A patient with abnormal behaviour HKCEM College Tutorial Author Dr. LP Leung revised by Dr. Li Yu Kwan Oct., 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 ? History Physical exam MSE Lab 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)

The end