Violence & Agitation

Question 1

What are some predisposing factors that contribute to a violent patient?

Answer 1

• Single Best Predictor: History of aggression or violent behavior
• Family history of violence
• Childhood abuse
• Use of alcohol or illicit substances
• Criminal history
• Non-adherence to therapy (both psychological and medication)
• Impulsivity
• Psychosis
• Hostility
• Personality disorder
• History of acute or chronic brain disorders/trauma
• Poorly managed chronic medical problems, including pain management

Question 2

What are some subjective findings found in a violent patient?

Answer 2

Acute violence:

• Agitation
• Rage
• Anxiety or fear

Abusive patient:

• Remorse/guilt, post violence
• Controlling nature towards abused person
• Verbal threats, agitation

Question 3

What are some subjective findings found in a patient who has been abused?

Answer 3

• Low self-esteem, guilt, inferiority complex
• Fear, anxiety, depression
• Evasiveness when questioned

Question 4

What are some physical exam findings seen in patients who are abusive?

Answer 4

• Hyperactivity
• Increasing physical tension signs such as, clenched jaw/fists, rigid posture
• Verbal profanity, loud voice
• Alcohol on breath

Question 5

What are some physical exam findings seen in patients who are abused?

Answer 5

• Old scars, fractures poorly healed, bite marks, bruises
• Vaginal/anal lacerations, STD’s
• Anxiety

Question 6

What labs/diagnostic tests should be done for an abusive patient?

Answer 6

• CT head (r/o subdural hematoma, malignancy)
• Urine/serum drug screen
• Electrolytes and metabolic panel
• EEG (r/o seizures)

Question 7

What labs/diagnostic tests should be done for an abused patient?

Answer 7

• Assess for trauma/injury
• X-rays of injuries
• Test for STDs

Question 8

How do you manage an abusive patient?

Answer 8

• Summon police if violent or armed with weapon
• Address calmly, non-violently
• Maintain adequate distance; stand between abuser and door (do not block your exit from room)
• Speak in soft voice, listen carefully, do not force eye contact
• Medication if warranted:
  
  • Lorazepam (Ativan) 1-2 mg (dependent upon age and size) po, IM or IV
  • Haloperidol (Haldol), 2-5mg (dependent upon age and size)
  • Ziprasidone (Geodon) 10-20mg IM dependent upon age and size
• Physical restraints (last option)
• Must have established protocol for use of restrained by trained personnel only
• Use least restrictive mechanism of restraint at all times.
• Consult psychiatry if danger to self or others
• Hospitalize if warranted
• Correct underlying medical problems
• Legal duty requires threatened individuals be warned if a person voices harmful intent against another person with notification of authorities

Question 9

How do you manage an abused person?

Answer 9

• All patients should be screened for domestic violence or abuse
• If current abuse exists:
  
  • Discuss options with patient, including all resources, i.e. shelters, family, friends, social service
  • Problem solve to avoid further episodes.