A 43-year-old man is brought to the emergency department by the police after being found walking in the middle of a busy parking lot while talking to himself and shouting at passing cars. The patient is barefoot and disheveled. He is oriented to person and place but is unable to give a coherent history. He says, "I've been in a lot of hospitals, but I won't take any medication." The patient appears tense and agitated. When the nurse attempts to take vital signs, he refuses and pulls his arm away. He glares at the nurse and shouts, "All you do is experiment on people." Which of the following is the most appropriate next step in management of this patient?
Aggressive patient in the emergency department | |
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Management |
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Initial management of agitation in the emergency department involves techniques of verbal deescalation, with chemical and physical restraints used as a last resort. This patient is agitated and uncooperative when approached by the nurse and shows signs that he is having difficulty caring for himself (barefoot, disheveled) and may suffer from a psychotic disorder (disorganized behavior, talking to himself, paranoid). However, the patient is communicating verbally and has not shown directed violence that endangers the staff's safety.
As a first step, efforts should be made to calm the patient down. Offering the patient something to eat and drink can be effective in meeting the patient's basic human needs and defusing the situation. Other guidelines for managing agitation include:
Although security personnel should be on standby, confronting the patient or threatening to administer medication, to use physical restraints, or to call security risks escalating the situation (Choice C).
(Choices A and B) Verbal deescalation techniques should be attempted first in this patient who is agitated but nonviolent. Immediate restraint by either chemical sedation (eg, intramuscular antipsychotic) or physical means is indicated when verbal deescalation has failed and violence by a patient is imminent or has already occurred. Prolonged use of physical restraints may result in active resistance, putting the patient at risk for electrolyte abnormalities, arrhythmias, and rhabdomyolysis.
Educational objective:
Verbal deescalation techniques should be used to calm agitated but nonviolent patients and may include the offer of something to eat and drink. Intramuscular antipsychotic medication and physical restraints are indicated when verbal deescalation has failed and violence by a patient is imminent.