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Managing a Patient with Abnormal Behaviour: Clinical Approach and Treatment Strategies

Learn how to approach a patient exhibiting abnormal behavior in an emergency setting, differentiate organic vs. functional causes, perform mental status exams, manage restraint effectively, and consider underlying medical conditions. Understand the importance of thorough assessment and intervention in cases of abnormal behavior. Developed by Dr. LP Leung and revised by Dr. Li Yu Kwan in October 2013.

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Managing a Patient with Abnormal Behaviour: Clinical Approach and Treatment Strategies

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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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