The Acutely Disturbed Patient

Introduction

The acutely disturbed patient presents in an excited, agitated or aggressive state.
There may be delusions and perceptual changes like hallucinations that overwhelm the patient.
Disorientation and alteration in consciousness are often prominent when the cause is organic.
The patients are usually brought in restrained by more than one person or by the police.
The condition must be regarded as an emergency since a few cases are potentially fatal.

Causes of acutely disturbed patient

Acute (Functional) Psychiatric Disorders

  1. Mania or hypomania
  2. Schizophrenia and like states
  3. Other psychotic disorders
  4. Agitated depression
  5. Acute psychosis

Acute (Organic) Psychiatric Disorders

  1. Toxic psychosis secondary to drug intoxication (amphetamines, cocaine, marijuana, heroin etc.)
  2. Abnormal reaction to alcoholic intoxication
  3. Acute Alcoholic Withdrawal Syndrome (delirium tremens)
  4. Infective causes e.g. typhoid, malaria, meningitis, HIV, encephalitis, hepatitis

Acute Metabolic Disorders

  1. Hypoglycaemia
  2. Thyroid disease
  3. Porphyria

Others

  1. Head trauma
  2. Subdural hematoma

Symptoms of acutely disturbed patient

(See relevant conditions for symptoms of specific disorders)

  1. Sleeplessness
  2. Restlessness – agitated or even combative patient
  3. Talking excessively and loudly, or low toned, reduced speech, even mute in some cases
  4.  Disinhibited behaviour or speech
  5. Hearing or seeing “imaginary” people or objects.
  6. Expression of fear, undue suspicion, inappropriate guilt or bizarre beliefs
  7.  Destructiveness

 

Signs of acutely disturbed patient

(See relevant conditions for signs of specific disorders)

  1. Elated, irritable, angry or depressed mood
  2. Physical aggression, agitation or restlessness
  3. Lack of insight
  4. Pressured or retarded speech
  5. Hyperactivity or reduced motor activity
  6. Disinhibition -social and sexual of
  7. Delusions of grandeur, guilt or paranoia
  8. Auditory hallucinations
  9. Visual hallucinations (especially in toxic, infectious and withdrawal states)
  10. Fever (infective conditions)
  11. Drowsiness, altered consciousness (mainly in alcohol withdrawal)
  12. Disorientation and confusion (mainly in alcohol withdrawal)
  13. Sweating
  14. Tremors (mainly in alcohol withdrawal)

Investigations

Usually none

  • Urine screen (for substances like amphetamines, cocaine, heroin, cannabis)
  • FBC,
  • Rapid Diagnostic Test for malaria parasites (when there is fever and suspected infections)
  • Random Blood Sugar
  • Blood culture

Treatment for acutely disturbed patient

Objectives

The treatment objectives of acutely disturbed patient include the following

  1. Rapid tranquilisation – to calm down the patient as quickly as possible using the safest drugs available without necessarily inducing sleep
  2. To treat underlying cause

Non-pharmacological treatment

  1. Restrain patient when necessary without causing injuries
  2. Talk to the patient in a firm but reassuring manner
  3. Avoid long periods of silence especially in paranoid patients
  4. Remove and store away any offensive weapons on or around patient.

Pharmacological treatment

Evidence Rating: [C]
Lorazepam, IV/IM,
Adults: 2-4 mg stat. Repeated once after 10 minutes if necessary.
Children

  • > 12 years; 500 microgram – 2 mg (max. 4 mg)
  • < 12 years; 500 microgram – 1 mg (max. 2 mg)

Or

Haloperidol, IM,
Adults: 2-5 mg stat. may repeat in 4-8 hours (max. 20 mg per day)
Children

  • 13-18 years; 2-5 mg 4-8 hourly as required
  • 6-12 years; 1-3 mg 4-8 hourly as required (max. 0.15)
  • <5 years; Not recommended

Note

Patient should be switched to oral as soon as possible

Then

Haloperidol, oral,
Adults: 3-5 mg 8-12 hourly (max. 30 mg per day)
Children

  • > 12 years; 3-5 mg 8-12 hourly as required (max. 30 mg per day)
  • 3-12 years (15-40 kg); 0.25-0.5 mg per day (max. 0.5 mg per day)
  • <3 years; Not recommended

Or

Chlorpromazine, IM, (for very agitated patients)
Adults: 50-150 mg stat. repeated after 30-40 minutes if necessary
Children:

  • 12-18 years; 25-50 mg 6-8 hourly
  • 6-12 years; 500 microgram/kg 6-8 hourly (max. 75 mg per day)
  • 1-6 years; 500 microgram/kg 6-8 hourly (max. 40 mg per day)

Note

Never give chlorpromazine intravenously!
It may lead to severe hypotension.

Or

Olanzapine, IM,
Adults: 10-20 mg stat. subsequent doses of 10 mg may be given 2 hours after initial dose, if necessary and 4 hours after 2nd dose (max. 30 mg per day)
Children: Not recommended

Or

Chloral hydrate, oral or rectal,
Adults: 500 mg-1g
Children:

  • 12-18 years; 500 mg-1 g
  • 1 month-12 years; 30-50 mg/kg (max. 1g)
  • Neonate; 30-50 mg/kg

Or

Diazepam, IV,
Adults: 10 mg slowly over 2-3 minutes (approximately 2.5 mg every 30 seconds)
Children: 200-300 microgram/kg slowly over 2-3 minutes.
This may be repeated after 10 minutes if necessary (max 10 mg)

Or

Diazepam, rectal,
Children

  • > 12 years; 0.2 mg/kg
  • 6-12 years; 0.3 mg/kg
  • 2-6 years; 0.5 mg/kg
  • 1 month-2 years; 2.5 mg
  • Neonates; 1.25-2.5 mg .

This may be repeated after 10 minutes (max 10 mg)
Note

If a rectal formulation is not immediately available, draw up the injectable form directly into a syringe and administer it into the rectum (after removing the needle).
Diazepam IV must be administered with care if the cause of the acute disturbance is thought to be organic.

Referral Criteria

Refer all acutely disturbed patients to a specialist.