The acutely disturbed patient

Question 1

Approach to management

Answer 1

React calmly.

Try to control the disturbed patient gently.

Ensure the safety of all staff.

An adequate number of staff to accompany the doctor is essential —six is ideal

• one for immobilisation of each limb
• one for the head and
• one to assist with drugs

Benzodiazepines usually the drug of first choice for tranquillisation.

• Oral preferred if possible but parenteral most practical.

Question 2

Treatment options (if appropriate), Oral:

Answer 2

diazepam 5–20 mg (o), rpt 2–6 hrly

• or lorazepam 1–2 mg (o), rpt 2–6 hrly;

add olanzapine 5–10 mg

• or risperidone 0.5–1 mg if nec.

Question 3

Treatment options (if appropriate), Parenteral:

Answer 3

diazepam or midazolam 2.5–5 mg increments IV:

• repeated every 3–4 mins
• until required level of sedation reached (max 20–30 mg)

or if IM route best:

–droperidol (Droleptan) 5–10 mg IM (probably best) or

–olanzapine 5–10 mg (o) up to 30 mg/d

• watch for possible laryngeal dystonia
• and treat with benztropine 2 mg IM) or

–midazolam (Hypnovel) 2.5–10 mg IM as single dose

Then search for the cause and/or refer accordingly