Thursday 11 May, 2006

Takedowns – Do not be a hero

Posted in Emergency Dept., May Su, Psychiatry, Wards at 10:28 by May Su

Original article by: May Su :: Printer friendly

Acute psychosis can be distressing
to both you and your patient

Remember that in a takedown it requires a minimum of five people to hold down an aggressive patient in order to safely restrain them from harm to themselves or others. Takedown of an aggressive patient means somebody holding the head, someone at each limb, and someone to administer medications (usually an intramuscular sedative +/- an antipsychotic). That is a minimum of six people.

If you feel that this may be at all necessary, then take the time to arrange the necessary number of people PRIOR TO SEEING THE PATIENT. Furthermore, if not in the same room as you, then they should be at least within close calling range for immediate assistance.

It takes a minimum of five people to hold down a patient in a take down. A sixth is needed to talk to the patient / administer medications.

Remember that it is not necessarily the big burly tattooed male who will be of threat. Any agitated patient can be aggressive. The little old lady can pack a surprising punch, usually because the unfortunate interviewer is not expecting it to come their way. If you are feeling at risk during an interview, there is probably a reason why.

Early warning signs

  • Increased body movements (you may notice this in the hands and feet first);
  • escalating towards standing up frequently;
  • increased volume and rate of speech;
  • difficulty with eye contact or too much eye contact.

Red Flags of extreme danger (by this time you should have escape route well planned and underway)

  • Pacing around the room, and towards you;
  • shouting and yelling abuse;
  • remaining standing, intruding into your personal space;
  • stating that “I will kill you” is a very bad sign.

De-escalation techniques:

One of the psychiatrists that I worked for an intern has an amazing aura of “calm” that surrounded him – almost a drone that could send an aggressive patient to sleep. This is what you are trying to achieve.


  • Calm, monotonous tone of voice.
  • Reasonable eye contact.
    • Too much staring can be intrusive.
    • Too little can give the patient the impression you are not interested in what they are saying.
  • Positioning
    • If possible, two escape doors (one for you and one for the patient).
    • Try to avoid the patient having to escape through you to get out.
  • Listen. I cannot emphasise this enough in the mental health assessment. Your aim is to listen to what the patient is saying with some mild re-direction if required for your assessment.
  • Use open ended questions when possible. It is much less confronting for a person to tell their story then have it dragged out question by question.
  • Try to determine what the patient is aggressive about, if possible.
  • Acknowledging a reason for anger can be very reaffirming that you are willing to work through what is troubling them.
    • This is not the time to convince somebody that aliens do not exist – acknowledge that “yes, I can understand that being frustrating if aliens were trying to abduct me”.
  • Negotiate. If they are angry that you will not destroy the aliens, then work out what can make them feel safer.
  • Try to de-escalate prior to the patient starting to pace.
  • Encourage them to remain in the sitting position if possible.
  • You may find it necessary to let them know that their behaviour is threatening. Some patients may not even realise this.

By the time you get to the “red flag” signs, you should have worked out your escape plan and signalled for help. Don’t be a hero. You’re helping no one if you get beaten to a pulp. To help your acutely mentally unwell patients, you need to protect yourself first.

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