A patient with

abnormal behaviour

HKCEM College Tutorial

AuthorDr. LP Leungrevised by Dr. Li Yu KwanOct., 2013

History at Triage

▪A middle aged man is brought in by police because of exhibiting abnormal behaviour in street.

▪Personal background unknown

▪BP (refused) P 100/min

▪Afebrile (tympanic)

What are your aims of managing this patient ?

Aims

▪to identify any immediate life threats

▪to deal with any disruptive behaviour e.g. aggression

▪to search for any treatable medical causes

▪to differentiate organic vs functional conditions

▪to arrange proper disposal

What are the possible treatable medical causes ?

Treatable medical causes

▪Drug effect

▪Metabolic disorders

▪Endocrine causes

▪Nutritional causes

▪Trauma and tumor

▪ Infection

▪Atherosclerotic complications

How would you perform mental status exam?

Mental State Examination

▪Appearance: dress, hygiene…

▪Sensorium: orientation, memory, LOC…

▪Speech: fast, slow, slur

▪Emotion: mood and affect

▪Thought: process, content, delusion

▪Perception: hallucination, illusion

▪Attitude = rapport, insight

Further observations

▪ He is around 40 years old.

▪ Dressed properly and clean.

▪ He is speaking fast, talking to air at times.

▪ Elated and attempted to PU in front of you.

▪ Afebrile, vital signs all normal.

▪ Physical exam incomplete since patient is not cooperative

▪ Any stat investigation?

H’stix = 5 mmol/L

Any suggestions to the cause of his behaviour ?

Ddx

▪Alcohol or drugs

▪endocrine e.g. hyperthyroidism

▪ infections esp of CNS

▪trauma

▪psychiatric e.g. mania

▪post-ictal

How would you differentiate organic / functional causes in general ?

HistoryPhysical exam

MSELab investigations

History

▪Course : first episode >> organic

▪Onset : sudden >> organic

▪Past hx : medical / psychiatric

▪Drugs

P/E

▪Age > 40 yr >>> organic

▪abnormal vital signs, including conscious level

▪ focal neurological signs / symptoms

MSE

▪ Organic

▪ labile mood

▪ visual , somatic, olfactory hallucinations

▪ recent memory impaired

▪ disoriented

▪ attends occasionally

▪ Fluctuating conscious state

Functional

▪blunted affect

▪auditory hallucination

▪remote memory impaired

▪oriented

▪unable to attend

▪Stable conscious state

He is becoming more and more elated and starts to disturb others.

What is your approach to control him ?

Approach

▪Ensure your own safety first

▪attempt to talk down patient, though this is usually not effective

▪consider restraint, physical or chemical or both

What drugs would you use for chemical restraint ?

Drugs

▪ Neuroleptic :

▪ drug of choice > haloperidol IMI

▪ Benzodiazepine :

▪ drug of choice : lorazepam or midazolam IMI / IVI

How would you perform physical restraint?

▪Who?

▪When?

▪How?

Physical restraint

▪ Team approach

▪ 5 persons with one act as leader

▪ Leader: head and trunk

▪ Each will hold one limb

▪ Documentation + monitoring essential

How may a patient die in restraint?

aspiration

Remember to document

▪ The reason to restrain

▪ Time of application and the intended duration

▪ Expected time of review

▪ Type of restraint device

▪ Discussion/explanation with patient and/or family members

▪ Regular monitor of vital signs, state of circulation

Complications of physical restraint

▪Bruises and Abrasions

▪Circulatory compromise

▪ Immobilization cause pressure sores, paresthesias

▪Aspiration

▪Suffocation especially in the prone position

▪Protracted struggling vs restraint cause hyperthermia, lactic acidosis, rhabdomyolysis

While the nurses attempt to restrain him, he develops a generalized seizure which lasts for 30 sec..

Apart from the standard emergency tx of seizure, any Ix would you consider in the A&E setting ?

Urgent Ix

▪Repeat Glucose

▪electrolytes

▪ABG

▪drug profile

▪CBP, LRFT, TFT, culture

▪ECG

▪CT brain (plain)

He is admitted and CT brain shows a frontal lobe tumor .

On review, his behavior is due to disinhibition caused by the tumor.

You should be aware :

▪ Abnormal behavior is not equivalent to psychiatric illness.

▪ Psychiatric illness is in fact a dx of exclusion in ED.

▪ Physcial exam is often incomplete since patient is not cooperative.

▪ High risk factors for organic causes :▪ the young and old▪ first episode▪ acute onset▪ abn. vital signs incl. Altered consciousness

Reference

▪HAHO guideline for the use of physical restraint (2008)

▪Physical and Chemical Restraints. Emerg Med Clin N Am 27(2009) 655-667

The end