Violence, Management Of

Basics

Description

  • Violence: Any verbal, physical, or psychological aggression toward health care workers, patients, or visitors, impacting safety and care
  • Agitation: Excessive psychomotor activity, emotional distress, or aggression, often requiring deescalation or medical intervention
  • Violence is increasingly prevalent in EDs ranging from verbal assaults to active shooter incidents
  • Abusive events occur nearly daily in EDs, with 20% resulting in physical violence
  • Higher risk associated with busier EDs (>260,000 patient visits/yr) and urban trauma centers
  • All emergency staff are affected with nurses generally at highest risk
  • Violent individuals may be a family member, friend, or visitor rather than the patient
  • Risk factors for violence:
    • Prior history of violence
    • Substance intoxication
    • Psychiatric decompensation

Etiology

  • Pathogenesis not well understood but typically multifactorial
  • Acute psychiatric problem:
    • Most commonly psychosis or mania
  • Chronic psychiatric problem:
    • “Cluster B” personality disorders: Antisocial, narcissistic, borderline
  • Substance intoxication (especially stimulants, alcohol, hallucinogens)
  • Alcohol and sedative–hypnotic withdrawal
  • Acute primary medical problem:
    • Infectious
    • Metabolic (eg, delirium, hypoglycemia)
    • Toxicologic (eg, anticholinergic toxicity)
    • Neurologic (eg, seizure, stroke, head injury)
  • Chronic primary medical problem (may make patient more vulnerable to acute etiologies or increase risk of violence independently):
    • Dementia
    • Intellectual disability
    • Traumatic brain injury
  • Psychopathy or criminal behavior

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