Violence

Question 1

Causes

Answer 1

Psychiatric illness/personality disorder
Substance misuse
Physical illness
Adverse ward environment, overcrowding, noise, alienation and nowhere to go
Danger if patient sequestered on ward due to bad behaviour

Question 2

Early warning signs

Answer 2

Tachypnoea
Clenched fists 
Shouting/chanting 
Restless
Repetitive motions
Pacing
Gesticulations

Question 3

Initial actions

Answer 3

Get help
Ensure closer to a door than the patient
Police if needed
Try calming and talking with patient, don’t try and touch them and reassure using body language

Question 4

Emergency management

Answer 4

Obtain consent or apply emergency treatment to save their life, or they are deteriorating seriously

Question 5

Rapid tranquilisation sequence

Answer 5

Oral treatment
Consider IM - 2 doses fail or patient/others at significant risk
Consider IV treatment is immediate effect needed (DIAZEPAM)
Senior advice and monitor if unconscious

Question 6

Oral treatment of rapid tranquillisation

Answer 6

Lorazepam or promethazine (don’t react with antipsychotics)

- repeat after 45-60 mins

Question 7

IM treatment of rapid tranquillisation

Answer 7

Lorazepam - disinhibition reactions are more likely
Promethazine - slow onset, useful in benzodiazepine intolerant patients
Olanzapine - don’t combine with benzo
Aripiprazole - less effective than olanzapine
Haloperidol - risk of acute dystonia