Aggression

Violence directed toward health care providers can occur in the emergency department.

The average physical fight between two individuals lasts for only seven seconds. In this short time span, up to 15 violent acts (punches, kicks, etc.) may be exchanged, with injury tending to occur within the first three seconds [1].

Because these incidents occur so quickly, one cannot rely on panic buttons, security staff, or hot lines to police stations to addressviolent outbursts in the ED.

Emergency providers should be able to recognise and address a potentially aggressive behavior before it escalates and causes harm.

Which common medical emergencies may make a patient aggressive?

Always consider medical conditions as potential causes of agitation.

Aggressive, or violent behavior is not a diagnosis; but it may occur due to many underlying medical, toxicologic, or mental problems, or a combination of these conditions. The more important issue for the emergency physician is to identify medical problems that may cause the patient’s violent behavior. One must not overlook emergency medical conditions, such as the following: hypo/hyperglycaemia, head injuries, hypoxia, drugs, alcohol, or sepsis. Many psychiatric conditions may also present with aggression. Where possible, these causes need to be carefully considered, and addressed. Even if the history and presentations are suggestive of a psychiatric condition, medical causes should still be considered. It is possible that patients may be prematurely labeled as “psycho,” especially if they have a history of mental health issues.

Reversible causes should be considered during the initial evaluation. The mnemonic FIND ME (Functional, Infectious, Neurologic, Drugs, Metabolic, and Endocrine) may be helpful in the identification of a serious underlying medical cause. A rapid bedside blood glucose determination and pulse oximetry should be obtained for all potentiallyviolent patients.

Medical

• Hyperthyroidism
• Hypoglycemia
• Traumatic Brain Injury
• Delirium

Psychiatric

• Depression
• Conduct Disorder
• Attention Deficit Hyperactivity Disorder
• Bipolar Disorder
• Impulse Control Disorder
• Psychosis
• Impulsive Behavior
• Substance Intoxication/ Withdrawal
• Post-Traumatic Stress Disorder