CRACKCast E187 – The Combative and Difficult Patient

In CRACKCast, Podcast by Adam ThomasLeave a Comment

This episode of CRACKCast covers Chapter 189 in Rosen’s Emergency Medicine (9th Ed.) – The Combative and Difficult Patient. Next time a severely agitated patient rolls into the department, you won’t even break a sweat!

Shownotes – PDF HERE


Rosen’s in Perspective

Difficult encounters not only harm us, but also harm patients.

Key priorities for us in the ED:

  • For the combative patient
    • control the patient and the situation,
    • diagnose and treat reversible causes of violence,
    • protect the patient and staff from harm.
  • For the difficult patient
    • Maintain a professional physician-patient relationship (appropriate emotional distance)
    • If possible, focus on a shared therapeutic alliance
    • Respectfully offer alternatives when the interaction is no longer therapeutic

[1] List 6 patient problems associated with violence. 


  • Psychiatric
  • Street drug abuse or withdrawal
  • Situational / Antisocial behaviour

Positive predictors of violence:

  • Male gender
  • Prior hx of violence
  • Drug or ETOH abuse

The Complete List…

Box 189.1: Selected Problems Associated with Violence


  1. Schizophrenia
  2. Paranoid ideation
  3. Catatonic excitement
  4. Mania
  5. Personality disorders
    1. Borderline
    2. Antisocial
    3. Delusional depression
    4. Post-traumatic stress disorder
    5. Decompensating obsessive-compulsive disorders

Situational Frustration

  1. Mutual hostility
  2. Miscommunication
  3. Fear of dependence or rejection
  4. Fear of illness
  5. Guilt about disease process

Antisocial Behavior

  1. Violence with no associated medical or psychiatric explanation (these patients may be managed by the police or security)



  1. Delirium
  2. Dementia
  3. Trauma
  4. Central nervous system infection
  5. Seizure
  6. Neoplasm
  7. Cerebrovascular accident
  8. Vascular malformation
  9. Hypoglycemia
  10. Hypoxia
  11. Acquired immunodeficiency syndrome (AIDS)
  12. Electrolyte abnormality
  13. Hypothermia or hyperthermia
  14. Anemia
  15. Vitamin deficiency
  16. Endocrine disorder


  1. Unanticipated reaction to prescribed medication (especially sedatives in brain-injured or elderly patients)
  2. Alcohol (intoxication and withdrawal)
  3. Amphetamines
  4. Cocaine
  5. Sedative-hypnotics (intoxication or withdrawal)
  6. Phencyclidine (PCP)
  7. Lysergic acid diethylamide (LSD)
  8. Anticholinergics
  9. Aromatic hydrocarbons (eg, glue, paint, gasoline)
  10. Steroids

[2] List 8 strategies for the management of a potentially violent patient other than chemical/physical restraint. 

Break this down into: system, department, and primary-secondary-tertiary prevention.

  1. Preparedness
    • Prohibition and screening for weapons
    • Alarm systems / panic buttons
    • Direct line to police / security
    • Centralized ED flow with buzzers, barriers, and protective glass
    • Secure, violent proof examination rooms with exits and panic buttons
    • No neck ties, stethoscopes, lanyards
  1. Primary prevention
  • Minimize frustration and aggression
  • Calm, efficient, short stay ED visits (preferentially see violent patients sooner)
  • Police / security / surveillance presence
  1. Secondary prevention
  • Recognize pre-violent scenarios or patients
  • Verbal de-escalation
  • Staff training and caregiver training
  1. Tertiary
  • Physical restraints – police, security
  • Chemical
  • QI – Post-incident debrief and review

See Box 189.2

[3] Describe essential elements for use of physical restraints. 

Essential elements:

  • Appropriate indication and failure of other non-physical strategies
  • Follow hospital protocol and use a restraint team (who has briefed the team on the plan)
  • The restraint team: explain to the patient in a calm and organized manner, explaining why restraints are needed and what the course of events will be
  • Restraints 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).
  • Close observation and extremity assessment for neurovascular injury
  • Remove as soon as safe
  • Documentation
  • Debrief and process improvement

See image in shownotes for technique – one arm up, one arm down.

[4] List 3 medications used for chemical restraints, their dose, and their side effects. 

Three main agents:

  • Benzodiazepines
    • SAFEST choice for the completely undifferentiated agitated patient of an unknown cause
    • particularly preferred for the management of agitation caused by ethanol or sedative-hypnotic drug withdrawal, as well as cocaine, amphetamines, and sympathomimetic drug ingestions.
    • Side effects:
      • sedation, ataxia, confusion, nausea, and respiratory depression, which may be amplified in the presence of concurrent alcohol and other depressant use.
    • Antipsychotics
      • Typical (Haldol) vs. Atypical (Olanzapine)
      • Side effects:
        • Vary based on the drug, but some are:
          • Sedation, hypotension, anticholinergic, EPS, QTc prolongation (highest risk when given IV)
          • EPS:
            • akathisia (extreme restlessness) and uncoordinated involuntary movements known as dystonia, including of the muscles of the mouth (buccolingual), neck (torticollis), back (opisthotonos), eyes (oculogyric crisis), and trunk (abdominopelvic).
            • Trxt benztropine 1-2 mg or diphenhydramine


  • Avoid with alcohol, benzodiazepine, or other sedative withdrawal syndromes, patients with known seizure disorders, and when possible avoided in pregnant or lactating females and patients with phencyclidine overdoses.
  • Ketamine
    • initial dose of 1 to 2 mg/kg IV or 4 to 5 mg/kg IM. The onset of drug action is typically 1 to 2 minutes after IV use and often 4 minutes or longer after IM administration, with duration of action of approximately 20 minutes.
    • Notable side effects include hypertension and tachycardia (usually mild and transient), drooling, laryngospasm and other respiratory complications (uncommon), emesis, and emergence reactions, worsening psychosis.


It is usually best practice to offer a PO version of sedation to the cooperative but agitated patient – assuming it is safe to wait and no immediate threat to the staff. Here the options are:

  • Lorazepam 2 to 4 mg PO or Risperidone 2 mg PO* or Olanzapine 5 to 10 mg PO*
  • For elderly patients, it’s probably best to reduce the dose by half


Ideally it’s helpful to think through the specific type of patient you’re trying to sedate:

  • Severely violent vs. stimulant intoxication vs. CNS intoxicated patient (ETOH) vs. the patient with a known psychiatric disorder


In general here are some options:

  • Droperidol 2.5 to 5 mg IM/IV, titrate as needed
  • or
  • Midazolam 2.5 to 5 mg IM/IV, titrate as needed
  • or
  • Midazolam 2.5 to 5 mg IM/IV with droperidol 2.5 to 5 mg IM/IV, titrate either as needed
  • or
  • Haloperidol 2. 5 to 5 mg IM/IV with lorazepam 2 mg IM/IV, titrate either as needed
  • Ziprasidone 20 mg IM* or Olanzapine 10 mg IM* (for the known psychiatric patient)


Could remember: 2+2 – lorazepam 2mg + haldol 2 mg; but we know that midazolam is the fastest of the choices when given IM. So I’ll keep it simple: Haldol 2.5 mg IM and Midaz 5 mg IM. Lorazepam takes 15-30 mins to work when given IM! Note that Droperidol and haldol are dosed similarly!

[5] List 6 Psychiatric, 8 Organic, and 8 Drug causes of violence. 

Unfortunately, these often overlap.  This is a repeat from question 1:

·       Schizophrenia

·       Paranoid

·       Mania

·       Personality disorder

·       Fear and guilt reactions

·       Antisocial behaviour

– Drugs

–  Infections

–  M

o   Hypoxia

o   Hypoglycemia

o   Electrolytes

o   Delirium

o   Dementia

– E

o   hypo/hyperthermia

o   CO or CN poisoning

–  S

o   CVA

o   Traumatic bleed

–  Withdrawal

o   ETOH

–  Intoxication

o   ETOH

o   Amphetamines

o   Cocaine

o   MDMA

o   PCP

–  Rx:

o   Steroids

o   Anticholinergics

o   Sedatives


[6] Distinguish organic from functional causes of violent behaviour. 



  • Family hx
  • Onset < 40 more likely functional
  • Recent trauma / drugs / stressors
  • Toxidrome
  • Y? Why are they presenting now?

Table 189.1: Distinguishing Organic from Functional Causes of Violent Behavior

Age at onsetAny>50 years old<40 years old
AlertnessAlteredNormalNormal or hyperalert
HallucinationsCommon; can be visual, auditory, or tactileNoneAuditory in schizophrenia, otherwise uncommon
Symptom pictureFluctuatingStableStable
Abnormal vital signsCommonUncommonUncommon
Psychiatric historyNoNoYes

Goal to determine whether the patient is “medically stable for psychiatric evaluation.”

[7] List 2 ED factors, 3 physician factors, and 2 patient factors that impair the physician patient relationship/interaction. 

Box 189.7: Factors Impacting the Difficult Patient-Physician Interaction

Emergency Department Factors

  1. Lack of patient choice of facility or physician
  2. Time constraints, frequent interruptions, other priorities of care
  3. Suboptimal patient privacy or comfort (eg, hallway examinations)
  4. Long waiting times, department crowding
  5. Negative non-physician bias toward the patient (eg, by prehospital team, nursing)

Physician Factors

  1. Poor communication
  2. Difficulty expressing empathy or becoming easily frustrated
  3. Personal negative bias and prejudices toward conditions and interactions
  4. Limited knowledge of the patient’s condition or psychosocial situation
  5. Overly rigid medical agenda or interaction
  6. Outside stresses affecting work
  7. Emotional burnout or insecurity
  8. Personal health issues
  9. Situational stressors and perceived time pressure
  10. Sleep deprivation or shift fatigue

Patient Factors

  1. Behavioral issues (eg, argumentative, manipulative, medical noncompliance)
  2. Fear of abandonment
  3. Psychiatric conditions
  4. Low literacy
  5. Financial constraints
  6. Chronic pain syndromes
  7. Multiple complaints
  8. Beliefs or goals of care foreign to the physician
  9. Unrealistic expectations
  10. Substance use disorder
  11. Past or current physical, emotional, or mental abuse
  12. Life stress or social disarray

[8] List 5 communication strategies for dealing with the difficult patient encounter. 


Structure the interview

Actively listen

Limit setting / ground rules

Take a time out


Redirect the interview to the main concern

Validate emotions

See Table 189.3 for more: Communication Strategies for the Difficult Patient Encounter.

[9] List 5 basic steps in crisis intervention. 

SAFER-R model.  See pdf on the subject:

  • Remove agitated patient from other provocative patients to a quiet area
  • Triage violent patients to be seen quickly
  • Utilize nonverbal (space, relaxed posture, exit plan) verbal de-escalation techniques

[10] In a single sentence, describe each of the Cluster A, B, and C personality disorders, and describe an alternative approach to labelling four difficulty patient behaviour types.

Cluster A – Odd, isolated, or paranoid.

  • Schizotypal, Schizoid, Paranoid

Cluster B – Dramatic, manipulative

  • Borderline, Narcissistic, Antisocial

Cluster C – Anxious, Fearful

  • OCPD, Dependent, Avoidant

Rosen’s divides this into the following groups:

  1. dependent clinger (formerly dependent, borderline, histrionic)
  2. entitled demander: CEO, narcissistic, paranoid
  3. manipulative help rejector: borderline, antisocial PD
  4. self-destructive denier: violent, chronic suicidal, substance abuser, borderline PD.



[1] What are four patient behaviours suggesting impending violence?

  • Loud speech
  • Tense posturing / angry demeanor
  • Pacing
  • Aggressive behaviour

See Box 189.3

[2] What are some elements of verbal de-escalation?


  • Safe space
    • Remove agitated patient from other provocative patients to a quiet area
    • Triage violent patients to be seen quickly
    • Distance yourself, remove hazards in the room (objects that can be thrown)


  • Posture
    • Non-confrontational body posture (arms at sides, palms facing up, sitting at eye level
  • Listen carefully
    • What can we help with today? What you hoping for? Tell me if I understand this correctly?
  • Acknowledge
    • Agree with truths: “we want to treat you with respect”, “there are others who feel like you”,
    • Note their frustration
  • Clarify limits and offer Choices
    • Clearly state that violence, threats and abuse will not be tolerated
    • “I can help you with your problem, but I cannot allow you to continue threatening me, the emergency department staff, or other patients.”
    • “You obviously have a lot of will power and are good at controlling yourself.”
    • Offer choice between
    • Consider offering a cold drink or a sandwich to build a bridge
    • Ask and explain what you’re doing before you do it:
      • “I’m going to feel your sore wrist; I’m going to listen to your lungs; I’m going to look at that wound”
    • Exit strategy
      • Know to trust your gut feeling if you notice things escalating
      • Have security nearby
      • Know where the exits are – have at least two exits
      • Don’t ask to leave, just walk out

[3] Describe seven toxidromes.  

TABLE189.2 Vital Signs and Toxic Syndromes


Withdrawal (ethanol, sedative-hypnotics)WetBenzodiazepine withdrawal


  • The sympathomimetic and withdrawal toxidrome present similarly
  • The main difference between the sympathomimetic and anticholinergic toxidrome is wet vs. dry skin

The seventh being the hallucinogenic toxidrome.

[4] What are some tools for managing negative physician-patient reactions? 

SOUR situation

Box 189.8 Tools for Managing Negative Reactions

Maintain Appropriate Emotional Distance

  1. Avoid reciprocating hostile behaviors while maintaining a sense of empathy for the patient

Understand Negative Behavior as a Symptom

  1. View the patient as a victim of their circumstances

Look for Cognitive Distortion

  1. Be cautious not to overly-stereotype and cloud clinical judgment and avoid perpetuating negative labels

View Negative Reactions in Context

  1. Recognize when one feels overwhelmed by the expectations of the emergency department (ED) work environment to gain perspective on personal reactions

Cannarella Lorenzetti R, Jacques CH, Donovan C, et al: Managing difficult encounters: understanding physician, patient, and situational factors. Am Fam Physician 87:419-425, 2013.


This post was uploaded and copyedited by Owen Scheirer.

Adam Thomas

CRACKCast Co-founder and newly minted FRCPC emergency physician from the University of British Columbia. Currently spending his days between a fellowship in critical care and making sure his toddler survives past age 5.
Chris Lipp is one of the founding Fathers for CrackCast. He currently divides his time as an EM Physician in Calgary (SHC/FMC) and in Sports Medicine (Innovative Sport Medicine Calgary). His interests are in paediatrics, endurance sports, exercise as medicine, and wilderness medical education. When he isn’t outdoors with his family, he's brewing a coffee or dreaming up an adventure…..