Abstracts

Rationale: The association between violence and epilepsy has been much debated in the literature. Aggressive behaviour related to seizures can be ictal, post ictal or inter ictal. Ictal violence is extremely uncommon with only rare cases documented in the literature (Delgado-Escueta et al 2002).These involved spontaneous non-directed stereotyped aggressive movements with violence that was resistive rather than directed. Resistive violence refers to unintended aggression towards others that occurs when someone attempts to restrain or assist a patient during a seizure. Post ictal aggression is often associated with confusion or psychosis and the episodes last longer than ictal violence. There is evidence that temporal lobe discharges which involve the hippocampus, amygdala and hypothalamus particularly involving the left hemisphere as well as specific frontal regions are likely to lead to episodes of violent behaviour (Fenwick,1986; Marsh and Krauss,2000). In Campbell s ongoing study (2009) on workplace violence 89% of physical aggression is patient related.We will present a case report of a patient exhibiting ictal rage as documented by video EEG which resulted in staff injury. Strategies for preventing and managing workplace violence as it pertains to this patient population will be reviewed. Methods: -Literature review of the neurobiology of aggression and patient related violence -retrospective review of incidents of aggression over the last 5 years in the EMU of our institution -case review of ictal rage Results: 13 incidents of aggression in 8 patients/ 1212 admissions in the past 5 years. Ictal: (1) A male patient with ictal rage had bitemporal independent inter-ictal discharges and seizures arising from the left temporal lobe. MRI showed abnormal left hippocampus and neuropsychology pointed to left hemisphere abnormalities. (Case Presentation) Post ictal:There were 4 events(3 male)following secondary generalized seizures:2 left hemisphere, 1 bitemporal and one right occipital. Inter ictal: There were 8 events (2 male and 2 female): 4 events in 1 female patient with severe behavior disturbances as a result of viral encephalitis, 2 events in intellectually delayed male post right temporal resection and occipital focus,1 male left temporal focus and psychiatric co morbidity, and 1 female with intellectual delay but no apparent epilepsy. Recommendations were made for improving patient and workplace safety. The event of ictal rage precipitated a review of the risks associated with the EMU patients. Senior administration, occupational health and safety, and unit leadership analyzed the situation using root cause analysis. Modifications to the environment and staffing quotas ensued. Conclusions: Ictal rage is a rare occurrence, 1% of admissions over 5 years. Its prediction and management is essential to provide a safe environment for patients and staff. Debriefing of this rare event using a root cause analysis model resulted in system changes. Use of telemetry monitoring and staff expertise are critical in managing peri ictal and ictal violence.