Dr Diane Mullins, RCSI Tutor in Psychiatry, St Itas Hospital, Portrane

Management of an acutely aggressive patient / management of behaviourally

disturbed patient
****see algorithm page entitled management of acute behavioural disturbance and
include all of the information on that page****

Acute behavioural disturbance may occur secondary to

1. Substance misuse (both intoxication and withdrawal),
2. Physical illness (such as post head injury, hypoglycaemia)
3. Psychiatric conditions (including psychotic and personality disorders)

The aims of rapid tranquillisation

1. To reduce further suffering for the patient: psychological and physical (through
self-harm or accidents)
2. To reduce the risk of harm to others
3. To do no harm (by prescribing safe regimes and monitoring physical health)

Rapid tranquillisation preliminary steps

1. Endeavour to establish the underlying diagnosis behind the acute behavioural
disturbance before making any treatment decision
2. Allow a period of de-escalation see below
3. Only when de-escalation has failed to curb the disturbed behaviour should
medication be considered

De-escalation techniques
One staff member should assume control of a disturbed/violent situation
The staff member who has taken control should:
o Remove other patients from the area, enlist the help of colleagues
o Give clear, brief, assertive instructions to the patient and others in the vicinity
o Move towards a safe place and avoid being trapped in a corner
o Attempt to establish rapport and emphasise cooperation
o Ask open questions and inquire about the reason for the anger
o Show concern and attentiveness through non-verbal and verbal responses
o Listen carefully and show empathy, acknowledging any concerns
o Appear calm, self-controlled and confident
o Ask for any weapons to be placed in a neutral location rather than handed over
o Consider asking the patient to make use of the designated area or room
specifically for the purpose of reducing arousal and/or agitation to help them
calm down

Other items which should be done

Consult Senior Colleague
Review chart for any previous reactions to antipsychotics/sedatives
Ensure appropriate resuscitation equipment available
Review legal status (i.e. Mental Health Act or voluntary patient?)

Incident reporting and post-incident reviews

Any incident requiring rapid tranquillisation, physical intervention or seclusion
should be recorded
A post-incident review should take place as soon after the incident as possible, but
in any event within 72 hours of the incident ending