We live in a violent society, which is easily demonstrated by the news media, television shows, and movies; the workplace has not been spared from the violence that surrounds us. The emergency department (ED) is a site of uncertainty, acuity, risk, and chaos that can create or exacerbate difficult situations that can potentially end in violent acts. On the basis of recently published studies, it has been estimated that there are thousands of assaults in American hospitals each year, and the ED is a site of major risk.<sup>15 Hughes D.H. Assessment of the potential for violence Psychiatr Ann 1994 ;  24 : 11

Cliccare qui per andare alla sezione Riferimenti</sup> Even though behavioral emergencies comprise a small number of ED patient visits, these types of situations and patients often require an inordinate amount of ED staff time and attention.<sup>34 Teuth M.J. Management of behavioral emergencies Am J Emerg Med 1995 ;  13 : 3

Cliccare qui per andare alla sezione Riferimenti</sup>

Emergency physicians encounter violent patients as predictably as they encounter airways. The frequency of these encounters depends somewhat on the ED size and location, but the encounter is inevitable. Fundamentally, the approach to violence in the ED is analogous to the approach to the airway. There are many different routes to airway compromise, yet, regardless of the cause, the emergency physician must be prepared to gain control, using whatever means necessary. Similarly, violent behavior is an endpoint for many different medical and psychiatric pathologies. The emergency physician must be prepared to act definitively when dealing with the violent patient, to prevent escalation and injury before moving on to further evaluation. The outcome of poorly managed violence can be no less catastrophic than the poorly managed airway. The defining difference is that violent patients in the ED put not only themselves, but also those around them, at risk.

The primary focus of this article is to aid the clinician in the immediate treatment of the behavior and not to dwell on the variety of pathologies that could have caused the behavior itself. It is assumed, more appropriately required, that the physician suspect that any decompensated behavior is the result of a medical or surgical condition until proved otherwise. Treatment of conditions that can cause agitation, such as hypoxia, can in fact resolve behavioral problems. More often, however, the behavior must be addressed before definitive care can take place. This article presents the progressive strategies used for diffusing the threat of violent patients in the ED. Procedural and documentation requirements for the use of physical and chemical restraints are reviewed, and an analysis of the literature regarding pharmacologic options is presented. Finally, a flowchart demonstrating responses to intervention is included (Figure 1).