, argumentativeness, violence


==Differential Diagnosis==
==Differential Diagnosis==
 
''FIND ME (functional, infectious, neurologic, drugs, metabolic, endocrine)''
* FIND ME (functional, infectious, neurologic, drugs, metabolic, endocrine)
*Psychiatric
*Psychiatric
**Schizophrenia
**[[Schizophrenia]], paranoid ideation, catatonic excitement
**Paranoid ideation
**[[Bipolar disorder|Mania]]
**Catatonic excitement
**Personality disorders ([[borderline personality disorder|borderline]], [[antisocial personality disorder|antisocial]])
**Mania
**Delusional [[depression]]
**Personality disorders (Borderline, Antisocial)
**Delusional depression
**Post-traumatic stress disorder
**Post-traumatic stress disorder
**Decompensating obsessive-compulsive disorders
**Decompensating obsessive-compulsive disorders
**Homosexual panic
*Situational Frustration
*Situational Frustration
**Mutual hostility
**Mutual hostility
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**Violence with no associated medical or psychiatric explanation
**Violence with no associated medical or psychiatric explanation
*Organic Diseases
*Organic Diseases
**Trauma (head)
**[[Head trauma]]
**Hypoxia
**[[Hypoxia]]
**Hypoglycemia or Hyperglycemia
**[[Hypoglycemia]] or [[hyperglycemia]]
**Electrolyte abnormality
**[[Electrolyte abnormality]]
**Infection
**Infection
***CNS infection (eg, herpes encephalitis)
***CNS infection (eg, herpes [[encephalitis]])
***AIDS
***[[AIDS]]
**Endocrine disorder
**Endocrine disorder
***Thyrotoxicosis
***[[Thyrotoxicosis]]
***Hyperparathyroidism
***[[Hyperparathyroidism]]
**Seizure (eg, temporal lobe, limbic)
**[[Seizure]] (eg, temporal lobe, limbic)
**Neoplasm (limbic system)
**[[CNS tumor]] (limbic system)
**Autoimmune Disease
**Autoimmune Disease
***Limbic encephalitis
***[[Limbic encephalitis]]
***Multiple sclerosis
***[[Multiple sclerosis]]
**Porphyria
**[[Porphyria]]
**Wilson’s disease
**[[Wilson's disease]]
**Huntington’s disease
**Huntington’s disease
**Sleep disorders
**Sleep disorders
**Vitamin deficiency
**[[Vitamin deficiencies]] (e.g. folate, B12, niacin, B6)
***Folate
**[[Delirium]]
***Vitamin B12
**[[Dementia]]
***Niacin
**[[Cerebrovascular accident]]
***Vitamin B6
**Vascular malformation (e.g. [[AVM]])
***[[Wernicke-Korsakoff syndrome]]
**[[Hypothermia]] or [[hyperthermia]]
**Delirium
**[[Anemia]]
**Dementia
*Tox
**Cerebrovascular accident
**Vascular malformation
**Hypothermia or hyperthermia
**Anemia
*Drugs
**Adverse reaction to prescribed medication
**Adverse reaction to prescribed medication
**Alcohol (intoxication and withdrawal)
**[[Alcohol]] (intoxication and withdrawal)
**Amphetamines
**[[Amphetamines]]
**Cocaine
**[[Cocaine]]
**Sedative-hypnotics (intoxication or withdrawal)
**[[Sedative/Hypnotics]] (intoxication or withdrawal)
**Phencyclidine (PCP)
**[[Phencyclidine]] (PCP)
**Lysergic acid diethylamide (LSD)
**[[Lysergic acid diethylamide (LSD)]]
**Anticholinergics
**[[Anticholinergics]]
**Aromatic hydrocarbons (eg, glue, paint, gasoline)
**Aromatic [[hydrocarbons]] (eg, glue, paint, gasoline)
**Steroids
**[[Steroids]]


==Evaluation==
==Evaluation==
*'''Screen for acute medical conditions that may contribute to the patient's behavior.'''
**Always obtain:
***Blood glucose
***Vitals, including pulse oximetry
**Consider:
***Metabolic panel: serum electrolytes, thyroid function
***Toxicology screen and blood alcohol levels
***Ammonia level
***Urine analysis
***[[Lumbar puncture]] (CNS infection)
***Aspirin and acetaminophen levels (intentional ingestion)
***Medication levels (sub- vs super-therapeutic)
***[[Electrocardiogram]] (elders, intentional ingestion).
***Cranial imaging
***Electroencephalography
*'''Unnecessary diagnostic testing prolongs ED stay and delays definitive psychiatric care.'''
**'''Organic cause unlikely''' → ''may not'' require further workup
***Younger than 40 years
***Prior psychiatric history
***Normal physical examination
****Normal vital signs
****Calm demeanor
****Normal orientation
****No physical complaints
**'''Organic cause more likely''' → ''does'' require further workup
***Acute onset of agitated behavior
***Behavior that waxes and wanes over time
***Older than 40 years with new psychiatric symptoms
***Elders (higher risk for delirium)
***History of substance abuse (intoxication or withdrawal)
***Persistently abnormal vital signs
***Clouding of consciousness
***Focal neurologic findings


Medical screening for acute medical conditions that may contribute to the patient's behavior.
==Management==


*Blood glucose and pulse oximetry
===Risk assessment===
*Consider
*Screen for weapons and disarm prior to entrance to ED
**Serum electrolyte
*'''Violence may occur without warning'''
**Toxicology screening
*'''Be aware of surroundings'''
**Serum ethanol level
**Signs of anger, resistance, aggression, hostility, argumentativeness, violence
**Thyroid function panel
**Accessibility of door for escape
**Cranial imaging
**Presence of objects that may be used as weapons
**Electroencephalography
**Lumbar puncture (if CNS infection)
**Aspirin and acetaminophen levels (if intentional ingestion)
**Medication levels (if levels would affect therapy)
**Electrocardiogram (in elders or if intentional ingestion).


Unnecessary diagnostic testing prolongs ED stay and delays definitive psychiatric care.
===Verbal de-escalation techniques===
*Be honest and straightforward; Ask about violence directly
**Suicidal or homicidal ideations and plans
**Possession of weapons
**History of violent behavior
**Current use of intoxicants
*Be nonconfrontational, attentive, and receptive
**Respond in a calm and soothing tone
**Express concern/worry about the patient
*'''Three Fs framework''':
**I understand how you could '''feel''' that way.
**Others in that situation have '''felt''' that way, too.
**Most have '''found''' that _____ helps."
*'''Avoid argumentation, machismo, and condescension'''
*'''Do not ''threaten'' ''' to call security — Invites patient to challenge with violence
*'''Do not ''deceive'' ''' (eg, about estimated wait times) — Invites violence when lie is uncovered
*'''Do not ''command'' ''' to calm down — Invites further escalation
*'''Do not ''downplay'', ''deny'', or ''ignore'' '''threatening behavior
*'''Do not ''hesitate'' ''' — Leave and call for help if necessary


*May require no further workup
===Chemical Restraints (Rapid Tranquilization)===
**Younger than 40 years
*Offer voluntary administration to patient — increased sense of control may calm patient
**Prior psychiatric history
*If need to temporary physical restraint the patient: One arm up, one arm down, tie legs to opposite side of bed. [https://emcrit.org/emcrit/human-bondage-chemical-takedown/ Reference with video]
**Normal physical examination
*Suggested protocol for continued agitation: antipsychotic Q5 min x 2, then ketamine IM
***Vital signs
**E.g. [[Droperidol]] 5mg (or [[haloperidol]] 5mg) IM Q5 min x 2, then [[ketamine]] 300mg IM
***Calm demeanor
*[[Ketamine]], at a dose of 4-6 mg/kg IM, achieves sedation in 2-10 minutes. Few medications, if any, reliably achieve effective sedation this quickly following a single dose. <ref> Westafer, Lauren. “Patients with Severe Agitation in the ED.” ACEP NOW, vol. 42, no. 12, https://www.acepnow.com/article/which-sedatives-are-best-for-managing-severe-agitation-in-the-emergency-department/.</ref>.
***Normal orientation
*Other protocols involve combination therapy<ref>[http://www.emdocs.net/the-art-of-the-ed-takedown/ The Art of the ED Takedown EMDocs]</ref>.
***No physical complaints
*Neuroleptics ([[Antipsychotics]])
*Organic cause more likely - requires further workup
**Atypical antipsychotics
**Acute onset of agitated behavior
***Less sedation and [[EPS]] (than typical)
**Behavior that waxes and wanes over time
***Increased mortality in elderly with dementia-related psychosis
**Older than 40 years with new psychiatric symptoms
***[[olanzapine]], [[ziprasidone]], and [[aripiprazole]]
**Elders (higher risk for delirium)
**Typical antipsychotics (low potency)
**History of substance abuse (secondary to intoxication or withdrawal)
***Greater sedation, hypotension, anticholinergic effects (than high-potency)
**Persistently abnormal vital signs
***[[chlorpromazine]] and [[thioridazine]]
**Clouding of consciousness
**Typical antipsychotics (medium potency)
**Focal neurologic findings
***[[loxapine]] and [[molindone]]
**Typical antipsychotics (high potency)
***Greater [[EPS]] (than low-potency)
***[[butyrophenones]]: [[haloperidol]] and [[droperidol]]
**Cautions
***[[Neuroleptic malignant syndrome]] &mdash; rare
***[[Extrapyramidal symptoms]] &mdash; treat with [[diphenhydramine]] or [[benztropine]]
***[[QTc prolongation]] and [[torsades de pointes]]
*[[Ketamine]]<ref>Ketamine as Rescue Treatment for Difficulty-to-Sedate Severe Acute Behavioral Disturbance in the ED. Annals of EM. May 2016 67(5):581-587</ref>
**4-6mg/kg IM or 1mg/kg IV
*[[Benzodiazepines]]
**''"There is increasing evidence that benzodiazepines alone and in combination with antipsychotics are associated with higher rates of adverse effects.''<ref>Ketamine as Rescue Treatment for Difficulty-to-Sedate Severe Acute Behavioral Disturbance in the ED. Annals of EM. May 2016 67(5):581-587</ref>
**[[Lorazepam]] &mdash; Eliminated without active metabolites
***Onset: 5-20 min (IV), 15-30 min (IM)
***Duration: 6-8 H
**[[Midazolam]]
***Onset: 15 min (IM)
***Duration: 2 H
*Typical intramuscular dosing for adult patients:<ref>Klein LR, Driver BE, Miner JR, et al. Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department. Ann Emerg Med. 2018;72(4):374-385.</ref>
**Haloperidol 5-10mg IM, ziprasidone 20mg IM, olanzapine 10mg IM, and midazolam 5mg IM.
***In order from slowest to quickest time to effect


==Management==
===Physical restraints===
 
*'''Not for convenience or punishment'''
*Risk assessment
*Indications for seclusion or restraint
**Violence may occur without warning
**Imminent danger to self, others, or environment
**Patients should be screened for weapons and disarmed
**Part of ongoing behavioral treatment
**Clinician should be aware of surroundings
*Contraindications to seclusion
***Signs of anger, resistance, aggression, hostility, argumentativeness, violence
**Patient is unstable and requires close monitoring
***Accessibility of door for escape
**Patient is self-harming (suicidal, self-mutilating, toxin ingestion)
***Presence of objects that may be used as weapons
*Caveats
*Verbal management techniques
**Allow for adequate chest expansion for ventilation
**Adopt an honest, straightforward manner
**Sudden death has occurred in the prone or hobble position
**Adopt a nonconfrontational, attentive, and receptive demeanor
**Respond in a calm and soothing tone
**Ask questions about violence directly
***Suicidal or homicidal ideations and plans
***Possession of weapons
***History of violent behavior
***Current use of intoxicants
**'''Avoid''' argumentation, machismo, and condescension
***'''Do not''' threaten to call security -- invites patient to challenge with violence
***'''Do not''' attempt to deceive (eg, about estimated wait times) -- invites violence when lie is uncovered
***'''Do not''' downplay or deny threatening behavior
***'''Do not''' hesitate to leave the room and summon help
*Physical restraints
**'''Do not''' restrain for convenience or punishment
**Indications for seclusion or restraint
***Imminent danger to self, others, or environment
***Part of ongoing behavioral treatment
**Contraindications to seclusion
***Unstable patient who requires close monitoring
***Patient is self-harming (suicidal, self-mutilating, ingestion of toxins)
*Chemical restraints (rapid tranquilization)
**Offer voluntary administration to patient
**Benzodiazipines
***[[lorazepam]]
****Elimination without active metabolites
****Onset: 5-20 min (IV), 15-30 min (IM)
****Duration: 6-8 H
***[[midazolam]]
****Onset: 15 min (IM)
****Duration: 2 H
**Neuroleptics
***[[Neuroleptic malignant syndrome]] is rare
***Treat [[extrapyramidal symptoms]] with [[diphenhydramine]] or [[benztropine]]
***Risk of [[QTc prolongation]] and [[torsades de pointes]]
***Typical, low potency - greater sedation, hypotension, anticholinergic effects
****[[chlorpromazine]] and [[thioridazine]]
***Typical, medium potency
**** [[loxapine]] and [[molindone]]
***Typical, high potency - greater [[EPS]]
****[[butyrophenones]]: [[haloperidol]] and [[droperidol]]
***Atypical - less sedation and [[EPS]]
****[[olanzapine]], [[ziprasidone]], and [[aripiprazole]]
****Increased risk of death in elderly with dementia-related psychosis


==Disposition==
==Disposition==
===Admit===
*Admit or commit when...
**Harm to self
**Harm to others
**Cannot care for self
**Uncooperative, refusing to answer questions
**Intoxicated
**Psychotic
**Organic brain syndrome


==External Links==
===Discharge===
*Consider discharge when...
**Temporary organic syndrome has concluded (eg, intoxication)
**No other significant problem requiring acute intervention
**Patient is in control and no longer violent


==See Also==
==See Also==
*[[Sedation (main)]]
*[[Altered mental status]]
*[[Altered mental status]]
*[[Excited delirium]]
*[[Excited delirium]]
*[[Acute psychosis]]
==External Links==
==Further Reading==
*Heiner JD and Moore GP.  The Combative Patient.  In: Marx J, Walls R, Hockberger R, eds.  Rosen's Emergency Medicine: Concepts and Clinical Practice.  8th ed.  Philadelphia, PA: Elsevier/Saunders; 2014: 188: 2414-2421.
*Moore GP, Pfaff JA.  [https://www.uptodate.com/contents/assessment-and-emergency-management-of-the-acutely-agitated-or-violent-adult Assessment and emergency management of the acutely agitated or violent adult].  UpToDate.  Feb 16, 2017.


==References==
==References==

Latest revision as of 18:29, 10 December 2025

Background

  • Violence may occur without warning
  • Positive predictors of violence
    • Male gender
    • History of violence
    • Substance abuse
    • Psychiatric illness
    • Increased waiting duration (for evaluation, results, treatment, etc)
  • Factors that do not predict violence
    • Ethnicity, diagnosis, age, marital status, and education
    • Evaluation by psychiatrist, regardless of experience

Clinical Features

  • Escalation behaviors may include progression through:
    • Anger, resistance, aggression, hostility, argumentativeness, violence

Differential Diagnosis

FIND ME (functional, infectious, neurologic, drugs, metabolic, endocrine)

Evaluation

  • Screen for acute medical conditions that may contribute to the patient's behavior.
    • Always obtain:
      • Blood glucose
      • Vitals, including pulse oximetry
    • Consider:
      • Metabolic panel: serum electrolytes, thyroid function
      • Toxicology screen and blood alcohol levels
      • Ammonia level
      • Urine analysis
      • Lumbar puncture (CNS infection)
      • Aspirin and acetaminophen levels (intentional ingestion)
      • Medication levels (sub- vs super-therapeutic)
      • Electrocardiogram (elders, intentional ingestion).
      • Cranial imaging
      • Electroencephalography
  • Unnecessary diagnostic testing prolongs ED stay and delays definitive psychiatric care.
    • Organic cause unlikely → may not require further workup
      • Younger than 40 years
      • Prior psychiatric history
      • Normal physical examination
        • Normal vital signs
        • Calm demeanor
        • Normal orientation
        • No physical complaints
    • Organic cause more likely → does require further workup
      • Acute onset of agitated behavior
      • Behavior that waxes and wanes over time
      • Older than 40 years with new psychiatric symptoms
      • Elders (higher risk for delirium)
      • History of substance abuse (intoxication or withdrawal)
      • Persistently abnormal vital signs
      • Clouding of consciousness
      • Focal neurologic findings

Management

Risk assessment

  • Screen for weapons and disarm prior to entrance to ED
  • Violence may occur without warning
  • Be aware of surroundings
    • Signs of anger, resistance, aggression, hostility, argumentativeness, violence
    • Accessibility of door for escape
    • Presence of objects that may be used as weapons

Verbal de-escalation techniques

  • Be honest and straightforward; Ask about violence directly
    • Suicidal or homicidal ideations and plans
    • Possession of weapons
    • History of violent behavior
    • Current use of intoxicants
  • Be nonconfrontational, attentive, and receptive
    • Respond in a calm and soothing tone
    • Express concern/worry about the patient
  • Three Fs framework:
    • I understand how you could feel that way.
    • Others in that situation have felt that way, too.
    • Most have found that _____ helps."
  • Avoid argumentation, machismo, and condescension
  • Do not threaten to call security — Invites patient to challenge with violence
  • Do not deceive (eg, about estimated wait times) — Invites violence when lie is uncovered
  • Do not command to calm down — Invites further escalation
  • Do not downplay, deny, or ignore threatening behavior
  • Do not hesitate — Leave and call for help if necessary

Chemical Restraints (Rapid Tranquilization)

  • Offer voluntary administration to patient — increased sense of control may calm patient
  • If need to temporary physical restraint the patient: One arm up, one arm down, tie legs to opposite side of bed. Reference with video
  • Suggested protocol for continued agitation: antipsychotic Q5 min x 2, then ketamine IM
  • Ketamine, at a dose of 4-6 mg/kg IM, achieves sedation in 2-10 minutes. Few medications, if any, reliably achieve effective sedation this quickly following a single dose. [1].
  • Other protocols involve combination therapy[2].
  • Neuroleptics (Antipsychotics)
  • Ketamine[3]
    • 4-6mg/kg IM or 1mg/kg IV
  • Benzodiazepines
    • "There is increasing evidence that benzodiazepines alone and in combination with antipsychotics are associated with higher rates of adverse effects.[4]
    • Lorazepam — Eliminated without active metabolites
      • Onset: 5-20 min (IV), 15-30 min (IM)
      • Duration: 6-8 H
    • Midazolam
      • Onset: 15 min (IM)
      • Duration: 2 H
  • Typical intramuscular dosing for adult patients:[5]
    • Haloperidol 5-10mg IM, ziprasidone 20mg IM, olanzapine 10mg IM, and midazolam 5mg IM.
      • In order from slowest to quickest time to effect

Physical restraints

  • Not for convenience or punishment
  • Indications for seclusion or restraint
    • Imminent danger to self, others, or environment
    • Part of ongoing behavioral treatment
  • Contraindications to seclusion
    • Patient is unstable and requires close monitoring
    • Patient is self-harming (suicidal, self-mutilating, toxin ingestion)
  • Caveats
    • Allow for adequate chest expansion for ventilation
    • Sudden death has occurred in the prone or hobble position

Disposition

Admit

  • Admit or commit when...
    • Harm to self
    • Harm to others
    • Cannot care for self
    • Uncooperative, refusing to answer questions
    • Intoxicated
    • Psychotic
    • Organic brain syndrome

Discharge

  • Consider discharge when...
    • Temporary organic syndrome has concluded (eg, intoxication)
    • No other significant problem requiring acute intervention
    • Patient is in control and no longer violent

See Also

External Links

Further Reading

References

  1. ↑ Westafer, Lauren. “Patients with Severe Agitation in the ED.” ACEP NOW, vol. 42, no. 12, https://www.acepnow.com/article/which-sedatives-are-best-for-managing-severe-agitation-in-the-emergency-department/.
  2. ↑ The Art of the ED Takedown EMDocs
  3. ↑ Ketamine as Rescue Treatment for Difficulty-to-Sedate Severe Acute Behavioral Disturbance in the ED. Annals of EM. May 2016 67(5):581-587
  4. ↑ Ketamine as Rescue Treatment for Difficulty-to-Sedate Severe Acute Behavioral Disturbance in the ED. Annals of EM. May 2016 67(5):581-587
  5. ↑ Klein LR, Driver BE, Miner JR, et al. Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department. Ann Emerg Med. 2018;72(4):374-385.
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