Violent Patients

Etiology

A meta-analysis identified patients as the most common perpetrators of violence (median 56%), followed by visitors (median 22%) in clinical settings. Certain characteristics can help healthcare providers recognize potential risks. Positive predictors of violence include male sex, prior violent behavior, police custody, victimization, substance impairment, and psychiatric disorders. Risk factors for experiencing violence include younger age, limited work experience, and nursing roles. In the emergency department, workplace violence risk increases with night shifts, prolonged patient wait times, high job demands, and weak worker-patient relationships.[4]

Epidemiology

The U.S. Bureau of Labor Statistics reported that healthcare and social assistance had the highest counts and annualized incidence rates of workplace violence among private industry sectors from 2021 to 2022. A total of 41,960 nonfatal workplace violence cases required days away from work, job restriction, or transfer in this sector, representing 72.8% of all cases in private industry during this period. The annual incidence rate for these cases was 14.2 per 10,000 full-time workers. Verbal violence affected up to 97% of healthcare workers, while up to 82% experienced physical violence.[5]

Pathophysiology

Violent patients may exhibit various characteristics that can help healthcare providers identify and manage potential risks. Positive predictors of violence include being male, having a prior history of violence, being brought in the custody of police, being a victim of violence, having impairment due to substance abuse, and experiencing a psychiatric disorder.

History and Physical

A comprehensive history and physical examination can help identify the root cause of violent behavior. A thorough review of the patient's past medical and surgical history, medications, alcohol and illicit drug use, family history, psychiatric history, and mental status examination can provide critical information about the exacerbating factors and predictors of violent behavior. The onset and duration of symptoms should be determined, and current medications, including any recent changes or missed doses, should be reviewed. The physical examination should include a head-to-toe assessment to check for signs of injury, as well as signs of intoxication.

Violent patients should be placed in designated safe rooms with padded furniture, reduced noise, and calm lighting. Examination devices, sharp objects, and furniture that could be used as weapons should be removed. When possible, hospital security or trained staff should be called and positioned nearby but not immediately visible to the patient to help prevent escalating tensions.

Creating a safe space for violent or agitated patients is essential for their de-escalation and safety, as well as for protecting staff and others in the area. A safe environment reduces external triggers, minimizes risks, and facilitates effective intervention.

Evaluation

Patient agitation can stem from various causes, broadly categorized into functional (psychological) and organic (physiological) origins. Understanding the distinction between these causes is crucial for accurate diagnosis and effective intervention.

Functional causes of agitation are primarily psychological or psychiatric. These conditions may include mental health disorders (eg, psychosis, personality disorders), substance abuse (intoxication, withdrawal), or acute psychological stress and trauma, such as posttraumatic stress disorder.

Organic causes of agitation are linked to physiological or medical conditions affecting the brain or body. These pathologies include neurologic disorders (e.g., delirium, dementia, traumatic brain injury), metabolic or endocrine imbalances (e.g., hypoglycemia, hyponatremia, thyrotoxicosis), infections causing encephalopathy (e.g., urinary tract infection-induced delirium), medication side effects (e.g., from anticholinergic drugs, steroids), and uncontrolled pain.

Differentiating between functional and organic causes requires a thorough history and physical examination. Laboratory tests, imaging (eg, head computed tomography), or a mental health evaluation may also be warranted.

Treatment / Management

De-escalation techniques are critical for managing violent or potentially violent behavior, aiming to reduce tension and prevent harm. De-escalation strategies must first be attempted before ordering any physical or chemical restraints. Strategies include offering reassurance, simplifying communication, demonstrating empathy, ignoring challenging arguments, and offering oral medication or food.[6]

The use of physical restraints on violent patients is a serious intervention and should only be considered as a last resort when all other de-escalation techniques have failed. The application of physical restraints involves significant concerns about civil rights and liberties, including the right to refuse care, freedom from imprisonment, and freedom of association. Restraints should be used when a patient poses a danger to themselves or others due to medical or psychiatric conditions, and their care presents an immediate risk of harm to the patient, staff, or others.

The Centers for Medicare and Medicaid Services (CMS) defines restraints as "any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or a drug or medication when used to manage the patient’s behavior or restrict the patient’s freedom of movement, not as a standard treatment or dosage for the patient’s condition." Restraints are categorized into physical and chemical types. 

The American College of Emergency Physicians (ACEP) has established the following principles for the use of physical restraints:

• Verbal de-escalation and treatment of underlying medical or psychiatric conditions should be attempted first when safe and appropriate before considering restraints.
• Restraint should be individualized and applied in a manner that preserves the patient’s privacy and dignity to the greatest extent possible.
• The method of restraint should be the least restrictive necessary to protect the patient and others.
• Staff must be trained in de-escalation techniques, trauma-informed care, proper use and application of restraints, and the monitoring of patients in restraint and seclusion.
• Protocols must be developed to ensure patient safety, including regular observation, treatment during restraint, and periodic assessments to determine whether restraint should continue or be discontinued.
• The use of restraints must be carefully documented, including the rationale for restraint, the methods used, alternatives explored, and ongoing assessments of the patient in restraint.
• ACEP opposes any requirement for emergency physicians to provide inpatient restraint or seclusion orders. Restraint or seclusion requires a comprehensive patient assessment, and emergency physicians are legally and ethically responsible for patients presenting for care in the emergency department.
• Restraints must adhere to all applicable laws, regulations, and accreditation standards. 

Types of physical restraints include 4-point or 2-point soft and hard restraints. Restraints must be applied properly to prevent injury, avoid excessive tightness, and reduce the risk of aspiration or asphyxiation.

Soft restraints can tighten and cause circulatory compromise if a patient pulls on their extremities. In contrast, leather restraints rarely compromise distal circulation, but they are difficult to cut and remove in an emergency. For this reason, leather or nylon restraints are preferred over soft restraints in combative patients. While restrained, patients must be constantly observed and closely monitored. Regular position changes are essential to prevent rhabdomyolysis, pressure sores, and paresthesia. Patients should also be frequently reassessed to determine whether restraints are still necessary.

When de-escalating from 4-point to 2-point restraints, the contralateral arm and leg should remain restrained. Physical restraints must always be a last resort, used with the utmost care, under strict guidelines, and with continuous efforts to ensure patient safety and dignity.

Chemical sedation involves using medications to quickly calm violent behavior or agitation, particularly when an immediate risk of harm to the patient or others is present, and nonpharmacological de-escalation techniques have failed. The process must be handled carefully to ensure safety and efficacy. Chemical restraint with antipsychotic and benzodiazepine medications has a long-standing safety and efficacy record. Chemical restraints help avoid adverse consequences associated with physical restraint, such as hyperthermia, dehydration, rhabdomyolysis, and lactic acidosis.[7]

Differential Diagnosis

Considering a broad differential diagnosis is critical when assessing a violent patient. Agitation may result from medical conditions, such as electrolyte abnormalities, postictal states, hypoxia, or stroke, substance-related factors like stimulant use or alcohol withdrawal, or acute behavioral changes. This overview highlights key conditions and factors to consider when evaluating violent behavior in patients, though it is not exhaustive.

Medical Causes

• Electrolyte imbalances: Hypoglycemia, hyponatremia, hypercalcemia
• Delirium: Infections such as urinary tract infections or sepsis
• Stroke: Ischemic or hemorrhagic strokes affecting specific brain regions
• Other neurological conditions: Brain tumors, traumatic brain injury, epilepsy
• Hypoxia: Asthma, pulmonary embolism
• Thyroid dysfunction: Hyperthyroidism or thyroid storm
• Encephalopathy: Hepatic or uremic encephalopathy
• Pain: Musculoskeletal trauma

Medication- or Substance-Induced Conditions

• Medication side effects: Steroids, anticholinergics
• Sympathomimetic use: Stimulants like cocaine or amphetamines
• Intoxication: Alcohol
• Withdrawal: Alcohol or benzodiazepine

Psychiatric Disorders

• Acute psychosis: Paranoid delusions or hallucinations may lead to aggressive behavior as a form of self-defense.
• Mood disorders: Mania or severe depression can result in agitation manifesting as violence.
• Personality disorders: Borderline or antisocial personality traits may predispose individuals to impulsive aggression.
• Posttraumatic stress disorder: Flashbacks or hypervigilance may provoke violent behavior.

Pediatric and Adolescent Conditions

• Autism spectrum disorder: Aggressive outbursts may occur due to difficulty with emotional regulation or communication.
• Attention deficit hyperactivity disorder: Impulsivity in children or adolescents can trigger aggression.
• Conduct disorder or oppositional defiant disorder: These conditions may predispose younger individuals to violent tendencies.

Environmental or Situational Causes

• Acute stress or anxiety: High stress or fear can provoke violent behavior.
• Overcrowding or prolonged waiting: Situational triggers that escalate frustration.

Considering various etiologies of violent behavior allows clinicians to identify underlying medical, psychological, or situational factors that may be contributing to the agitation. This comprehensive approach ensures a more targeted and effective management plan, improving patient outcomes while minimizing the risk of harm to both the patient and healthcare providers.

Prognosis

Patients with severe agitation represent high-risk cases, often due to acute medical emergencies, acute intoxication, or psychiatric conditions. Violent patients consume significant resources and pose a risk of harm to medical staff, nearby patients, visitors, and themselves.[8] Chemical restraint may be necessary to evaluate and treat these patients, who are at high risk for morbidity and mortality while ensuring a safe environment for both patients and staff.

Oral medication is the preferred option when patients are willing to cooperate. Oral benzodiazepines (1-2 mg lorazepam) and orally disintegrating tablets (ODTs), such as risperidone (1-2 mg) and olanzapine (5-10 mg), are effective choices. Pregnant patients may be treated with diphenhydramine. Atypical antipsychotics offer greater tranquilization and less sedation than typical antipsychotics, and their additional serotonergic activity reduces the incidence of extrapyramidal symptoms (EPS).[9]

In a violent, medically undifferentiated patient, the most commonly used combination is referred to as "B52," which includes haloperidol 5 mg administered intramuscularly, lorazepam 2 mg given intramuscularly, and, sometimes, 50 mg intravenous diphenhydramine. Historically, combination therapy with antipsychotics and diphenhydramine or benztropine was used to enhance sedation and reduce extrapyramidal effects. The combination of haloperidol and lorazepam blocks dopaminergic transmission and enhances γ-aminobutyric acid (GABA) receptor binding to reduce agitation, typically within 30 minutes. Known disadvantages of this combination include geriatric oversedation, slower onset, prolonged QT interval, ataxia, EPS, and additive central nervous system depression.

Droperidol was routinely used in the emergency department for rapid tranquilization until 2001, when the Food and Drug Administration (FDA) issued a black box warning for prolonged QT syndrome and fatal arrhythmia.[10] Compared to haloperidol, droperidol has a faster onset of action, shorter duration, more consistent effects, and similar side effects, even in severely intoxicated patients. Since the FDA warning, several large retrospective reviews have found no significant increase in morbidity and mortality between droperidol and haloperidol.[11][12]

Second-generation antipsychotics, such as risperidone, olanzapine, quetiapine, and ziprasidone, provide more tranquilization with less sedation. The additional serotonergic activity of these agents also reduces the incidence of EPS.

According to the 2023 ACEP guidelines, 1st-line medications for undifferentiated violent patients include a combination of intramuscularly injected haloperidol 5 mg, lorazepam 2 mg, ziprasidone 20 mg, and olanzapine 10 mg. However, ziprasidone and olanzapine must be administered with caution.

Ziprasidone increases the QTc interval more than any other atypical antipsychotic, and its FDA approval is limited to the treatment of schizophrenia and bipolar mania. Olanzapine is known to cause mild hypotension and has significant anticholinergic properties, which could exacerbate agitation in patients who have overdosed on anticholinergic agents, such as diphenhydramine. Olanzapine has also been shown to have a synergistic effect with other central nervous system depressants. Therefore, this drug should not be used in patients who are severely intoxicated or taking benzodiazepines.

Ketamine is widely used in the emergency department for pain management (0.1-0.3 mg/kg given intravenously), procedural sedation (1 mg/kg given intravenously or 3-5 mg/kg injected intramuscularly), or induction of intubation (2 mg/kg administered intravenously). This agent has a rapid onset of sedation, occurring in less than 2 minutes following intravenous administration and 2 to 10 minutes following intramuscular administration.

Compared with antipsychotic or benzodiazepine-based regimens, ketamine appears to provide faster and more consistent management of agitation after a single dose. However, ketamine use carries risks, including laryngospasm (1-4%), hypersalivation (up to 20%), respiratory depression (2-20%), and the need for intubation (0-62%).[13][14][15][16][17] Ketamine administration should be followed by observation for potential respiratory and hemodynamic compromise. The 2023 ACEP policy statement recommends the use of ketamine for sedation of agitated patients in the emergency department, as emergency physicians are already familiar with its use and capable of managing potential complications.

Complications

Patients with dementia or delirium have an increased risk of severe side effects when given antipsychotics or benzodiazepines. Lower doses should be used, preferably 25% to 50% of standard adult doses if necessary.[18] Certain antipsychotics, such as olanzapine and ziprasidone, should be avoided in patients with a history of dementia due to the increased risk of stroke and death.[19][20]