Violent Behaviour in the ED
Violent or severely agitated behaviour in the emergency department (ED) is a clinical presentation, not a diagnosis. It can escalate rapidly and may reflect a reversible medical, toxicological or psychiatric cause.
Management priorities are: (1) preserve safety for the patient, staff and others; (2) identify and treat reversible causes in parallel with behavioural management; and (3) use the least‑restrictive, proportionate and time‑limited interventions necessary to restore safety (NICE NG10; RCEM ABD guidance; DHSC Positive and Proactive Care).
Scope and guiding principles
- Aggression is a symptom; interventions must be necessary, proportionate, time‑limited and the least restrictive available (NICE NG10; gov.uk).
- Anticipate escalation and prioritise de‑escalation; restrictive measures (physical restraint, seclusion, parenteral sedation) are last‑resort measures and must be documented, reviewed and governed locally.
- ED teams must be prepared for rapid physiological deterioration after sedation or restraint; airway, breathing and circulation (ABC) support must be immediately available.
- Local policies should align with national guidance (NICE NG10, RCEM ABD guidance, DHSC Positive and Proactive Care) and include training, equipment, observation standards and post‑incident governance.
Recognition and differential - FIND ME (practical ED checklist)
Use a parallel approach: de‑escalate while rapidly searching for reversible causes. The following checklist helps structure assessment and differential diagnosis.
- Functional: consider pain, fear, sensory overload, unmet needs, delirium related to environment, and withdrawal states.