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