Special Considerations

SC4 PATIENT VIOLENCE

Andrea M. Kondracke, Justin M. Lewin, Cathy A. Kondas, and Erin A. Zerbo

The aggressive and/or violent patient presents unique challenges. Like physical restraint. It also provides an overview of potential risk factors
suicidal patients, aggressive individuals are difficult to treat and they for violent behavior.
tend to elicit strong negative reactions in hospital personnel ranging from
anger to fear.42 Workplace violence is unfortunately commonplace within Differential Diagnosis
the health care setting, and is particularly prominent in the inpatient psy- There are many causes of violent behavior; some are social, medical, or
chiatry ward and emergency department settings.20 Of the approximately biological in nature. The most common characteristic of the violent patient
24,000 annual workplace assaults occurring between the years of 2011 is alteration in mental status. Factors such as metabolic derangements,
and 2013 in the United States, approximately 75% were within the health exposure to xenobiotics (both licit and illicit), withdrawal syndromes,
care and social service settings.37 The prevalence of verbal and physical seizures, head trauma, stroke, psychosis, cognitive impairment, and
assaults reported by emergency nurses within a 12-month period is as personality disorder all predispose a patient to aggression and violence.
high as 100% and 82%, respectively.34 Additionally, a survey of emergency Additionally, patients with severe pain, delirium, or extreme anxiety often
physicians within the state of Michigan showed that 25% of emergency respond to the efforts of emergency personnel with resistance, hostility, or
physicians reported being a target of physical assault within 12 months.27 overt aggression.
These statistics on workplace violence in health care settings are likely The stress-vulnerability model suggests that violence should be con-
underestimates as events are often underreported to health care super- sidered as the outcome of a dynamic interaction among numerous factors
visors and administrators. Workplace violence occurs so frequently that both intrinsic and extrinsic to the individual. Although education theoreti-
there is a perception among health care workers that violence is “the cally provides alternatives to violence, xenobiotic-induced delirium will
norm” and an expected part of their job.44 render any education ineffective because delirium prevents patients from
Workplace violence is classified into 4 broad categories that are depen- reasoning or exercising impulse control. Once confused, the patient often
dent on the relationship of the perpetrator to the workplace. In type I, misinterprets health care efforts in a paranoid manner, and becomes vio-
which accounts for approximately 80% of workplace homicides, there is lent under circumstances that would not normally be sufficient to provoke
not an association between the two. These incidents are generally moti- a violent outburst in that individual. Some patients, on the other hand,
vated by theft, with hospitals and pharmacies being susceptible because come from cultures in which aggressive behavior is more acceptable and/
of their abundance of opioids, equipment, and money. However, this type or expected, and these patients require little stress or provocation before
of violence is no more likely to be experienced in health care settings. Pre- responding in what is often perceived as aggression by Western cultural
ventive measures include environmental security measures such as metal standards.
detectors. In type II, the most common type in the hospital setting, the per-
petrator is a patient or customer. In general, these acts of violence occur Prediction of Violence
while workers are performing basic work functions. An example of this Although there is a high expectation that violence is predictable, there are
would be an intoxicated patient who punches a nurse while obtaining vital no proven predictors of violence. Prior history of violence is postulated as a
signs. In type III, the perpetrator is a current or former employee. In type IV, risk factor for future violence. Patients in police custody are involved in 29%
the perpetrator has a personal relationship with a specific employee but of shootings in emergency departments.37 Predicting violent behavior based
not with the institution.41 The most common types of hospital violence on medical diagnosis (eg, patients with HIV) is unfruitful and leads to bias or
are incidents of aggression against objects in the hospital (57%), violence discrimination. Other factors such as personality disorders, mental illness,
directed against the hospital staff (28%), and violence directed against dementia, and substance abuse are areas that need further study.42 Studies
other patients (14%).43 of emergency department violence show the following risk factors: the presence
In one study of violence in the emergency department, directors of emer- of guns, area of gang activity, low socioeconomic status, and interacting with
gency medicine residency programs were surveyed as to the frequency of patients who were recently given bad news.37
verbal threats, physical attacks, and the presence of weaponry in the area. There are several structured approaches to violence risk assessment.46
Of the 127 institutions surveyed, 74.7% of the residency directors responded; Examples are the Psychopathy Checklist–Revised (PCL-R); Historical Clini-
41 (32%) reported receiving at least one verbal threat each day; 23 (18%) cal Risk Management–20 (HCR-20); Classification of Violence Risk (COVR);
reported that weapons were displayed as a threat at least once each month. Violence Risk Appraisal Guide (VRAG).46 Structured approaches tend to have
Fifty-five program directors (43%) noted that a physical attack on medical better efficacy for predicting violence than an unstructured approach. How-
staff members occurred at least once a month.29 ever, they also have many shortcomings: the sensitivities and specificities
These studies underscore the need for timely identification of the tend to hover around 0.7 and they are time consuming and require specific
potentially violent patient, as well as appropriate management for this training to administer, rendering them impractical in the emergency depart-
diagnostically heterogeneous group.13 The assessment and management ment setting.16
of the violent patient should include provisions for patient and staff
safety as well as a thorough search for the underlying cause of violent Substance Use and Violence
behavior.23,42 The association between substance use and violence is well established.
The section below addresses the differential diagnosis of violent Alcohol is found in the offender, the victim, or both in one-half to two-thirds
behavior, predictions of violence, the pharmacotherapy for the treat- of homicides and serious assaults.9,38 Substance use is seldom the sole cause,
ment of aggressive and/or agitated behavior, and the use of seclusion and but it contributes to violence in a number of ways. Substance use interacts
384

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 SPECIAL CONSIDERATIONS 4 • PATIENT VIOLENCE 385

with other physiologic, cognitive, psychological, situational, and cultural impaired perception. Violence risk is also associated with cognitive dys-
factors including any underlying mental illness. A tripartite model for function such as traumatic brain injury and dementia. These patients are
substance-related violence is described:18,19 unable to engage in a rational manner and verbal de-escalation is often futile.
1. systemic violence related to the sale and distribution of drugs, Additional Factors in Aggressive Behavior
2. economic compulsive violence associated with profit-oriented criminal Many of the factors correlated with aggression are easy to observe and moni-
activity to maintain the expenses of an individual’s drug habit, and tor in the hospital, yet some additional factors are not so easy to detect. One
3. psychopharmacologic violence resulting from the direct effects of the study found that most violent incidents in the hospital occur on Mondays
particular xenobiotic. and Fridays, and others have postulated that there is a seasonal variation
Toxicity causes disinhibition, impulsivity, perceptual disturbance, para- of violence, with violence occurring more often in extreme temperatures.10
noia, irritability, misinterpretation, affective instability, and/or confusion. There is an increase in the frequency of assaults by inpatients during the
For example, synthetic cannabinoids, synthetic cathinones, and phencycli- winter months, and it is hypothesized that increased population density,
dine are well known to cause agitation, which is often accompanied by vio- cold temperature, and less sunlight during the day could account for the
lent and uncontrollable behavior. increased violence. This finding is in contrast to the literature on outpatient
Withdrawal syndromes also promote aggressive behavior for a multitude violence, which has reported greater incidence of violence during the warmer
of reasons, including physical discomfort, anticipatory anxiety, irritability months.2 However, this same review conceded that any extreme temperature
as a direct result of withdrawal, and withdrawal-related delirium. Patients could evoke aggressive urges and frustration.
experiencing any of these symptoms have the potential to become aggres- Although it is unclear whether cold temperatures provoke aggression to
sive, verbally abusive, or threatening. Prompt recognition of these syndromes the same extent as hot temperatures, it does seem clear that overcrowding
and immediate treatment will prevent some aggressive outbursts or esca- and social stressors, long wait times, and inadequate food supplies can lead
lation to assaultive behaviors. Well-known xenobiotics that cause irritabil- to violent behavior.
ity and associated behaviors in withdrawal include ethanol, benzodiazepines,
and opioids. Because drug use is often concealed, is difficult to ascertain on Assessment of the Violent Patient
­clinical grounds, and frequently contributes to violent behavior, urine and The comprehensive evaluation of the violent patient include a complete
blood toxicologic studies are useful in enhancing the understanding and physical examination with the intent of revealing the underlying cause of the
long-term treatment of some patients.8 violent behavior as well as ensuring the discovery of secondary patient inju-
ries. It is important to attempt to differentiate toxicity or withdrawal, cogni-
Mental Illness and Violence tive impairment, delirium, and mental illness as treatment differs depending
The relationship between mental illness and violence is also complex. The on etiology. Recommended laboratory analyses include blood chemistries
impact of present-day media and the counteracting efforts made to des- (glucose, electrolytes), a complete blood count, liver function tests, renal
tigmatize mental illness often confound this issue. There are several stud- function tests, thyroid function tests, and urinalysis. The need for lumbar
ies showing an association between mental illness and increased risk for puncture and/or neuroimaging is best guided by clinical history and physical
violence.38 In one large epidemiologic study, the prevalence of violence for examination.
those without mental illness was 2%, whereas schizophrenia was associated
Treatment
with an 8% rate of violent behavior. But, of all respondents reporting violent
There are 3 main approaches to controlling aggressive behavior in order of
behaviors, 42% had a substance use disorder. In patients with schizophrenia,
escalation: First and foremost, there is verbal de-escalation. When this has
having a co-occurring substance use disorder more than tripled the rate of
failed, medical anxiolysis and sedation will be the next approach. Finally,
violence.45 However, based on a cohort study from the Netherlands, most of
under the most extreme circumstances where there is significant risk for
the common mental disorders were associated with violence until adjusting
harming self or others, the use of physical restraints are indicated.
for violent victimization, negative life events, and social supports. Then the
association of violence with most mental disorders was negligible, with the Verbal De-escalation
exception of substance use disorders, which retain a strong association with Because of several high-profile deaths involving restraints, there is a contin-
violent behavior.45 ued focus on advancing techniques and training in de-escalation. These are
In addition to substance abuse and severe mental illnesses, researchers now paramount to the treatment of agitation and violence in the medical set-
have consistently found a greater prevalence of personality disorders among ting. These techniques use both verbal and nonverbal communication, and
individuals who become violent in an inpatient setting as compared to non- include talking to a patient, building rapport, listening and understanding in
violent inpatients.7 Antisocial personality disorder is the condition most a calm and compassionate manner, using a calm voice, making eye contact,
strongly associated with both substance use and aggression. Patients with and focusing on the person and not the behavior.
either borderline or antisocial personality disorders are at risk for violent Many hospitals have behavioral response teams. At our institution, the
behavior as a result of chronic poor impulse control and impaired frustration creation of a crisis management team has proven to be a very successful
tolerance in the context of poor coping skills. way of intervening and avoiding the escalation of a violent situation. The
Although persons with psychotic disorders are not generally aggressive, purpose of these teams is to respond, assess, protect, and treat the patient
there are aspects of their psychosis that place them at risk for aggressive with behavioral disturbances. The teams are generally multidisciplinary in
behavior. Hallucinations lead to aggression, such as when patients explicitly nature and consist of mental health, medical, and security professionals. The
follow the instructions of a violent command auditory hallucination. Para- members should have specialized training in evaluation, conflict resolution,
noid ideation that leads an individual to believe that she or he is at imminent and de-escalation techniques. Team members should possess good personal
risk of bodily harm (“They’re trying to kill me”), sexual victimization (“Men control, verbal and nonverbal engagement skills, and learn when and how
and women are raping me”), or humiliation (“Everyone is laughing at me”) to intervene while ensuring a safe environment. There is a balance between
or feeling physically trapped are examples of thoughts that lead psychotic autonomy and limit-setting.
patients to be aggressive.
Psychopharmacologic Interventions
Alternative Etiologies The goal of acute pharmacologic intervention for agitated or violent behavior
Delirium from any underlying condition is a cause of aggression. Patients is to target the suspected cause of the agitation while regaining behavioral
are often suddenly confused, frightened, or frankly psychotic as a result of control and ensuring safety. Targeting the underlying cause reduces the

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 386 PART B • THE FUNDAMENTAL PRINCIPLES OF MEDICAL TOXICOLOGY

likelihood of recurrent agitation even after the sedating effects of the medica- as well as which approaches were safer, as determined by the proportion of
tions have diminished. Sedation alone may frighten and/or anger the patient reported adverse events. This systematic review concluded that a larger por-
and does not address the underlying etiology of the problematic behavior. tion of patients remained sedated with therapeutic combination (use of both
For example, the patient in ethanol withdrawal presenting with agitation benzodiazepine and antipsychotic) compared to benzodiazepines alone.
would benefit from a benzodiazepine, whereas, an antipsychotic could be Additionally, antipsychotic monotherapy and combinations both required
detrimental and lead to unnecessary side effects (Chap. 77). fewer repeated administrations for sedation than benzodiazepines alone.
Given that the goals of treatment are specific to the suspected etiology Benzodiazepine monotherapy was also associated with a higher incidence
of agitation, the formerly used term of “chemical restraints” has fallen out of adverse events than the antipsychotics alone or combinations.26 We rec-
of favor. Chemical restraint is defined as “chemical measures for confining a ommend the use of antipsychotic monotherapy in the presumed agitated
patient’s bodily movements, thereby preventing injury to self or others and psychosis in those primarily calm enough to be cared for by a psychiatrist
reducing agitation.”12 Given that aggression results from multiple etiologies, with limited likelihood of a consequential toxicologic problem, whereas toxi-
there is much debate about the specific sedative and route of administration cologists treating undifferentiated episodes of toxicity and agitation prefer
that should be used. Overall, studies show that both benzodiazepines and midazolam, diazepam or lorazepam. When appropriate regimens of mono-
antipsychotics result in rapid control of agitation and aggression.6,14,24,28 therapy are initiated in these two scenarios and fail, a combination of benzo-
Haloperidol is safely used in the treatment of agitation and aggression diazepines and antipsychotics is reasonable.
in patients with psychoses and delirium.1,6,14,28 It can be administered orally, There are multiple indications for the use of ketamine within the field of
intravenously, or intramuscularly. Dosing intervals range from 30 minutes medicine, including a potential treatment for major depressive disorders, as
to 2 hours, with a usual regimen of haloperidol 5 mg given every 30 to 60 minutes; well as use in the emergency department as sedation for procedures and for
most patients respond after one to 3 doses. Older studies indicated that intubation. Ketamine is an antagonist of the glutamate N-methyl-d-aspartate
the dose of haloperidol needed to achieve sedation rarely exceeded a total (NMDA) receptor that is a dissociative anesthetic, which provides both
of 50 mg in acute management, but it is unusual that more than 20 mg is analgesia and amnesia.47 There is some recent interest in the potential use
needed.31,32 It is important to take the individual patient into consideration. of ketamine for acute agitation in the emergency department setting and
For example, in elderly and/or medically compromised patients, behavioral in the prehospital setting.30,40 In a retrospective cohort study, 32 cases of
control is often achieved at doses as little as 1 to 2 mg. During a behavioral acute agitation in the emergency department were treated with ketamine
crisis, most psychiatrists would switch to a second-generation antipsychotic and monitored for vital sign changes and the need for rescue sedating medi-
such as olanzapine or add a mood stabilizer such as valproic acid rather than cations within 3 hours of ketamine administration. This study found that
continue to titrate haloperidol because of escalating risks of side effects as 62.5% of cases required additional sedating medications within 3 hours of
haloperidol dose is increased (such as extrapyramidal symptoms and QT initial ketamine administration. The authors hypothesized that the reason
interval prolongation). that the effects of ketamine on agitation were not sustained were unre-
Droperidol is an older antipsychotic used in United States since the 1960s. lated to the underlying causes of the agitation. However, there were 8 cases
It is widely used in Europe for treatment of acute and chronic psychoses as where the subject received multiple doses of an antipsychotic or benzodi-
it has sedating properties.25 Droperidol is rarely used as an antipsychotic in azepine without resolution of agitation, but on receiving a single dose of
the United States. Several studies compared the use of droperidol with alter- ­ketamine, no further medication for agitation was required for at least another
natives to treat acute agitation, and evidence overall supports its use as a 3 hours. This may indicate a unique role for ketamine as a potential alter-
first-line treatment option for acute agitation. When compared to both halo- native medication for agitation when the agitation is refractory to tradi-
peridol and olanzapine, droperidol had comparable efficacy in sedation on tional pharmacologic interventions. In addition to examining the efficacy,
first administration of medication while having a lower risk of participants this study also investigated the safety of using ketamine for agitation in the
needing additional sedating medications after 60 minutes.25 Although mid- emergency department setting. Based on pre- and postadministration vital
azolam is proven to induce adequate sedation more rapidly than droperidol, signs, there were mild increases in systolic blood pressure and heart rate
15 versus 30 minutes, respectively, midazolam also has a significantly higher but none of any clinical significance, and there were no cases of oxygen
rate of needing rescue medication for sedation, when compared to droperi- desaturation.22 In 2017, a single-center, prospective, observational study
dol, 50% versus 10%, respectively.33 Droperidol is taken orally at doses from compared the time to a defined reduction in agitation scores, rate of medica-
5 to 20 mg every 4 to 6 hours as needed; given intramuscularly at doses tion redosing, vital sign changes, and adverse events in agitated individu-
up to 10 mg every 4 to 6 hours as needed; or intravenously at doses of 5 to als in the emergency department receiving ketamine, benzodiazepines, and
15 mg every 4 to 6 hours as needed25 (Chap. 67). haloperidol, alone or in combination. This prospective study showed that the
Various benzodiazepines are quite effective for sedation; their use has ketamine group had more patients who were no longer agitated at 5, 10, and
been examined in patients with psychoses, stimulant toxicity, sedative– 15 minutes after receiving medication. The ketamine group had similar rates
hypnotic and alcohol withdrawal, and postoperative agitation.17,35 Diazepam of redosing, changes in vital signs, and adverse events compared to the benzo-
is given intravenously (IV) 5 to 10 mg, with rapid repeat dosing titrated to diazepine and haloperidol groups.39 The findings in the 2 studies mentioned
desired effect. Because diazepam is poorly absorbed from intramuscular above are in stark contrast to a few studies on the prehospital administra-
(IM) sites, its preferred route of administration is either IV or oral. Lorazepam tion of ketamine to treat agitation, which reported intubation rates between
1 to 2 mg or midazolam 5 to 10 mg is given orally or parenterally and 39% and 63%.11,36 In addition, a case series on prehospital use of ketamine for
repeated at 15- or 30-minute intervals, respectively, until the patient is calm. agitation showed that 3 of 13 patients (23%) developed hypoxia and another
Midazolam is frequently used in the emergency department because of its patient developed laryngospasm.5 Given the conflicting and limited data on
rapid onset of action and short duration of effect of 1 to 4 hours, but it has its safety in treating agitation, ketamine is not recommended as a first-line
a significant amnestic effect. Diazepam has a rapid onset of action intrave- therapy to treat agitation in the emergency department setting, and physi-
nously and has a prolonged duration of action. The disadvantage of loraz- cians should use caution when using ketamine given concerns for significant
epam is its delay to effect, which limits the rapidity of clinical response. adverse events which means evaluation for airway compromise and resusci-
A 2016 systematic review and meta-analysis aimed to compare the use tative preparedness (Chap. 83).
of benzodiazepines, antipsychotics, and a combination of these 2 classes If a patient is agitated in the context of alcohol intoxication, we recommend
in the treatment of agitated patients in the emergency department. antipsychotics and we suggest that benzodiazepines should be avoided because
The investigators’ aim was to determine which of these pharmacologic of the potential to cause additive respiratory depression. In contrast, benzodi-
approaches were more effective, measured by the proportion of individuals azepines have a unique role in the treatment of agitation secondary to cocaine
who remain sedated at 15 to 20 minutes and the need for repeat sedation, toxicity (Chap. 75 and Antidotes in Depth: A26). Antipsychotics, particularly

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 SPECIAL CONSIDERATIONS 4 • PATIENT VIOLENCE 387

low-potency antipsychotics (such as chlorpromazine), lower the seizure thresh- TABLE SC4–2 S.A.F.E.S.T. Approach
old in animals, so their use for patients with cocaine/amphetamine toxicity or
alcohol/sedative–hypnotic withdrawal is not recommended. Spacing Maintain a safe distance
There is special concern about sedation and respiratory depression with Allow both patient and you to have equal access to the door
IM olanzapine, given that 8 fatalities were reported in the European (but you should be closest)
literature when olanzapine was used in excessive dosages or combined Do not touch the patient
with benzodiazepines and/or other antipsychotics. Although significant Appearance Maintain empathetic and professional detachment
comorbidities were present in the patients who died, we now recommended Use one primary person to build rapport
against using IM olanzapine with other CNS depressants.4 In general, con-
Have security available as a show of strength
cerns regarding respiratory depression mandate careful observation and
monitoring of patients receiving sedation with any xenobiotic (Chap. 67). Focus Watch the patient’s hands
Look for potential weapons
Physical Restraint
Isolation and mechanical restraints are also used in the treatment of violent Watch for escalating agitation
behavior. Isolation or seclusion can help to diminish environmental stimuli Exchange Attempt to de-escalate by use of calm/continuous talking
and thereby reduce hyperreactivity. However, a few aspects are worth men- Avoid punitive or judgmental statements
tioning: Because seclusion is defined by a condition of very limited interac- Use good listening skills
tive and environmental cues, it is not indicated for patients with unstable
Elicit patient cooperation by targeting the current problem
medical conditions, delirium, dementia, self-injurious behavior such as cut-
ting or head banging, or those who are experiencing extrapyramidal reac- Stabilization By the least restrictive and most appropriate approach(s) possible:
tions as a consequence of antipsychotics such as an acute dystonic reaction.15 Physical restraints
Mechanical restraint is used to prevent patient and staff injury, although it Sedation (benzodiazepines)
does occasionally lead to patient and staff injury itself.3,21 All facilities should Antipsychotics
have clear, written policy guidelines for restraint that address monitoring,
documentation, and provisions for patient comfort. Frequent reassessment Treatment Treat underlying cause
of the patient and documentation of the need for continued restraint are May need to treat involuntarily
essential and should be performed according to state law. However recom- Data from FitzGerald D: S.A.F.E.S.T. Approach. Tactical Intervention Guided Emergency Response (TIGER)
mendations are that patients be constantly observed while being physically Textbook; 2003.
restrained or in seclusion. Attention is necessary to assess excessive restraint
and excessive straining which may lead to sudden cardiac death.
See Tables SC4–1 and SC4–2 for violence warning signs and the
S.A.F.E.S.T. Approach.
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