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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