Version July 2025
INTRODUCTION —
Clinicians must be prepared to effectively manage agitated or violent patients to reduce the risk of serious injury to the patient and clinical team. Agitation is defined as a state of excessive psychomotor activity with increased excitability and deterioration of normal functions [1]. An episode of agitation can last from a few minutes to days and exists on a continuum of severity ranging from irritability to violent behavior [2]. Agitation can signal a medical or psychiatric emergency and escalate to violence that can pose danger to the patient and others. The significant illness, prolonged waiting and boarding times, and confusion often found in busy emergency departments creates a stressful atmosphere that can exacerbate symptoms of agitation among patients and their families.
The evaluation and nonpharmacologic management of the acutely agitated or violent patient is reviewed here. Our approach is based on the available evidence and our experience since research into the best methods of managing acutely agitated patients is limited [3]. The following related issues are discussed in separate topics:
●The pharmacologic management of the acutely agitated or violent patient (see "The acutely agitated or violent adult: Pharmacologic management")
●Evaluation of delirium, confusional states, and abnormal behavior in the emergency department (ED) (see "Diagnosis of delirium and confusional states" and "Evaluation of abnormal behavior in the emergency department")
●Management of specific psychiatric ailments (see "Suicidal ideation and behavior in adults" and "Psychosis in adults: Epidemiology, clinical manifestations, and diagnostic evaluation")
●Management of poisoned or ethanol intoxicated patients (see "General approach to drug poisoning in adults" and "Ethanol intoxication in adults")
●Pathogenesis and prevention of restraint-related cardiac arrest (see "Restraint-related cardiac arrest: Pathogenesis, strategies for prevention, and management for hospital clinicians")
EPIDEMIOLOGY
Agitation — Agitation is a common issue in emergency departments (EDs), psychiatric emergency service facilities, and other health care settings [1,2,4-7]. The incidence is difficult to estimate since it varies by setting and underlying etiology for the behavioral disturbance. In an observational study performed at a major urban United States (US) ED, researchers screened 43,838 patients and found that 1146 (2.6 percent) manifested significant agitation with 84 percent requiring physical restraint and 72 percent requiring administration of calming agents by intramuscular injection [8]. Twenty three percent of the patients with agitation met the clinical criteria for delirium. In an observational study conducted in two urban settings in Germany, 3.2 percent of patients transported by emergency medical services exhibited signs of agitation or violence [9].
Violence — Violence in health care settings is a growing problem [10-13]. Up to 50 percent of health care providers are victims of violence at some time during their careers [14,15]. A survey found that, from 2018 to 2022, there was an increased incidence of assaults in EDs (47 versus 55 percent of emergency physicians were personally assaulted and 71 versus 79 percent witnessed an assault) [16]. A 2008 survey of over 3500 US ED clinicians at 65 sites reported that 3461 physical attacks occurred over a five-year period and that guns or knives were brought to the ED on a daily or weekly basis [17]. Other studies have found that 78 to 98 percent of ED clinicians have experienced at least one act of verbal and/or physical violence [18-20]. In a 2023 study at a large urban US ED, an average of 0.85 events per day were reported by health care workers; most victims were nurses and racist, sexist, or homophobic comments were involved in 2 to 14 percent of incidents [7]. Some US and international studies report the prevalence of violence directed towards ED nurses is 90 percent or greater [21].
The problem of violence is not limited to the US or to EDs. Surveys of emergency care workers and nurses in Turkey and Australia report similar rates of violence as those in US studies [22,23]. A 1997 survey of psychiatry residents revealed that 73 percent reported being threatened, and 36 percent had been physically assaulted in residency. Two-thirds of them had received either no or inadequate training in managing combative patients [24].
Violence against health care workers increased during the coronavirus disease 2019 (COVID-19) pandemic, and this trend has continued globally [25,26]. An interrupted time-series analysis in Italy from 2017 to 2021 found an increase in violent attacks on health care workers since the beginning of the COVID-19 pandemic (4.3 attacks/1000 encounters per month, compared with the pre-pandemic rate of 0.04 attacks/1000 encounters per month) [27]. This trend stabilized but did not return to the pre-pandemic rate.
INTERVIEW PREPARATION AND SETTING —
Evaluation of the agitated patient begins with risk assessment and attention to safety measures. Hospitals should have protocols, adequate security teams, and clinician trainings on various strategies (eg, clinician positioning, room arrangement, nonconfrontational body posture); a systems approach is discussed further below. (See 'Systems approach to preventing violence in the ED' below.)
●Weapons confiscation – All patients must have any weapons confiscated prior to an interview [10]. We assume that all violent patients, especially those presenting with major trauma, have a weapon (eg, knife, gun) until proven otherwise [28]. The presence of weapons among many emergency department (ED) patients increases the potential for rapid escalation of violence, but it is not easy to predict weapons carriage in any particular patient [29-31].
Metal detectors can be used to identify weapons before patients are allowed entry into the ED [28]. The routine practice of patients undressing and changing into a gown is a nonconfrontational approach to searching for weapons. Searches should be performed in a nondiscriminatory manner [32]. A warning sign should be prominently displayed (eg, "For the safety of patients and staff, individuals entering the ED may be screened for weapons"). Almost all patients and families/caregivers will cooperate with searches and may feel safer as a result [33].
●Interview room preparation – The setting of the patient interview should be private but not isolated [34,35]. Some EDs have seclusion rooms specifically intended for interviewing a potentially aggressive or dangerous patient. During the interview, security personnel should be nearby and the door left open to allow both intervention and escape by the clinician. Ideally, two exits should be available and doors should swing outward. This facilitates escape but may increase the chance of injury to anyone standing outside the door. The interview room should not contain heavy objects that may be thrown, such as ashtrays, or other potential weapons, such as electrical cords, scalpels, needles, or hot liquids.
●Prevent delaying patient evaluation – The evaluation of an agitated or violent patients should be expedited to prevent any escalation of aggression since increased waiting times correlate with violent behavior [36-38]. Triage protocols should include distinct criteria for prioritizing agitated patients. Ancillary staff should be instructed on the importance of prioritizing rapid attention to the patient when dealing with potential violence. Often, the aura of preferential treatment will defuse patient anger.
While the patient is waiting to be brought to an interview room, they should be removed from contact with belligerent accomplices or other provocative patients to prevent escalation. A quiet area with a window or video monitoring that enables direct observation is optimal.
●Clinician preparation – The clinician should not wear glasses, earrings, neckties, necklaces, or a stethoscope around the neck nor should they have personal accessories that may be used to cause harm (eg, scissors, pocketknives). The clinician should be aware of any objects within the room or on the patient's body, such as pens, watches, or belts, that may be used as weapons [35,39].
●Clinician and patient positioning – The interviewer should stay at least 1.5 to 3 feet from the patient to allow personal space while keeping a distance out of limb reach. The interviewer may position themselves between the patient and the door. The patient should NOT sit between the clinician and the exit, nor should the exit be blocked. Blocking the door poses a risk of harm to the clinician if the patient feels the need to escape. The clinician should have unrestricted access to the door and therefore should never sit behind a desk.
●Contingency preparation – Each hospital should have a plan of action in the case of extreme violence. The plan should include prevention and safety measures, a means for rapid notification of security and police personnel, evacuation plans, medical treatment, and crisis intervention [28,32]. The clinician should have a mechanism for alerting others of danger, such as a panic button or a code word or phrase that instructs others to call for security (eg, "I need Dr. Armstrong in here").
INITIAL ASSESSMENT
Categorizing degree of agitation — Our approach is based on the degree and potential etiology of agitation (algorithm 1):
●Severe agitation – Currently violent or aggressive, danger to self and others, attacking objects or people, or not redirectable and not responding to verbal de-escalation techniques.
●Moderate agitation – Physically or verbally threatening without danger, extremely active, or difficult to redirect.
●Mild agitation – Signs of overt physical and/or verbal activity or redirectable.
Rapid determination of most likely etiology — The most likely etiology of agitation is often apparent early in the course of assessing the patient (eg, odor of alcohol, persecutory delusions). Common and dangerous causes of agitation are presented in the table (table 1). Vital signs, a rapid examination for external signs of trauma and focal neurologic deficits, and a fingerstick glucose measurement (if altered sensorium) should be obtained as soon as possible. Drug and alcohol intoxication or withdrawal are common diagnoses in combative emergency department patients, but a wide range of factors can contribute including the environment, a patient's social and medical history, interpersonal relations, genetics, neurochemistry, and endocrine function [40-43].
Every agitated or violent patient requires a thorough assessment for a medical etiology and for potential complications of agitation as soon as this can be done safely. (See 'Medical evaluation when patient calm' below.)
Identifying the potentially violent patient
Signs of impending violence — Active threats of violence are predictive and should be taken seriously. In the ED, an obviously angry patient should always be considered potentially violent. Signs of impending violence include [35]:
●Provocative behavior
●Angry demeanor
●Demanding
●Loud, aggressive or mumbling speech
●Threatening to leave
●Tense posturing (eg, gripping arm rails tightly, clenching fists)
●Frequently changing body position, pacing
●Aggressive acts (eg, pounding walls, throwing objects, hitting oneself)
Violence typically erupts after a period of mounting tension. The astute clinician may identify verbal and nonverbal cues and seize the opportunity to defuse the situation [42]. In a typical scenario, the patient first becomes angry, then resists authority, and finally becomes confrontational.
Clinician should pay attention to any "gut feeling" that a dangerous situation may be developing [35]. An uncomfortable or threatening feeling during an interview is ominous, and appropriate precautions should be taken without delay.
However, identifying a potentially violent patient can be difficult, and most clinicians cannot accurately predict impending violence. Violent behavior can erupt without warning, especially when caused by medical illness or dementia. Clinicians should not feel overly confident in their ability to sense impending danger.
Risk factors for violent behavior — Known psychiatric illness, male sex, a history of violent behavior, and drug or alcohol misuse are associated with violence; ethnicity, diagnosis, age, marital status, and education do not reliably identify such behavior [44-48]. Patients with a history of violent behavior are more likely to act violently again and to inflict serious injury [49-51]. Whenever possible, it is important to learn from family, caregivers, clinicians familiar with the patient, and medical records about any past violent episodes.
Psychiatric illnesses that are most often associated with violent behavior include schizophrenia, personality disorders, mania, and depression with psychosis [34,42,44,52]. Patients with psychosis and a history of incarceration due to violence are likely to redemonstrate violent behavior [10].
Studies have found that prediction of violent behavior can be improved with consistent use of risk assessment tools, such as the Aggressive Behavior Risk Assessment Tool (ABRAT), the Dynamic Appraisal Situation Aggression (DASA), and Broset Violence Checklist (BVC) [53-55].
INITIAL MANAGEMENT
Verbal de-escalation for all patients — We attempt verbal de-escalation techniques in nearly all patients who present with agitation or violent behavior prior to implementing physical restraints or administering calming medications. Agitated but redirectable, nonviolent patients may be amenable to verbal de-escalation techniques, although clinical evidence supporting such an approach is limited [56].
We employ the elements described below during the initial interaction with an agitated patient. This helps us to assess the patient's mental status and often, it quickly becomes evident whether the patient will cooperate or will require restraints and calming medication. If verbal techniques are unsuccessful and escalation occurs, we excuse ourselves and summon help.
Key elements — We agree with the key elements for verbal de-escalation described in a consensus statement from the American Association for Emergency Psychiatry De-escalation Workgroup, which include the following [57]:
●Respect personal space – Maintain a distance of two arm's lengths and provide space for easy exit for either party [35].
●Do not be provocative – Keep your hands relaxed, maintain a nonconfrontational body posture, avoid direct eye contact and staring at the patient, and do not approach the patient from behind or move suddenly [35]. Adopt an honest and straightforward manner with a calm and soothing tone of voice [58]. A nonconfrontational but attentive and receptive manner without conveying weakness or vulnerability is optimal.
●Establish verbal contact – The first person to contact the patient should be the leader. Avoid multiple people verbally interacting with the patient.
●Use concise, simple language – Elaborate and technical terms are hard for an impaired person to understand.
●Identify feelings and desires – The patient should be asked relevant questions such as: "what are you hoping for?"; "do you feel like hurting yourself or someone else?"; and "do you carry a gun?" [46,58] Stating the obvious or an observation (eg, "you look angry") may help the patient to begin sharing emotions. If the patient becomes more agitated, speak in a conciliatory manner and offer supportive statements to diffuse the situation, such as, "you obviously have a lot of will power and are good at controlling yourself." An offer of medication (eg, "would you like some medication to help you calm down?") or comfort items (eg, food, water, blanket) may prevent further escalation and is often welcomed.
●Listen closely to what the patient is saying – After listening, restate what the patient said to improve mutual understanding (eg, "Tell me if I have this right…"). Some patients become angry because they feel they are not being taken seriously or treated with respect and their anger abates when these concerns are addressed.
●Agree or agree to disagree – Either agree with clear specific truths; agree in general: "Yes, everyone should be treated respectfully"; or agree with minority situations: "There are others who would feel like you."
●Lay down the law and set clear limits – Inform the patient that violence or abuse cannot be tolerated (eg, "I can help you with your problem, but I cannot allow you to continue threatening me or the emergency department staff"). An agitated patient may be aware of their behavior and may welcome limit-setting behavior by the clinician [35]. It is difficult to predict which patients will respond to this limit-setting approach and some may interpret such statements as confrontational and escalate their behavior. Balance with an empathic statement that the efforts to help the patient can be derailed when the clinical feels threatened or fearful.
●Offer choices and optimism – Patients feel empowered if they have some choice in matters. If possible, offer and present options for calming medications (eg, route of administration, medication types).
●Debrief – After any involuntary intervention, debrief both the patient and staff and prioritize restoring the therapeutic relationship.
Other techniques that can be helpful include the following (some of these have been developed to manage upset customers):
●Friendly gestures – Offer a soft chair or something to eat or drink (not a hot liquid, which may be used as a weapon) to establish trust. Many patients will improve since offering food or drink appeals to basic human needs and builds trust.
●The three Fs – The three Fs (feel, felt, found) approach provides a framework for responding to the patient's emotional needs: "I understand how you could feel that way. Others in the same situation have felt that way, too. Most have found that (doing ____) can help." [59]
●The philosophy of yes – Respond to the patient affirmatively. Examples of initial clinician responses using this approach might include: "Yes, as soon as," "Okay, but first we need to," or "I absolutely understand why you want that done, but in my experience, there are better ways of getting what you need." [59]
Pitfalls to avoid — Some common approaches to the combative patient are counterproductive and can lead to escalation, including the following:
●Arguing, machismo, condescension, or commanding the patient to calm down can have negative consequences. Patients often interpret such approaches as a challenge to "prove themselves."
●Threating to call security personnel often invites aggression.
●Failing to address violence directly [46,58].
●Criticizing or interrupting the patient.
●Responding defensively or taking the patient's ire personally.
●Not clarifying what the patient wants before responding.
●Lying to the patient (eg, "I am sure you will be out of here in no time" when this is not the case). Once the lie becomes apparent, the patient may take out frustrations violently upon an unsuspecting clinician who follows the interviewer.
●Not taking all threats seriously. Do not deny or downplay threatening behavior, which can place the interviewer at increased risk of assault and injury. An example of this principle involves a psychiatrist who was killed after entering the waiting room with a patient he knew was potentially violent and armed because he erroneously believed that the strength of the clinician-patient relationship ensured his safety [46].
Patient with severe agitation or violent behavior
Indications for physical restraints and/or seclusion — Physical restraints can be used when verbal techniques are unsuccessful despite a professional and proper approach to the agitated patient. Calming medications must be offered and tried in conjunction with verbal de-escalation before the decision to apply physical restraints. Indications for emergency seclusion and restraint include:
●Imminent harm to others
●Imminent harm to the patient
●Significant disruption of important treatment or damage to the environment
●Lack of insight into environment and events (either for psychiatric or other reasons) or are unable to communicate and are perceived by medical staff to be potentially violent
●Failed attempt to manage agitation with pharmacologic treatment
The use of restraints and/or seclusion can be humane and effective while facilitating diagnosis and treatment and preventing injury to the patient and medical staff [1,60,61]. Restraints can facilitate an evaluation in a patient with a medical cause for their agitation. Restraints can facilitate administration of medication in a patient with psychosis, a personality disorder, or substance misuse for whom verbal techniques are often not effective [35,62]. Seclusion may be used to decrease environmental stimulation and may be desirable for some patients [63]
Restraints are never to be applied for convenience or punishment, and should be removed as soon as possible, usually once adequate de-escalation or medication effect is achieved. Seclusion is unsuitable for any patient who is hemodynamically unstable, suicidal, self-abusive, self-mutilating, or has overdosed [42,64].
A clinician's perceptions of threat can be influenced by implicit racial bias, especially since acute agitation demands rapid decision-making with limited information [65]. The patient's own perceived level of threat also needs to mitigated with trauma-informed care strategies [66]. In the United States (US), the characteristics of patients associated with ED visits that involve physical restraint include younger age, male sex, public or no insurance, diagnosis of bipolar disorder or psychosis, and diagnosis pertaining to substance use [67-70]. Black or Hispanic patients are more likely to be restrained and spend more time in restraints in the ED setting [67-72]. A retrospective study in a US inpatient setting found that Black patients were 30 percent more likely to experience a security emergency response [73].
Proper restraint application — Restraints should be implemented systematically, ideally using an approved institutional protocol. The process begins when the examiner leaving the patient's room and summons assistance. Documentation should include the specific indication for restraints and a colleague's agreement that restraints were necessary. It may be helpful to consider the application of restraints analogous to running a cardiac resuscitation (eg, team with specified roles) and to providing critical care [74].
●Restraint team – The team should have at least five people, including a team leader. The leader can be a clinician or security officer, should be the most experienced implementing restraints, and is the only person giving orders. Similar to the leader of a cardiac resuscitation, the team leader should ideally maintain a bird's-eye view, provide instructions to maintain the safety of the patients and the staff, and not apply the restraints themselves. Whenever possible, the treating clinician should not participate directly in applying restraints in order to preserve the clinician-patient relationship and not be viewed as adversarial. Optimally, restraint teams should be of mixed gender to diminish potential allegations of sexual assault.
The basic approach is similar in hospitals with designated trained violence management teams that respond to all patient encounters in which restraints may be needed [75,76]. (See 'Comprehensive measures' below.)
●Prior to entering room – The team leader should outline the restraint protocol and warn of anticipated danger (eg, the presence of objects that may be used as weapons). All team members should remove personal effects, which the patient could use against them. All team members must be aware of their roles.
●Upon entering the room – The team should enter in force and display a professional, rather than threatening, attitude. Many violent individuals will improve at this point, as a show of force protects their ego (eg, "I would have fought back but there were too many against me"). The leader speaks to the patient in a calm and organized manner, explaining why restraints are needed and what the course of events will be (eg, "You will receive a medical and psychiatric examination as well as treatment"). The patient is instructed to cooperate and lie down to have restraints applied. Some patients will be relieved at the protection to self and others afforded by restraints. However, even if the patient suddenly appears less dangerous, physical restraints must be placed once the decision to use them has been made. Do not negotiate with the patient at this point.
●If force is necessary – If the team leader judges that force is required to control the patient, each team member restrains a preassigned extremity by controlling the major joint (knee or elbow). This can be accomplished by locking the major joint in extension. To prevent lower extremities from flailing independently, it may be best to cross the legs at the ankles. The team leader controls the head. If the patient is armed with a makeshift weapon, two mattresses can be used to charge and immobilize or sandwich the patient.
●Physical restraint material – Leather is the optimal material for restraints because it is strong, prevents escape, and is less constricting than typical soft restraints. Gauze should not be used. Soft restraints are helpful in restricting extremity use in a semi-cooperative patient but are less effective in the truly violent patient who continues to struggle.
●Applying the restraints – These are applied securely to each extremity and tied to the solid frame of the bed (not side rails, as later repositioning of side rails also repositions the patient's extremity). There should a distance of two fingers between the restraint and the patient's skin. If the legs are crossed at the ankles, attach the restraint to the bed frame at the opposite side. Applying a soft Philadelphia collar to the patient's neck will help to prevent head-banging and biting. If chest restraints are used, it is vital that adequate chest expansion for ventilation is ensured.
●Patient positioning – We position patients supine with the head elevated since it is more comfortable for the patient and allows a more thorough medical examination but still provides some protection against aspiration [42,43]. Restraining patients on their side helps to prevent aspiration. We recommend avoiding the prone restraint position since it is associated with sudden, unexpected cardiac arrest. (See "Restraint-related cardiac arrest: Pathogenesis, strategies for prevention, and management for hospital clinicians".)
●Debrief – Once the patient is immobilized, announcing "the crisis is over" will have a calming effect on the restraint team and the patient. We immediately make a plan to administer calming medication with rapid-onset, which is critical in a patient who continues to struggle against physical restraints. The restraint team should review their performance and discuss ways to improve effectiveness. Debriefing the patient by explaining why the intervention was necessary is a patient-centered approach that can help re-establish a therapeutic engagement and may avoid future coercive interventions [57,77].
Administer calming medications — A patient in physical restraints requires calming medications as these can prevent adverse events related to struggling against restraints. Medication selection is presented in the algorithm (algorithm 1) and discussed separately. (See "The acutely agitated or violent adult: Pharmacologic management", section on 'Approach to medication selection'.)
Monitoring and care of a physically restrained patient — The following are important in care of the patient after restraints have been applied:
●Frequent monitoring – A standardized form is recommended for this monitoring and should be developed by every emergency department (ED) or ward that physically restrains patients. Vital signs should be taken immediately after application of restraint, hourly thereafter, and upon discontinuation of the restraint.
For a patient in four-point restraints without access to the call light, we recommend continuous monitoring by a trained observer and at least every 15 minutes, clinically assessing the patient's behavioral response and considering removing restraints or a less restrictive restraint. A patient receiving parenteral calming medications while in physical restraints should have continuous pulse oximetry since they are unable to reposition themselves. (See "The acutely agitated or violent adult: Pharmacologic management", section on 'Monitoring for adverse effects'.)
In a patient who was restrained prone or was struggling against restraints for more than five minutes, we begin continuous cardiac monitoring for at least one hour, frequently re-evaluate clinical status, exclude hyperthermia, and perform a full trauma evaluation once it is safe to do so.
●Anticipate potentially serious adverse effects – Continuous struggling against restraints can cause rhabdomyolysis, hyperthermia, metabolic acidosis, and/or cardiac arrest. Restrained patients who are intoxicated with cocaine, amphetamines, or other sympathomimetic agents appear to be at particularly high risk for adverse outcomes [78-80]. (See "Restraint-related cardiac arrest: Pathogenesis, strategies for prevention, and management for hospital clinicians".)
●Patient repositioning – We reposition the patient every two hours or more frequently if maintenance of proper body alignment is needed to prevent neurovascular sequelae such as circulatory obstruction, pressure sores, and paresthesias. Perform range of motion exercise and skin checks during repositioning.
●Ensure basic needs are met – Offer hydration and nutrition. Assist with toileting on the stretcher using a bedpan or a urinal. Restraints can be removed temporarily from one or two limbs to assist with feeding and toileting.
●Restraint removal – Physical restraints should be removed as soon as possible (ie, patient calm). In a patient who is not completely calm or has a history of violence, it is reasonable to remove restraints from two extremities for a brief time prior to removing all restraints.
●Evaluation for medical causes – (See 'Medical evaluation when patient calm' below.)
Patient with mild to moderate agitation — In a patient with agitation that does not resolve with verbal de-escalation, offer the patient calming medication. Medication selection is presented in the algorithm (algorithm 1) and discussed separately. (See "The acutely agitated or violent adult: Pharmacologic management", section on 'Mild to moderate agitation'.)
A patient with ongoing or worsening agitation despite verbal de-escalation and calming medications may need physical restraints. (See 'Indications for physical restraints and/or seclusion' above.)
If the agitation does resolve, continue to monitor the patient and assess for medical causes of agitation.
Maneuvers if clinician assaulted — Physical assault may unfortunately occur despite appropriate precautions and interventions. If assaulted, immediately summon help, preferably by use of a panic button. The following are maneuvers for selected situations:
●Faced with a punch or a kick – Deflect with an arm or a leg. Maintain a sideward posture, keeping the arms ready for self-protection.
●Attempted choking – Tuck the chin in to protect the airway and carotid arteries. If bitten, do not pull away, but rather push toward the mouth and hold the nares shut to entice opening of the mouth.
●Threatened with a weapon – Try to appear calm and comply with demands [35]. Adopt a nonthreatening posture and avoid sudden movements. Do not attempt to reach for the weapon. If a weapon is put down, do not reach for it, but rather attempt to verbally resolve the crisis while awaiting security arrival. Avoid argument, despair, or whining.
●Taken hostage – Attempt to establish a human connection with the hostage taker, as a hostage taker will rarely kill someone if a relationship has been established [32,34]. Offering to administer to ill or injured hostages makes them appear less expendable. Do not bargain or make promises, and do not lie, as the consequences could be disastrous. Reassure the hostage taker that someone authorized to hear complaints or demands should arrive promptly [32]. Call law enforcement authorities to provide a professional hostage negotiator if needed.
MEDICAL EVALUATION WHEN PATIENT CALM —
Evaluating for a medical cause of agitation (table 1) is required as soon as this can be done safely. At a minimum, this includes obtaining a rapid serum glucose measurement (eg, fingerstick glucose), pulse oximetry, complete set of vital signs, and thorough history and physical examination.
The mnemonic FIND ME (functional [ie, psychiatric], infectious, neurologic, drugs, metabolic, endocrine) may be helpful to organize a diagnostic search for the etiology of delirium or confusion (table 2), if present. Delirium or dementia may lead to violent behavior. Agitation can be caused by sympathomimetic (eg, cocaine, methamphetamine) or ethanol intoxication, ethanol or sedative withdrawal syndromes, anticholinergic poisoning, and others. The differentiation of medical from psychiatric disorders, the evaluation of delirium and confusional states, and the general assessment of drug overdose patients are discussed in greater detail elsewhere. (See "Diagnosis of delirium and confusional states" and "Evaluation of abnormal behavior in the emergency department".)
The following are important concerning the medical evaluation:
●The importance of obtaining a complete set of vital signs and performing a thorough mental status and neurologic examination cannot be overemphasized. Patient restraint may be necessary to accomplish even the most rudimentary physical inspection. (See "The detailed neurologic examination in adults".)
●A rapid blood glucose determination and pulse oximetry should be obtained in all combative patients.
●Combative patients who are sedated and subsequently deteriorate frequently suffer from an unrecognized infection or drug overdose.
●A patient with a history of drug or alcohol misuse may exhibit violent behavior as a manifestation of an intoxication or withdrawal syndrome. (See "Cocaine: Acute intoxication" and "Methamphetamine: Acute intoxication" and "Management of moderate and severe alcohol withdrawal syndromes" and "Benzodiazepine withdrawal" and "Anticholinergic poisoning".)
●A patient less than 40 years of age, with a prior psychiatric history and a normal physical examination including vital signs, and who is oriented and regains a calm demeanor likely requires no further diagnostic testing. Most patients with agitation from an underlying psychiatric illness are alert and oriented. Multiple observational studies and position statements support this approach and recommend that diagnostic testing be based on findings obtained from a careful history and physical examination [81-84]. (See "Psychosis in adults: Epidemiology, clinical manifestations, and diagnostic evaluation", section on 'Determining the etiology'.)
●A patient who is 40 years or older with new psychiatric symptoms, who has acute onset of agitated behavior, behavior that waxes and wanes over hours to days, has persistently abnormal vital signs, or is disoriented or confused is more likely to have an underlying medical etiology [85-87]. In one study, older adults who were restrained were more likely to have a medical cause for their agitation [68]. (See "Diagnosis of delirium and confusional states", section on 'Evaluation'.)
DISPOSITION
●Role of psychiatric evaluation — In general, agitated or violent behavior from underlying psychiatric illness should be followed by psychiatric evaluation. If drug or alcohol intoxication contributed to the agitation, the patient should be observed until the effects of the toxicants have abated and a therapeutic interview can be performed, either by the emergency department (ED) or the consulting psychiatric clinician, to decide to begin commitment proceedings or discharge the patient.
●Patient with temporary nonpsychiatric syndrome – A patient who is calm and oriented following violent behavior that was caused by a temporary nonpsychiatric syndrome (eg, drug intoxication or withdrawal) with an evaluation that reveals no other significant problem requiring acute intervention, may or may not need psychiatric evaluation depending on the circumstances and cause of the agitation. For example, a patient with agitation solely from alcohol intoxication likely does not need psychiatric evaluation if they have normal mental status and mood once sober.
●"Medical clearance" – The clinician should clearly convey findings and recommendations directly to the consulting mental health clinicians rather than pronouncing the patient "medically clear." The medical record should reflect that the ED evaluation, at this time, has not identified an acute medical condition as the cause for the patient's behavior and therefore, the patient is "medically stable" for further psychiatric treatment [85]. The term "medical clearance" is not precise since an ED evaluation does not exclude all possible medical conditions; the goal of the focused ED medical assessment is to evaluate for conditions causing or contributing to the patient's agitated behavior that can be treated medically (eg, infection).
●Admission to a psychiatric facility – This is appropriate for violent patients who state specific intentions to hurt themselves or others, refuse to answer questions or cooperate, have psychosis, have demonstrated they cannot care for themselves, or have an underlying neuropsychiatric syndrome [35,88]. If the patient needs to be transferred, the accepting clinician should be warned of possible violence. (See "Psychosis in adults: Initial management", section on 'Safety risk and level of care' and "Management of neuropsychiatric symptoms of dementia".)
●Discharge criteria – Discharge may be appropriate for a patient with a temporary nonpsychiatric syndrome or following evaluation by a mental health clinician if performed. If the patient is in police custody, they can be discharged as long as authorities are warned of potential danger. All discharged patients should be given specific follow-up evaluation and discharge instructions.
●Escaped patient — Law enforcement authorities must be notified if a violent patient escapes the ED. If the patient threatened violence to a specific individual before escape, that individual should be notified as well.
LEGAL CONSIDERATIONS —
Perhaps no area of medicine is more fraught with legal considerations and potential risks than care of the agitated or violent patient. Different laws apply according to the location, and an exhaustive discussion of the relevant legal issues is beyond the scope of this topic. Regardless of the legal system in which a clinician practices, adherence to the following guidelines will help to minimize potential liability [85,89]:
●The clinician must assess whether the patient has the capacity to make reasonable decisions about their health care, evaluation, and treatment. As long as clinicians were acting in good faith, courts have consistently provided great latitude in retrospect. Assessment of decision-making capacity is reviewed separately (table 3). (See "Assessment of decision-making capacity in adults".)
●Another clinician's agreement that restraints were necessary represents powerful supporting documentation. A nurse or physician who is not primarily responsible for the patient can document the circumstances and reason that restraints were applied. Although obtaining court approval in advance of actions is ideal, it is often impossible given time constraints and the limited availability of legal authorities.
●If a clinician decides to suspend the liberty of a patient and make decisions for them, the reasons must be clearly documented in the medical chart and any required forms completed. We suggest documenting that an emergency existed, the patient was unable to consent for their treatment, and the treatment was for the patient's benefit [89].
●When a clinician restrains a patient physically or with medications, they become responsible for the well-being of the patient. Patients describe their experience of restraint as a loss of personal dignity, a sense of dehumanization, and lacking compassion from staff; challenges in resolving these experiences may lead to lasting negative consequences on well-being such as distrust and avoidance of future healthcare interactions [77]. Attention to adequate comfort, hydration, respiration, bathroom needs, and protection are required. The patient must be closely monitored.
●If physical restraints are placed, they should be removed as soon as possible. Reassessment and the reason for continuing restraint use must be documented.
●A patient with the capacity to make reasonable decisions and who poses no threat to himself, the medical staff, or others cannot be confined or restrained without their permission. Doing so can lead to a legal charge of false imprisonment or battery. In the United States, false imprisonment and battery are generally not covered under medical malpractice insurance policies.
●Duty to Warn is a legal concept in some jurisdictions that requires a clinician to warn a person who is in danger from a violent patient. Failure to warn the third party may make the clinician liable for future injury.
SYSTEMS APPROACH TO PREVENTING VIOLENCE IN THE ED
Improve preparation — The prevention of violence is best accomplished by developing a system that includes ongoing staff education, adequate personnel, and a well-designed physical structure.
Clinicians are largely under-protected and underprepared to prevent and manage violent patients. A telephone survey of 250 United States (US) hospitals with emergency departments (EDs) revealed that the majority (63 percent) do not have security formally assigned to the ED at any time during the day; approximately 23 percent of hospitals have a 24-hour security presence and 14 percent have security present part of the day [90]. Only 21 percent control access to the ED during high-risk hours, 39 percent use a security code, 46 percent have alarm buttons, 14 percent have a seclusion room, 36 percent use closed-circuit surveillance, and 1.6 percent use metal detectors. Security measures have increased in parallel with the rising ED census [90].
Comprehensive measures — A comprehensive approach is needed to reduce violence at high-risk sites, including the following:
●Security personnel – A well-trained and responsive security force is a key element of any safety system. Nevertheless, security personnel constitute a significant expense, and their services are often curtailed or eliminated when hospitals face fiscal difficulties. The use of guns by hospital security personnel is controversial. Guards may be allowed to carry guns after completing extensive weapons training. Other devices, such as electric stun guns and pepper spray, represent less lethal alternatives but are not free of risk. (See "Chemical terrorism: Rapid recognition and initial medical management", section on 'Chemical agent definitions' and "Evaluation and management of injuries from conductive energy devices (eg, TASERs)".)
●Alarm systems – Alarm systems are commonly used in the ED and psychiatric wards. The goal of any alarm system is to obtain rapid assistance. False alarms must be minimized. A tiered alarm system is usually best. Panic buttons in each room activate a central buzzer in the ED. Several designated ED personnel respond initially and judge the level of response needed. Every ED should have at least one telephone with a direct line to police or security in case additional personnel are needed. A verbal code (eg, "Dr. Armstrong to Room 9") to call for additional help is useful [35].
●Limiting access – Controlling access into the ED and hospital helps to prevent violence. This can be done by limiting the number of entrances, controlling entryways (eg, buzzer activated doors), and monitoring who enters. High-risk EDs should limit access to one or two entrances, especially during the evening hours. During non-visiting hours, all entrances to the hospital other than the ED should be locked.
●Clinical team education – Regular de-escalation training sessions with clinicians, nurses, and ancillary staff in prevention and management of agitated and violent patients may reduce the incidence of violence and improve work satisfaction [91,92].
●Trained violence management teams – Interprofessional, team-based interventions have been successful in promoting de-escalation, minimizing restraint use, and reducing violent workplace incidents [75,76,93]. Teams are composed of members with expertise managing violent patients and may include a psychiatric nurse. This approach decreases the difficulty of providing regular training for all hospital staff and helps to ensure a consistent approach to potentially violent situations. At smaller institutions, this approach may not be feasible. An ED study found that implementation of an interprofessional agitation code response team was associated with a 27 percent decrease in the rate of physical restraint use between the before and after implementation phases [93]. A similar intervention implemented in the inpatient setting was associated with a 40 percent decrease in the nursing staff injury rate [76].
●Medical record behavioral flags – Medical record warnings ("flags") of prior violent behavior can alert the clinical team of potential violence risk and improve preparation during future encounters. These flags are relatively uncommon, and evidence does not exist that they improve patient care or prevent violent encounters [94]. Implementation should ensure that bias is not introduced and that they are periodically reviewed and removed if indicated [95]. In a 2023 study of 25 ED nurses, flags served as an important forewarning to approach patient interactions with more caution or use safety skills; however, nurses were skeptical of the ability of flags to prevent violence from occurring and noted concern for the unintended consequences of introducing bias into patient care [96].
One large urban US hospital with a high incidence of violent behavior reported no incident of weapons-related violence or injury in the ED following implementation of a large security force, metal detectors, bulletproof Plexiglas in triage areas, keypad security entry system, monitoring entry into the ED, and strong barriers to prevent cars from driving into the ED [28,97].
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Adult with altered mental status in the emergency department".)
INFORMATION FOR PATIENTS —
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Beyond the Basics topic (see "Patient education: Delirium (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Etiology and evaluation for medical causes – In the emergency department (ED), drug and alcohol intoxication or withdrawal are common causes of severe agitation. Every agitated or violent patient requires assessment for potentially dangerous causes as soon as this can be done safely (table 1). A rapid serum glucose measurement (eg, fingerstick glucose), pulse oximetry, complete set of vital signs, and thorough history and physical examination should be obtained in all patients. (See 'Rapid determination of most likely etiology' above and 'Medical evaluation when patient calm' above.)
●Risk factors and signs of impending violence – Male sex, a history of violence, and drug or alcohol misuse are associated with violence. Take all threats seriously. Signs of impending violence include (see 'Identifying the potentially violent patient' above):
•Provocative behavior
•Angry demeanor
•Demanding
•Loud, aggressive or mumbling speech
•Threatening to leave
•Tense posturing (eg, gripping arm rails tightly, clenching fists)
•Frequently changing body position, pacing
•Aggressive acts (eg, pounding walls, throwing objects, hitting oneself)
●Safety measures for the interview – Basic safety measures should be followed during all interviews with potentially violent patients. All patients must have any weapons confiscated prior to an interview. The setting should be private but not isolated, and no obstacle should exist between the clinician and the exit. (See 'Interview preparation and setting' above.)
●Approach to the management of an agitated or violent patient – The approach presented in the algorithm (algorithm 1) is based on the degree of agitation. A patient who is currently violent or aggressive, attacking objects or people, or requiring multiple people to restrain AND not responding to verbal de-escalation techniques or pharmacologic treatment requires immediate restraint and calming medication. (See 'Initial management' above.)
●Verbal de-escalation techniques – We attempt verbal de-escalation techniques in nearly all patients who present with agitation or violent behavior prior to implementing physical restraints or administering calming medications. The following suggestions increase the likelihood of a successful interview (see 'Verbal de-escalation for all patients' above):
•Respect personal space. Stand at least two arm's lengths away.
•Do not be provocative. Avoid direct eye contact. Adopt an honest, nonthreatening, and straightforward manner.
•Establish verbal contact. Use concise, simple language.
•Identify and confirm the patient's feelings and desires. Offer choices and optimism.
•Listen closely to what the patient is saying. Agree or agree to disagree.
•Lay down the law and set clear limits. Inform the patient that violence or abuse cannot be tolerated but avoid arguing, machismo, condescension, or commanding the patient to calm down.
•Address violence directly: The patient should be asked relevant questions, such as, "Do you feel like hurting yourself or someone else?"
•Perform friendly gestures (eg, offer food).
●Physical restraint – Physical restraints can be used when verbal techniques are unsuccessful despite a professional and proper approach to the agitated patient. The restraint team should have at least five people with specified roles, including a team leader. Each team member restrains a preassigned extremity by controlling the major joint (knee or elbow), securely applies the restraint, preferably leather material, and ties to the solid frame of the bed. (See 'Proper restraint application' above.)
In a patient who needs physical restraints, we suggest avoiding restraining in a prone posture and rapidly turning a patient supine if prone positioning occurs during the restraint process (Grade 1C). We avoid applying any pressure on the neck during the restraining process. The evidence is discussed separately. (See "Restraint-related cardiac arrest: Pathogenesis, strategies for prevention, and management for hospital clinicians".)
Every restrained patient must be carefully and frequently monitored. Physical restraints should be removed as soon as possible. (See 'Monitoring and care of a physically restrained patient' above.)
●Pharmacologic management – Administration of calming medication is discussed separately. (See "The acutely agitated or violent adult: Pharmacologic management".)
ACKNOWLEDGMENTS —
The UpToDate editorial staff acknowledges Gregory P Moore, MD, JD, and James A Pfaff, MD, FACEP, FAAEM, who contributed to earlier versions of this topic review.
