Chapter 23 - Management of aggressive and violent behavior in the emergency department

Summary

With the risk of violence being so high in the emergency department (ED), it is essential for ED physicians and staff to have an understanding of the progression of violence and the appropriate de-escalation techniques to defuse potentially violent situations. Techniques for de-escalation should occur in a step-wise pattern beginning with verbal techniques, followed by the offering of a pharmacologic intervention, a show of force, and finally physical restraint. At times, it may be necessary to use physical restraints until parenteral medications have had their desired effect. The most frequently used medication strategies consist of benzodiazepines, second-generation antipsychotic medications alone or in combination with a benzodiazepine, and haloperidol (Haldol) alone or in combination with a benzodiazepine. The ED can best be prepared for a hostage crisis by developing well-defined procedures for securing the area, for alerting the appropriate law enforcement agencies, and by designating clear lines of authority.