What is the management for a patient with acute aggression?

Management of Acute Aggression in Patients

The management of acute aggression requires a structured approach beginning with verbal de-escalation techniques, followed by pharmacological interventions when necessary, with benzodiazepines or antipsychotics based on the suspected etiology of agitation. 1

Initial Assessment and De-escalation

Rapid Assessment

• Determine pattern of anger manifestation: state vs. trait, proactive vs. reactive, group-inspired, psychotic, or drug-induced 1, 2
• Screen for substance use, intoxication, or withdrawal 2
• Identify triggers and warning signs of aggression 1
• Assess for underlying psychiatric conditions that may present with emotional lability 2

Verbal De-escalation Strategies

1. Respect personal space

   • Maintain two arms' length distance
   • Ensure unobstructed path out of room for both patient and staff 1

2. Minimize provocative behavior

   • Maintain calm demeanor and facial expressions
   • Keep hands visible and unclenched
   • Avoid defensive body language (hands on hips, arms crossed) 1

3. Establish verbal contact

   • Designate one staff member to interact with patient
   • Introduce self and orient patient to environment
   • Reassure patient that you will help them 1

4. Use concise communication

   • Simple language and concise sentences
   • Allow adequate time for patient to process information 1

5. Identify patient's goals

   • "What helps you at times like this?"
   • "I'd like to know what you hoped would happen here" 1

6. Practice active listening

   • "Tell me if I have this right..."
   • "What I heard is that..." 1

7. Set clear limits and expectations

   • "We're here to help, but it's important that we're safe with each other"
   • Establish consequences of unacceptable behaviors in a non-punitive manner 1

Pharmacological Management

Decision Algorithm for Medication Selection

Based on suspected etiology of agitation: 1

1. Medical/Intoxication Etiology:

   • Mild/Moderate: Benzodiazepine (first-line)
   • Severe: Benzodiazepine first, consider adding first-generation antipsychotic

2. Psychiatric Etiology:

   • Mild/Moderate: Benzodiazepine or antipsychotic
   • Severe: Antipsychotic (preferred)

3. Unknown Etiology:

   • Start with benzodiazepine or antipsychotic
   • Consider adding the other if first dose is not effective

Medication Options

Benzodiazepines (e.g., Lorazepam)

• Dosing: 0.05-0.1 mg/kg IM/IV; for adults typically 2 mg IM 3
• Onset: 15-20 minutes IM
• Advantages: Preferred for intoxication and withdrawal; no extrapyramidal symptoms
• Cautions: Use with caution in patients with respiratory compromise 1

Antipsychotics (e.g., Haloperidol)

• Dosing: 2-5 mg IM for prompt control of acutely agitated patients 4
• Administration: May be given as often as every hour, though 4-8 hour intervals are usually sufficient
• Considerations: Switch to oral form as soon as practicable 4
• Monitoring: Watch for extrapyramidal symptoms, especially in younger patients 1

Special Considerations

Staff Training and Safety

• Staff should receive regular training in managing aggressive behavior 1
• Adequate staffing based on patient acuity is critical 1
• Perform shift-by-shift acuity assessments to determine appropriate staffing levels 1

Post-Incident Management

• Debrief with patient after any intervention
• Explain why intervention was necessary
• Ask patient to explain their perspective
• Review alternative strategies for future situations 1

Special Populations

• For patients with trauma history, physical and mechanical restraint should be discouraged; seclusion may be preferable 1
• For patients with developmental disabilities, modify strategies to meet cognitive needs 1

Common Pitfalls to Avoid

• Failing to identify medical causes of agitation that require specific treatment
• Overlooking substance intoxication or withdrawal as causes of agitation
• Escalating the situation through confrontational body language or communication
• Using medications without attempting verbal de-escalation first
• Inadequate monitoring after medication administration
• Insufficient staff training in de-escalation techniques and proper restraint procedures 1

Remember that the goal of managing acute aggression is to ensure safety while helping the patient regain control of their behavior using the least restrictive means possible 5.