Management of the Aggressive/Violent Patient

Aggressive/violent patient Opener

This module describes the procedure of managing an aggressive or violent patient using physical or pharmacological containment. This approach pertains to the

rather than the

or

patient.


Patients displaying potential, imminent or emergent violence caused by:

  1. Non-medical causes such as criminal behaviour

  2. Personality disorders such as antisocial personality disorder

  3. Substance use — intoxication and withdrawal

  4. Mental illness

  5. Medical conditions such as head injury


  1. Do not restrain or sedate patients unless absolutely necessary for patients’ and healthcare providers’ safety


Stay calm and speak to the patient in a low voice. Never insult the patient or make promises or commitments you cannot keep. Avoid direct body contact and prolonged eye contact. While it may seem counterintuitive in the heat of the moment, try to engage the patient and caregivers, reassuring them that you want to help.

How do I explain this procedure?

“I want to help you and make you more comfortable. I want to protect you from hurting yourself or others. If you can cooperate with me, we may not need the help of the nursing staff or the security.”

What can my patient expect?

“To help you, I need to ask you some questions about your health, your medications, or other problems. Some of these questions might annoy or upset you, but are necessary for me to help you. After that I will examine you to check for any injuries or illness that might cause you to feel this way. I might have to give you an injection to help with your frustration. You will experience a small prick, after which you will feel very relaxed and sleepy.”

What is my patient’s role?

“Try to relax and work with me. Tell me if you need a break from the questions or examinations.”


Documentation

  1. Patient notes

  2. Relevant Mental Health Care Act documents, if certifying a patient

Equipment if sedation is indicated

Agressive patient_Equipment

  1. Non-sterile gloves

  2. Alcohol swab

  3. IV cannula

  4. Short extension set (J loop) primed with normal saline or water for injection

  5. containing the necessary medications

  6. Transparent film dressing


  1. Stay calm

  2. to provide monitoring, backup, or assistance with restraining.

  3. Once they arrive,

    and relocate the patient if needed.


  1. Avoid physical confrontation. Instead, contain the patient with reassurances and try to elicit their cooperation.

  2. Offer

    medication.

  3. If this fails, immobilise the patient using four point immobilisation in order to tranquillise the patient:

    • Restrain the patient on a trolley, bed, or floor by having four male staff members each holding onto the patient’s hips and shoulders and respective limbs.
    • Apply the minimum degree of force, attempting to calm rather than provoke.
    • Proceed by removing the patient’s shoes or boots, checking for concealed weapons or potentially dangerous objects. Be aware of biting and spitting.
  4. If the patient is not willing to take the oral route and resuscitation equipment is not available, use intramuscular injections.

  5. If resuscitation equipment and monitoring is available, you and your staff are familiar with the medication and rapid tranquilisation is needed, use an intravenous injection.

  6. Administer the following medications via the route chosen above:

    • Benzodiazepine such as lorazepam (2 - 4 mg) AND antipsychotic such as haloperidol (5 - 10 mg). Lorazepam is the drug of choice as it is rapid in onset, has a short half life and is relatively safe.
    • Substitute for lorazepam: midazolam (7.5 - 15 mg)
    • Substitute for haloperidol: risperidone (1 - 2 mg PO) OR olanzapine (10 mg). Risperidone is a good option if the family or caregiver is content and able to take the patient home, to return for a consultation the next day. Never give olanzapine with benzodiazepines, as it is potentially fatal.
  7. Assessment: Look for underlying causes of aggressive behaviour such as

    , and substance use. Exclude head injury, especially in inebriated patients.

  8. Complete the patient notes as well as any required Mental Health Care Act Forms.

  9. vital signs as well as neurological observations for as long as the patient is sedated.


The restraints are causing bruising or abrasions.

Assess the need for physical restraints, which should be unnecessary if the patient is sufficiently sedated. Restlessness and agitation can be caused by physical discomfort. Check for thirst, loosen tight clothing, ensure they are warm or cool enough, make a bedpan or urinal available. If the patient is at risk of falling off the bed or trolley, rather place a mattress on the floor. If physical restraints are absolutely required, place a sponge between the patient’s skin and the restraint.

The sedation is not working or is wearing off.

The combination of lorazepam and haloperidol can be repeated up to twice at 30-60 minute intervals as required. If a second dose does not work, consult a senior.


  1. Injury to the patient

  2. Injury to other people

  3. Damage to property

  4. Risks of sedation include: obscuring signs of underlying illness, loss of protective reflexes, respiratory depression, adverse cardiovascular events such as hypotension and arrhythmias

  5. Intervention seen as ‘medical assault’ by the patient with the risk of


  1. Swingler D. The agitated or violent patient. In: Baumann S. Primary Health Care South Africa: A practical guide for Southern Africa. 3rd ed. Kenwyn: Juta and Co Publishers; 2008: 123-132

  2. Wyatt J.P. General Approach. In: Oxford Handbook of Accident and Emergency Medicine. 2nd ed. New York: Oxford University Press; 2005: 28-29

  3. Mash B. An approach to the aggressive patient. In: Oxford Handbook of Family Medicine. 4th Ed. Cape Town: Oxford University Press South Africa; 2017: 146