Screen for weapons and disarm prior to entrance to ED
Violence may occur without warning
Be aware of surroundings
Signs of anger, resistance, aggression, hostility, argumentativeness, violence
Accessibility of door for escape
Presence of objects that may be used as weapons
Signs of anger, resistance, aggression, hostility, argumentativeness, violence
Accessibility of door for escape
Presence of objects that may be used as weapons
Be honest and straightforward; Ask about violence directly
Suicidal or homicidal ideations and plans
Possession of weapons
History of violent behavior
Current use of intoxicants
Be nonconfrontational, attentive, and receptive
Respond in a calm and soothing tone
Express concern/worry about the patient
Three Fs framework:
I understand how you could feel that way.
Others in that situation have felt that way, too.
Most have found that _____ helps."
Avoid argumentation, machismo, and condescension
Do not threaten  to call security — Invites patient to challenge with violence
Do not deceive  (eg, about estimated wait times) — Invites violence when lie is uncovered
Do not command  to calm down — Invites further escalation
Do not downplay, deny, or ignore threatening behavior
Do not hesitate  — Leave and call for help if necessary
Suicidal or homicidal ideations and plans
Possession of weapons
History of violent behavior
Current use of intoxicants
Respond in a calm and soothing tone
Express concern/worry about the patient
I understand how you could feel that way.
Others in that situation have felt that way, too.
Most have found that _____ helps."
Offer voluntary administration to patient — increased sense of control may calm patient
If need to temporary physical restraint the patient: One arm up, one arm down, tie legs to opposite side of bed. Reference with video
Suggested protocol for continued agitation: antipsychotic Q5 min x 2, then ketamine IM
E.g. Droperidol 10mg (or haloperidol 5mg) IM Q5 min x 2, then ketamine 300mg IM
Other protocols involve combination therapy.
Neuroleptics (Antipsychotics)
Atypical antipsychotics
Less sedation and EPS (than typical)
Increased mortality in elderly with dementia-related psychosis
olanzapine, ziprasidone, and aripiprazole
Typical antipsychotics (low potency)
Greater sedation, hypotension, anticholinergic effects (than high-potency)
chlorpromazine and thioridazine
Typical antipsychotics (medium potency)
loxapine and molindone
Typical antipsychotics (high potency)
Greater EPS (than low-potency)
butyrophenones: haloperidol and droperidol
Cautions
Neuroleptic malignant syndrome — rare
Extrapyramidal symptoms — treat with diphenhydramine or benztropine
QTc prolongation and torsades de pointes
Ketamine
4-6mg/kg IM or 1mg/kg IV
Benzodiazepines
"There is increasing evidence that benzodiazepines alone and in combination with antipsychotics are associated with higher rates of adverse effects.
Lorazepam — Eliminated without active metabolites
Onset: 5-20 min (IV), 15-30 min (IM)
Duration: 6-8 H
Midazolam
Onset: 15 min (IM)
Duration: 2 H
Typical intramuscular dosing for adult patients:
Haloperidol 5-10mg IM, ziprasidone 20mg IM, olanzapine 10mg IM, and midazolam 5mg IM.
In order from slowest to quickest time to effect
E.g. Droperidol 10mg (or haloperidol 5mg) IM Q5 min x 2, then ketamine 300mg IM
Other protocols involve combination therapy.
Atypical antipsychotics
Less sedation and EPS (than typical)
Increased mortality in elderly with dementia-related psychosis
olanzapine, ziprasidone, and aripiprazole
Typical antipsychotics (low potency)
Greater sedation, hypotension, anticholinergic effects (than high-potency)
chlorpromazine and thioridazine
Typical antipsychotics (medium potency)
loxapine and molindone
Typical antipsychotics (high potency)
Greater EPS (than low-potency)
butyrophenones: haloperidol and droperidol
Cautions
Neuroleptic malignant syndrome — rare
Extrapyramidal symptoms — treat with diphenhydramine or benztropine
QTc prolongation and torsades de pointes
Less sedation and EPS (than typical)
Increased mortality in elderly with dementia-related psychosis
olanzapine, ziprasidone, and aripiprazole
Greater sedation, hypotension, anticholinergic effects (than high-potency)
chlorpromazine and thioridazine
loxapine and molindone
Greater EPS (than low-potency)
butyrophenones: haloperidol and droperidol
Neuroleptic malignant syndrome — rare
Extrapyramidal symptoms — treat with diphenhydramine or benztropine
QTc prolongation and torsades de pointes
4-6mg/kg IM or 1mg/kg IV
"There is increasing evidence that benzodiazepines alone and in combination with antipsychotics are associated with higher rates of adverse effects.
Lorazepam — Eliminated without active metabolites
Onset: 5-20 min (IV), 15-30 min (IM)
Duration: 6-8 H
Midazolam
Onset: 15 min (IM)
Duration: 2 H
Onset: 5-20 min (IV), 15-30 min (IM)
Duration: 6-8 H
Onset: 15 min (IM)
Duration: 2 H
Haloperidol 5-10mg IM, ziprasidone 20mg IM, olanzapine 10mg IM, and midazolam 5mg IM.
In order from slowest to quickest time to effect
In order from slowest to quickest time to effect
Not for convenience or punishment
Indications for seclusion or restraint
Imminent danger to self, others, or environment
Part of ongoing behavioral treatment
Contraindications to seclusion
Patient is unstable and requires close monitoring
Patient is self-harming (suicidal, self-mutilating, toxin ingestion)
Caveats
Allow for adequate chest expansion for ventilation
Sudden death has occurred in the prone or hobble position
Imminent danger to self, others, or environment
Part of ongoing behavioral treatment
Patient is unstable and requires close monitoring
Patient is self-harming (suicidal, self-mutilating, toxin ingestion)
Allow for adequate chest expansion for ventilation
Sudden death has occurred in the prone or hobble position
Combative patient
FIND ME 
Asplenic patient
Psychiatric
The obese patient
Schizophrenia, paranoid ideation, catatonic excitement
Second victim
Mania