Last updated on 02 Nov 2022 at 10:46 AM (ED04)

Agitated and combative patient
A 68 year old NZ European man, with no fixed abode, presents under police escort to the Emergency Department agitated and aggressive. He has presented on previous occasions as intoxicated on alcohol, sedated and non-confrontational. He has also sometimes presented with physical symptoms that can’t be medically explained with the hope of acquiring an overnight stay in hospital. However, on this presentation he has threatened to punch you and the nursing staff when you discussed the need for him to stay in the Emergency Department for further investigations.

 

Applied Science for Medicine
Anatomy of the brain
Pathophysiology of delirium and dementia
Microbiology of herpes simplex virus
Role of drug intoxication and withdrawal in altered mental states
Awareness of nutritional deficiencies and how this may compound certain presentations e.g. delirium tremens
Pharmacology of haloperidol, olanzapine, rispiridone, benzodiazepines

Clinical and Communication Skills
History from an agitated patient; elicit a collateral history; assess risk factors for delirium
Perform a general examination, as complete as is possible; recognise drug withdrawal and intoxication
Differential diagnosis of the aggressive patient, delirium
Indications for CT head, MRI brain, lumbar puncture
Perform capillary glucose level, measurement of blood pressure, lumbar puncture
Interpret full blood count, electrolytes, liver function tests, blood glucose level, calcium, thyroid function tests, vitamin B12/ B12 (NZF link) folate, toxicology screen, pathology report on cerebrospinal fluid (CSF), chest X-ray, syphilis serology, short synthacen test
Management of the challenging patient: pharmacological and non-pharmacological
Awareness of high mortality rates with delirium tremens and the medical treatments required for this
Role of security staff, levels of observation and de-escalation measures
Role of liaison psychiatry, social worker, nurse
Understand how medically unexplained physical symptoms can present

Personal and Professional Skills
Deescalating an aggressive situation
Self-care: personal safety
Decision-making capacity
Best interests principle
Assent and consent
Legal aspects of compulsory assessment and treatment, Mental Health Act, Right 7(4) of the Health and Disability Commissioner’s Code of Rights

Hauora Māori
Cultural safety in examining an agitated person
Access to cultural resources in an Emergency Department
Ethnic disparities in 'homelessness', mental disorder and alcohol/drug misuse

Population Health
Epidemiology of delirium/acute confusion state, schizophrenia, substance abuse, substance withdrawal, herpes simplex virus, meningitis
Homelessness: reasons, support programmes, discrimination

 

Conditions to be considered relating to this scenario

Common

subdural haemorrhage, psychosis of any cause, hypoglycaemia, hypoxia, hypo/hypernatraemia, urinary tract infection, hypercalcaemia, hypocalcaemia, concussion, vitamin B12/folate deficiency, hypothyroidism, delirium tremens, Wernicke's encephalopathy, acute coronary syndrome (STEMI, NSTEMI and unstable angina), intoxications, extradural haemorrhage

Less common but 'important not to miss'

cerebral tumour, tertiary syphilis, meningitis, encephalitis, subarachnoid haemorrhage

Uncommon

Whipple's disease, uraemic encephalopathy, hepatic encephalopathy, Addison's disease