Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Violent

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Violent/Aggressive Patient - Key Features

1. In certain patient populations (e.g., intoxicated patients, psychiatric patients, patients with a history of violent behaviour):
a) Anticipate possible violent or aggressive behaviour.
b) Recognize warning signs of violent/aggressive behaviour.
c) Have a plan of action before assessing the patient (e.g., stay near the door, be accompanied by security or other personnel, prepare physical and/or chemical restraints if necessary).

2. In all violent or aggressive patients, including those who are intoxicated, rule out underlying medical or psychiatric conditions (e.g., hypoxemia, neurologic disorder, schizophrenia) in a timely fashion (i.e., don`t wait for them to sober up, and realize that their calming down with or without sedation does not necessariy mean they are better).

3. In a violent or aggressive patient, ensure the safety (including appropriate restraints) of the patient and staff before assessing the patient.

4. In managing your practice environment (e.g., office, emergency department), draw up a plan to deal with patients who are verbally or physically aggressive, and ensure your staff is aware of this plan and able to apply it.

Common Causes of violent behaviour:

Toxicologic: Alcohol or other drug intoxication/withdrawal (stimulants, sedatives, steroids)
Metabolic: Hypoglycemia, hypoxia
Neurologic: Stroke, intracranial lesion (eg, hemorrhage, tumor), CNS infection, seizure, dementia
Other medical conditions: Hyperthyroidism, shock, AIDS, hypo/hyperthermia
Psychiatric: Psychosis, schizophrenia, paranoid delusions, personality disorder
Antisocial behaviour

Warning Signs of Impending Violent Behavior

Male gender, a history of violence, and drug or alcohol abuse are associated with violence.
• Provocative behavior
• Angry demeanor and/or loud, aggressive speech
• Tense posturing (eg, gripping arm rails tightly, clenching fists)
• Frequently changing body position, pacing
• Aggressive acts (eg, pounding walls, throwing objects, hitting oneself)

Management Points

• Immediate blood glucose (one-touch finger poke), vital signs and pulse oximetry
• Assume that all violent patients are armed until proven otherwise
• patients must be disarmed before any interview
• interview in private but not isolated area, clear exit path for clinician
• have security present for interview and leave door open
• interview room must not contain any objects that could be used as weapons
• have a panic button, code word/phrase to alert others to danger
• remove glasses, earrings, neckties and necklaces and other potentially dangerous personal accessories prior to interview
• Actively violent patients and uncooperative, agitated patients, particularly those who exhibit signs of impending violence, require immediate restraint.

Interview Strategies

• Adopt an honest and straightforward manner
• Perform friendly gestures (eg, offer food)
• Avoid direct eye contact; do not approach the patient from behind or move suddenly; stand at least one arm's length away
• Address violence directly: The patient should be asked relevant questions, such as, "Do you feel like hurting yourself or someone else?"
• Avoid arguing, machismo, condescension, or commanding the patient to calm down
• Never lie to the patient, and take all threats seriously

When Verbal Techniques Fail:

• Physical restraints (must monitor patient carefully and frequently; remove as soon as possible)
• Rapid tranquilization may be required in the agitated or violent patient.
• If severely violent patients requiring immediate sedation, try haloperidol, loxapine or lorazepam (or combination of haloperidol and lorazepam)
• If drug intoxication or withdrawal, we suggest treatment with a benzodiazepine.
• If violence originates from psychiatric disorder, use first or second generation antipsychotic

Study Guide

Violent/Aggressive Patient