Behavioural Emergency Management

The Violent and Aggressive Patient:

Behavioural disturbances and aggression in the emergency department is an increasing problem confronting emergency clinicians every day. 50% of attacks on health care workers occur in the emergency department. These patients may self refer or be referred to the ED by concerned family members, other health professionals i.e., GPs, community mental health teams, or transported by police or paramedics in an aroused and agitated state for assessment, management and to rule of organic cause for their behaviour.  Its is the responsibility of emergency clinicians to assess and manage these patients properly, with-out biases, and with the same thoroughness that you assess every patient with.  These patients can challenge yourself as a clinician, your colleagues that you work with, and some can even be a challenge to whole emergency department. These patients have a high morbidity and  mortality, and present you with an even higher medico-legal risk from their behaviour, injuries they may have obtained, or from the underlying organic illness that is causing their adverse behaviour.

Duty of care and zero tolerance policies:

  • Some emergency departments and hospitals have adopted zero tolerance policies in order to prevent verbal and physical abusive behaviour towards staff.
  • The concept of zero tolerance originated in the USA, and refers to specific actions or behaviours that will not be tolerated, and were originally used to stop crime, gangs and drugs in schools.
  • The concept of introducing a zero tolerance policy into the emergency department setting is fundamentally flawed.
  • Patient’s presenting to the  ED who are abusive towards staff could be displaying  behaviour that is related to head injury, overdose, psychiatric condition or other organic problem.  You as a clinician have a duty of care to these patients to provide assessment and treatment.
  • Don’t be fooled into a policy that takes away a patients fundamental right to access care and proper treatment.

Medical causes of violence and aggression in patients:

  • Head injury
  • Substance abuse and intoxication
  • Underlying mental illness
  • Hypoxia
  • Metabolic disturbances/ Hypoglycaemia
  • Infection: meningitis, encephalitis, sepsis
  • Hyperthermia or hypothermia
  • Seizures: post ictal or status epilepticus
  • Vascular: stroke or subarachnoid haemorrhage

Pearl: Its never a good look to have charted  Midazolam 5mg, Midazolam 5mg, and then amp of dextrose 50%. Always look for medical causes!!!

Risk factors for sudden related violence:

  • Younger age
  • Male gender
  • Lower income
  • History of violence
  • Past juvenile detention
  • History of physical abuse by parent or guardian
  • Substance dependence only
  • Comorbid mental health and substance disorder
  • Victimization in past year
  • Unemployed and looking for work in the past

ABC of  assessing the potentially violent patient:

A= Assessment:

Primary Survey

  • Appearance
  • Current medical status
  • Psychiatric History (history of violence)
  • Current medication
  • Oriented (time, place, person)

Physiological indications for impending aggression

  • Flushing of skin
  • Dilated pupils
  • Shallow rapid respiration
  • Excessive perspiration

B= Behavioural indications:

Observation of behaviour

  • General behaviour (intoxicated, anxious, hyperactive)
  • Irritability
  • Hostility, anger
  • Impulsivity
  • Restlessness, pacing
  • Agitation
  • Suspiciousness
  • Property damage
  • Rage (especially children)
  • Intimidating physical behaviour (clenched fist, shaping up)

C= Conversation

Patient self-report

  • Admits to weapon
  • Admits to history of violence
  • Thoughts about harm to others
  • Threats to harm
  • Admits to substance use/abuse
  • Command hallucinations to harm other
  • Admits extreme anger

Investigating the violent and aggressive patient:

Investigations should be guided by history and physical examination.


  • Blood sugar level
  • Full blood count
  • Urea, Electrolytes, Creatinine
  • Paracetamol, Ethanol level
  • Urinalysis
  • Urine drug screen if available
  • +/- Head CT/MRI
  • +/- Lumbar Puncture

ED management for violence and aggression:

  • Early recognition and use of de-escalation strategies aimed at diffusing a volatile situation is the preferred approach.
  • Consider personal safety at all times
  • Consider the safety of other patients and their visitors at all times
  • Place the person in a quiet and secure area and let staff know what is happening and why
  • Never turn your back on the individual
  • Don’t walk ahead of the individual and ensure adequate personal space
  • Provide continuous observation and record behaviour changes in patient notes
  • Wear personal duress alarm if available
  • Let the person talk (everyone has a story to tell, let them tell it)
  • Never block off exits and ensure you have a safe escape route

Indications for Restraining and sedating a violent and aggressive patient:

  • Preventing harm to the patient
  • Preventing harm to other patients
  • Preventing harm to caregivers and other staff
  • Preventing serious disruption or damage to the environment
  • To assist in assessing and management off the patient
  • Restraints should never be use for ease of convenience

Managing the violent and aggressive patient:

Physical/Mechanical Restraints

  • Clinicians should beware of local policies, laws and acts before restraining patients
  • Applying physical restraint’s is a team sport, 1 for each limb and 1 to lead the restraint and manage the airway.
  • Physical restraint should always be followed up with chemical and mechanical restraints.
  • Physical restraints need to be secure enough to restrain the patient, but able to be easily removed if the patient begins to vomit, seizure, or loose’s control of their airway.
  • Restraints must be applied in the least restrictive maner and for the shortest period of time.
  • Padding should be applied between restraints and the patients to prevent neurovascular injury, and regular neurovascular observations should be perform every 15-30mins whilst patient is physically restrained.
  • The clinician ordering the restraints should document the reason for restraints, what limbs are restrained, how frequent neurovascular observations are needed, and when the restraints need reviewed, generally every 2 hours restraints should  be reviewed by treating clinician.

Pearl: You can’t change someone’s personality; but you can obliterate it with drugs. Dr Billy Mallon

Chemical Restraints/Sedation:

  • Remember you are generally treating the undifferentiated patient, with limited access to past medical history.
  • These patients are generally reluctant to take oral medications, IV access needs to be obtained, or IM or SL sedation can be given while attempting IV canulation,
  • Once you choose to start chemical sedation, you have full responsibility to maintain the patient’s airway, breathing, circulation,  provide bladder care, hydration, and general nursing care to that patient.
  • Benzodiazepines are preferred in the ED, as have prompt onset of action, and a good safety profile.
  • Antipsychotic”s have a role when patient is not responding to benzodiazepines, and as an adjunct to the benzo’s to achieve sedation.



  • Start with 2.5-5mg IV or IM increments and work upwards
  • Short acting medication that provides rapid sedation, in titrated doses
  • Maximum effect in 10mins, and last up to 2 hours.


  • Start with 5-10 PO or IV increments and work upward
  • Longer acting than Midazolam, works well for managing withdrawal symptoms
  • IV administration causes short lived stinging sensation, do not dilute dose to prevent this


  • 1-2mg PO
  • Patient needs to be willy to take oral medication
  • Provides sedation up to 4-6 hours

Pearl: If the patient is handcuffed and taser barbs still attached; start drawing up the Midazolam.



  • Start with 5-10mg PO or SL, or 10mg IM
  • Newer atypical antipsychotic
  • Risk of hypotension after IM injection
  • Maximum dose 30mg in 24 hour period


  • 2.5-10mg IV or IM
  • Older conventional antipsychotic
  • Avoid in patients with QT prolongation as increases risk of torsades de points
  • Risk of dystonic drug reaction


  • 2.5-10MG IV or IM
  • Older conventional antipsychotic
  • Avoid in patients with QT prolongation as increase risk of torsades de points
  • Risk of  dystonic drug reaction


  • 25-200MG PO
  • Newer atypical antipsychotic
  • Patient needs to be willing to take oral medication


  • 0.25-2mg PO/SL
  • Newer atypical antipsychotic
  • Works very well in elderly, and combative dementia patients.
  • Orthostatic hypotension common early in treatment


  • 100-200mg IV infusion over 24 hours
  • Used in patients resistant to newer antipsychotics and benzodiazapines
  • Avoid S/C or IM as risk of skin necrosis, maximum daily dose 1000mg.



  • 25mg IV increments until sedation has been achieved
  • Very controversial, however recent reports have shown effectiveness in managing patients with benzodiazepine tolerance, using low dose barbiturates with good effect.

Complications of sedation and restraining patients:

  • Respiratory depression and pulmonary aspiration
  • Sudden cardiac death/Excited delirium
  • Hypotension
  • Deep venous thrombosis & pulmonary embolus
  • Rhabdomyolysis
  • Dystonic reactions
  • Neuroleptic malignant syndrome
  • Anticholinergic effects
  • Delirium
  • Lactic acidosis
  • Lowered seizure threshold
  • Special problems in the elderly

Pearl: “ We have the drugs; they have the receptors, just put the two together” Dr Billy Mallon

Pitfalls in managing the violent and agitated patient:

  • Always remember that your goal of  sedating and restraining these patients is for their benefit not yours, your doing to it so that you can manage and investigate these patient
  • Assuming a patient’s confusion and agitation is related to alcohol intoxication, its estimated up to 50% of head injuries are alcohol related.
  • Psychiatric conditions rarely present suddenly or with visual, tactile, or olfactory hallucinations. These patient require thorough medical assessment to rule out organic cause.
  • Alcohol intoxication increases suicide risk. 40-60% of of people who commit suicide have alcohol in their system at time of death. Proper evaluation of the suicidal patient cannot be undertaken until their sober, and you have a duty of care to ensure this happens. These patients should not be allowed to sign out against medical advice.


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  • Downes, M.  Healy, P. Page, C. Bryant, J. Isbister, G.  (2009).  Structured team approach to the agitated patient in the emergency department.  Emergency Medicine Australasia.  21, 196-202.PMID: 19527279
  • Hodge, A. & Marshall, A. (2007).  Violence and aggression in the emergency department: A critical care perspective.  Australian Critical Care. 20, 60-67.PMID: 17568534
  • Howes, M., & Rensberg, W.  (2009). Thiopentone sedation for sedation of acutely agitated, violent, intoxicated patients: Evaluation of 2 cases. Internet Journal of Emergency Medicine (2009) 2:47–49 PMID: 19390917
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  • Kennedy, M. (2005). Violence in emergency departments: under-reported, unconstrained, and unconscionable. Medical Journal of Australia. 183: 362-365.
  • Rossi, J. Swan, M. & Isaacs, E. (2010). The Violent or Agitation Patient. Emergency Medicine Clinics North America.  28, 235-256. PMID: 16201954
  • Sands, N. (2007). An ABC approach to assessing the risk of violence at triage. Australasian Emergency Nursing Journal. 10, 107-109.
  • Viken, R. (2008).  Combative Delirium.  American Family Physician. 77 (3).  363-364. PMID: 18297963
  • Wand, T. & Coulson, K. (2006). Zero tolerance: A policy in conflict with current opinion on aggression and violence management in health care.  Australasian Emergency Nursing Journal. 9, 163-170.

Emergency nurse with ultra-keen interest in the realms of toxicology, sepsis, eLearning and the management of critical care in the Emergency Department | LinkedIn |

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