managing aggressive patients
DESCRIPTION
CME presentationTRANSCRIPT
MANAGING AGGRESSIVE
PATIENTS
Dr Wan Afifah Wan Jaafar
Supervisor: Dr Azlie Hassan
OUTLINES
Aetiology
Management:
Verbal restraint
Physical restraint
Chemical restraint
AETIOLOGY:
WHAT CAUSES THE AGGRESSIVE
BEHAVIOUR?
ORGANIC CAUSES
Head injury
Substance abuse and intoxication
Hypoxia
Metabolic disturbances/ Hypoglycaemia
Infection: meningitis, encephalitis, sepsis
Hyperthermia or hypothermia
Seizures: post ictal or status epilepticus
Vascular: stroke or subarachnoid haemorrhage
INVESTIGATIONS
Blood sugar level
Full blood count
Urea, Electrolytes, Creatinine
Paracetamol, Ethanol level
Urinalysis
Urine drug screen if available
+/- Head CT/MRI
+/- Lumbar Puncture
MANAGEMENT
RED ZONE?
ASSESSMENT
Clinical and behaviour
Weapon
Police/security
Safe environment
Near to exits
Safe distance
Not alone
VERBAL: DE-ESCALATION/DISTRACTION
Only one person should talk to the patient
In control, calm
DO NOT confront
Emphasise desire to help
Gain trust
Know when to withdraw from the patient and
proceed with next steps
PHYSICAL RESTRAINT
Human or mechanical actions that restrict a
person’s freedom of movement
Manual restraint vs mechanical restraint
Indications:
Medical or psychiatric condition AND
Incapable of rsponding to reasonable requests from
health care staffs to co-operate AND
Putting themselves or others at risk AND
Less restrictive alternatives are not appropriate
Good practice of physical/mechanical restraint:
As a last resort
Proportional to the antecedent behaviour
Applied in a safe and appropriate manner
Not prolonged
Under supervision
Not used as a substitute for inadequate staffing or as
punishment
Documentation
If possible to release restraint every hour for
10minutes (1 limb at time if necessary)
PHARMACOLOGICAL RESTRAINT
PHARMACOLOGICAL RESTRAINT
TAKE HOME MESSAGES
Not all aggressive patients are psychiatric
patients
The different types of restraints
“You can’t change someone’s personality; but
you can obliterate it with drugs.”
Dr Billy Mallon
REFERENCES
VF Gallego et al. Management of the agitated
patient in the Emergency Department.
Emergencias 2009; 21: 121-132
Judith E. Tintinalli, J. Stephan Stapczynski, O.
John Ma, David M. Cline, Rita K. Cydulka, Garth
D. Meckler. Tintinalli's Emergency Medicine:
A Comprehensive Study Guide, 7e. The
American College of Emergency Physicians.
Mental Health for Emergency Department.
NSW Health Department, Sydney, 2009
Life in the fast lane