Violent Behaviour in the ED

Author: Anthony Bleetman / Editor: Michael John Stewart / Reviewer: Muhammad Waseem, Anthony Bleetman / Code: A5, CC7 / Published: 06/12/2021


Managing aggressive and violent behaviour is challenging. Aggressive behavior may indicate a serious, ongoing mental health condition that poses a safety concern. This behavior may be either impulsive (occurs due to a trigger) or proactive (premeditated and well thought out).

Patients with mental health problems are increasingly being evaluated and treated in the emergency department (ED). There has been a steady rise in the number of ED visits due to by patients exhibiting a range of mental health conditions. For example, in 2000, 5.4% of ED visits were due to mental health reasons compared with 12.5% in 2007. Since they are occurring more commonly, it is important to be familiar with the causes of aggressive behavior. It is becoming necessary to effectively address this type of behavior in order to ensure the safety of both the patients and the ED staff.

By the end of this session you will be able to:

  • Recognise the factors which result in aggressive or violent behavior in the ED
  • Anticipate and quickly recognise the risk to yourself, the patient individual and other ED staff when dealing with potentially violent people in the ED
  • Learn the application of conflict resolution strategies to prevent and control violence
  • Determine when rapid sedation is required
  • Use rapid tranquilizing or sedation techniques according to the National Institute for Health and Care Excellence (NICE) guidance.


  1. Northants Police: Personal safety training. 1994.
  2. The Health and Safety at Work Act, 1974
  3. The Human Rights Act, 1998.
  4. National Institute for Health and Clinical Excellence. Clinical Guideline 25. Violence. 2005; London; NICE.
  5. National Institute for Health and Clinical Excellence. NICE Guideline 10. Violence and Aggression: Short-term management in mental health, health and community settings. 2015; London; NICE
  6. NHS security management
  7. Karas S. Behavioral Emergencies: Differentiating Medical from Psychiatric Disease. March 2002; Volume 4, Number 3: EB Medicine
  8. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on the Adult Psychiatric Patient, Nazarian DJ, Broder JS, Thiessen MEW, Wilson MP, Zun LS, Brown MD. Ann Emerg Med. 2017 Apr;69(4):480-498
  9. Violence prevention in the mental health setting: The New York State experience. [accessed Sep 26 2018]
  10. World Health Organization (WHO). Violence Prevention Alliance. Global Campaign for Violence Prevention: Plan of Action for 2012-2020.Geneva: World Health Organization; 2012. [Last accessed on 2018 August 18].
  11. Onyike CU, Lyketsos CG. Aggression and violence. In: Levenson JL, Wulsin L., editors. The American Psychiatric Publishing Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill.Arlington, VA: American Psychiatric Publishing, Inc; 2011. pp. 161168
  12. Richmond JS, Berlin JS, Fishkind AB, Holloman GH Jr, Zeller SL, Wilson MP, Rifai MA, Ng AT. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup.West J Emerg Med. 2012 Feb;13(1):17-25

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