- 1 Introduction
- 2 Causes of acutely disturbed patient
- 3 Acute (Functional) Psychiatric Disorders
- 4 Acute (Organic) Psychiatric Disorders
- 5 Acute Metabolic Disorders
- 6 Others
- 7 Symptoms of acutely disturbed patient
- 8 Signs of acutely disturbed patient
- 9 Investigations
- 10 Treatment for acutely disturbed patient
- 11 Objectives
- 12 Non-pharmacological treatment
- 13 Pharmacological treatment
- 14 Referral Criteria
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
- Mania or hypomania
- Schizophrenia and like states
- Other psychotic disorders
- Agitated depression
- Acute psychosis
Acute (Organic) Psychiatric Disorders
- Toxic psychosis secondary to drug intoxication (amphetamines, cocaine, marijuana, heroin etc.)
- Abnormal reaction to alcoholic intoxication
- Acute Alcoholic Withdrawal Syndrome (delirium tremens)
- Infective causes e.g. typhoid, malaria, meningitis, HIV, encephalitis, hepatitis
Acute Metabolic Disorders
- Thyroid disease
- Head trauma
- Subdural hematoma
Symptoms of acutely disturbed patient
(See relevant conditions for symptoms of specific disorders)
- Restlessness – agitated or even combative patient
- Talking excessively and loudly, or low toned, reduced speech, even mute in some cases
- Disinhibited behaviour or speech
- Hearing or seeing “imaginary” people or objects.
- Expression of fear, undue suspicion, inappropriate guilt or bizarre beliefs
Signs of acutely disturbed patient
(See relevant conditions for signs of specific disorders)
- Elated, irritable, angry or depressed mood
- Physical aggression, agitation or restlessness
- Lack of insight
- Pressured or retarded speech
- Hyperactivity or reduced motor activity
- Disinhibition -social and sexual of
- Delusions of grandeur, guilt or paranoia
- Auditory hallucinations
- Visual hallucinations (especially in toxic, infectious and withdrawal states)
- Fever (infective conditions)
- Drowsiness, altered consciousness (mainly in alcohol withdrawal)
- Disorientation and confusion (mainly in alcohol withdrawal)
- Tremors (mainly in alcohol withdrawal)
- Urine screen (for substances like amphetamines, cocaine, heroin, cannabis)
- Rapid Diagnostic Test for malaria parasites (when there is fever and suspected infections)
- Random Blood Sugar
- Blood culture
Treatment for acutely disturbed patient
The treatment objectives of acutely disturbed patient include the following
- Rapid tranquilisation – to calm down the patient as quickly as possible using the safest drugs available without necessarily inducing sleep
- To treat underlying cause
- Restrain patient when necessary without causing injuries
- Talk to the patient in a firm but reassuring manner
- Avoid long periods of silence especially in paranoid patients
- Remove and store away any offensive weapons on or around patient.
Evidence Rating: [C]
Adults: 2-4 mg stat. Repeated once after 10 minutes if necessary.
- > 12 years; 500 microgram – 2 mg (max. 4 mg)
- < 12 years; 500 microgram – 1 mg (max. 2 mg)
Adults: 2-5 mg stat. may repeat in 4-8 hours (max. 20 mg per day)
- 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
Patient should be switched to oral as soon as possible
Adults: 3-5 mg 8-12 hourly (max. 30 mg per day)
- > 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
Chlorpromazine, IM, (for very agitated patients)
Adults: 50-150 mg stat. repeated after 30-40 minutes if necessary
- 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)
Never give chlorpromazine intravenously!
It may lead to severe hypotension.
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
Chloral hydrate, oral or rectal,
Adults: 500 mg-1g
- 12-18 years; 500 mg-1 g
- 1 month-12 years; 30-50 mg/kg (max. 1g)
- Neonate; 30-50 mg/kg
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)
- > 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)
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.
Refer all acutely disturbed patients to a specialist.