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Assessment and emergency management of the acutely agitated or violent adult

Gregory Moore, MD, JD
James A Pfaff, MD, FACEP, FAAEM
Section Editor
Robert S Hockberger, MD, FACEP
Deputy Editor
Jonathan Grayzel, MD, FAAEM


Patient violence occurs in many clinical settings and clinicians must be prepared to cope effectively with agitated patients in order to reduce the risk of serious injury to the patient and caretakers. The significant illness, prolonged waiting times, and confusion often found in busy emergency departments (ED) creates a stressful atmosphere that can exacerbate feelings of agitation among patients and their families. The ED's 24-hour open door policy, availability of potential hostages, and widespread accessibility of drugs and weapons compound the problem.

The evaluation and management of the acutely agitated or violent patient will be reviewed here. The management of specific psychiatric ailments and intoxicated or poisoned patients is discussed elsewhere. (See "Suicidal ideation and behavior in adults" and "Diagnosis of delirium and confusional states" and "Evaluation of abnormal behavior in the emergency department" and "General approach to drug poisoning in adults" and "Ethanol intoxication in adults" and "Clinical manifestations, differential diagnosis, and initial management of psychosis in adults".)


Up to 50 percent of healthcare providers are victims of violence sometime during their careers [1,2]. A 2008 survey of over 3500 United States emergency department (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 [3]. Another survey of 263 emergency medicine residents and attending physicians found that 78 percent of participants experienced a violent workplace act in the prior year, distributed equally between males and females [4]. Smaller surveys in the United States have found comparable rates of verbal and physical violence directed against ED clinicians [5,6].

The problem of violence is not limited to the United States or to EDs. Surveys of emergency care workers and nurses in Turkey and Australia report similar rates of violence as those in United States studies [7,8]. 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 [9].

Approximately 4 to 8 percent of patients who present to psychiatric EDs are armed [10,11]. At one large urban county hospital ED in the United States, an average of 5.4 weapons was confiscated each day using metal detector screening [12]. At this center, 26.7 percent of major trauma patients seen in the ED over a 14-year period were armed with lethal weapons (84 percent knives and 16 percent guns). The presence of weapons among many ED patients increases the potential for rapid escalation of violence. Unfortunately, predicting weapons carriage in any particular patient is not easy [13].


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