A Quick Approach to an Aggressive Patient

Topics / Psychiatry / Psychiatric Emergencies

Summary This article attemptos to summarize the approach to a patient that is aggressive. This includes a five step approach: De-escalation, physical restraint, sedation, mechanical restraint and post sedation care.

Phases of Management Include:

Phase 1: De-escalation
Phase 2: Physical restraint
Phase 3: Sedation
Phase 4: Mechanical restraint
Phase 5: Post sedation / Seclusion / Transfer

1. De-escalation

You first try to defuse a potentially violent or aggressive situation without having to resort to physical restraint. This form of intervention is usually verbal and it should include the following. (List from the KZN Treatment Protocol for Mental Health Disorders)

Speak quietly but clearly and calmly; don’t argue
Assist patient to stay in control
Set limits firmly but do not threaten
Allow extra personal space
Deal with the issue at hand
Ensure a safe environment and remove all potential weapons (alert SAPS if
the patient has dangerous weapons on hand)
Ensure safe exit point for staff
Encourage the patient to talk and make use of appropriate listening skills
Offer medication to a patient; initially oral therapy
Allow the patient to find a solution to the problem

2. Physical Restraint

For this phase, you should use 5 members of a team. The other staff members should evacuate the room. You inform the patient of your intent to restrain and sedate them. Each member holds a limb while the leader holds the head. Ensuring that no harm is done to the patient and to the team in the process.

3. Sedation

We initially offer the patient medications that can be taken orally. If the patient refuses, you can sedate the patient using IM/IV medications. Be careful with IV medications due to respiratory depression. Also, keep in mind that IV access might be difficult and may risk a needlestick injury.

Oral:
1. Chlorpromazine 25 – 75mg initially (max 300mg/24hrs). The sedation takes around 30mins and it lasts around 4 hours. Contraindicated in Epilepsy, Elderly, Alcohol Abuse, Liver disease, CVS disease, coma or CNS depression. OR
2. Haloperidol 5 – 10mg (Max 30mg/24hrs) – not for use if patient has never had any neuroleptics.

Intra-Muscular:
1. Lorazepam 2-4mg IM/IV (Max 6mg/24hrs), slowly over 3mins after diluting it. Takes around 30mins and it lasts 6 hours.
2. Haloperidol 5mg IMI (Max 18mg/24hrs). Sedation in 10mins. OR
3. Olanzapine 5-10mg IMI (20mg/24hrs) OR

Review the patient every 10-30mins. Keep a look out for the side effects of the medications above.

If by this time the patient has not been sedated, then review and consult a senior. Other choices include Diazepam 10mg IV and Clopixol Acuphase 50-150mg IM. However, you should familiarize yourself with the use of these medications.

4. Mechanical Restraint

Should be used only while we wait for sedation to take place. Should not be used for longer than 30mins at a time according to the MHCA. Form 48 MHCA should be filled and submitted. to the hospital manager on a daily basis. Ideally, a staff member should stay with the patient to monitor them.

5. Post Sedation/Seclusion

Once the patient is calm, you may attempt to take a history, do a physical examination/MSE, or do any other investigations. Vitals should be monitored every 10mins for the first hour, then every 15mins until the patient is ambulant. Remember the side effects of the sedatives you have given and treat accordingly. Try to achieve venous access if necessary. If the systolic drops below 100mmHg, elevate the legs. However, the patient may need IV fluids. If there is respiratory depression consider Flumazenil.

Remember, that once the patient has been fully assessed and the results are reviewed, a decision needs to be made. The MHCA allows for a patient to be reviewed over a period of 72hour. After this time has passed, the patient should be transferred to a psychiatric hospital if needed.