Acute behavioural emergencies

Acute behavioural problems can present in any unit in a general hospital. The first priority is to discover whether or not the patient is severely physically ill and suffering from delirium, in which case—apart from managing the behavioural disturbance—treatment clearly needs to be directed towards the primary cause.

General principles of management—all patients with behavioural disturbance need to be cared for in appropriate facilities: rooms should be well-lit, with an observation window and more than one outwardly opening door; furniture and fittings should not be usable as weapons; and there should be an easily accessible panic button. Staff need to remain calm and polite.

Medication—early intervention is desirable to bring disturbed behaviour under control as soon as possible if nondrug calming measures fail. Oral medication should be offered first, e.g. lorazepam 2 mg every 1 to 2 h (with higher dosing depending on response, maximum daily dose 20–40 mg). If this is refused, then the most rapidly effective and safest major tranquillizer is haloperidol, 5 to 10 mg every 1 h (maximum daily dose about 80 mg) given by intramuscular injection. Reduced doses should be used in older people, and patients should not be left unattended in the hours following rapid tranquillization: they require frequent assessment for conscious level, vital signs, and evidence of dystonia, with an antiparkinsonian drug such as procyclidine advisable prophylactically.