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A patient with abnormal behaviour

HKCEM College Tutorial. A patient with abnormal behaviour. 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

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A patient with abnormal behaviour

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  1. HKCEM College Tutorial A patient with abnormal behaviour Author Dr. LP Leungrevised by Dr. Li Yu Kwan Oct., 2013

  2. 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)

  3. What are your aims of managing this patient ?

  4. 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

  5. What are the possible treatable medical causes ?

  6. Treatable medical causes • Drug effect • Metabolic disorders • Endocrine causes • Nutritional causes • Trauma and tumor • Infection • Atherosclerotic complications

  7. How would you perform mental status exam?

  8. 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

  9. 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

  10. Any suggestions to the cause of his behaviour ?

  11. Ddx • Alcohol or drugs • endocrine e.g. hyperthyroidism • infections esp of CNS • trauma • psychiatric e.g. mania • post-ictal

  12. How would you differentiate organic / functional causes in general ? History Physical exam MSE Lab investigations

  13. History • Course : first episode >> organic • Onset : sudden >> organic • Past hx : medical / psychiatric • Drugs

  14. P/E • Age > 40 yr >>> organic • abnormal vital signs, including conscious level • focal neurological signs / symptoms

  15. 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

  16. He is becoming more and more elated and starts to disturb others.What is your approach to control him ?

  17. Approach • Ensure your own safety first • attempt to talk down patient, though this is usually not effective • consider restraint, physical or chemical or both

  18. What drugs would you use for chemical restraint ?

  19. Drugs • Neuroleptic : • drug of choice > haloperidol IMI • Benzodiazepine : • drug of choice : lorazepam or midazolam IMI / IVI

  20. How would you perform physical restraint? • Who? • When? • How?

  21. aspiration 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?

  22. 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

  23. 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

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

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

  26. Urgent Ix • Repeat Glucose • electrolytes • ABG • drug profile • CBP, LRFT, TFT, culture • ECG • CT brain (plain)

  27. He is admitted and CT brain shows a frontal lobe tumor .On review, his behavior is due to disinhibition caused by the tumor.

  28. 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

  29. Reference • HAHO guideline for the use of physical restraint (2008) • Physical and Chemical Restraints. Emerg Med Clin N Am 27(2009) 655-667

  30. The end

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