House party

Question 1

A 21 year old male is brought to the ED by police after breaking up a house party. He is aggressive and disoriented. How would you assess and manage him?

Answer 1

Impression
With aggression and disorientation in young male patient from house party, mostly concerned about intoxication/substance use as an explanation for his acute condition.

DDx to consider

• alcohol vs other stimulant/depressant substances, potentially a combination of substances
• psychiatric: drug induced psychosis, other primary psychotic disorder (schizophrenia, etc)
• Drug withdrawal (altho may not fit with timeline)

Goals of Mx

• ensure safety of patient and staff by using appropriate security staff, keep patient in low-stimulus quiet room, remove anything that can be used as a weapon
• implement verbal de-escalation tactics before progressing to chemical sedation if necessary before conducting assessment of patient to determine likely cause of presentation with Hx/Ex/Ix

Question 2

Acute aggression - Approach

Answer 2

Approach

• verbal de-escalation: calm voice, don’t antagonise, keep safe distance, address concerns, offer food/drink, set ground rules
• chemical sedation: benzo’s or anti-psychotic (quetiapine, droperidol/haloperidol); ideally get patient to take PO
• safety measures: security it door, duress alarms, keep distance, keep patient in quiet and soft room,

Question 3

Acute aggression - History

Answer 3

History

• full history from patient and substances taken, quantities etc, collateral from police
• understand reasons for aggression, any underlying medical conditions/injuries
• D&A history: in acute setting and in the past
• risk assessment: risk of harm to self and others
• Psych: delusions, hallucinations, thought disorder, past psych history

Question 4

Acute aggression - Examination

Answer 4

Examination
Only to be conducted if safe and patient is agreeable;
- Vitals
- MSE (including general appearance)
- Neuro examination: pupils

Question 5

Acute aggression - Investigations

Answer 5

Investigations

• Bedside: urine drug screen, VBG, BSL
• Bloods: LFT for chronic alcohol use, UEC
• Imaging: consider CT Brain if ?head injury, or considering intracranial cause of presentation.

Otherwise, if first presentation psychosis then conduct complete workup including additional bloods.

Question 6

Acute aggression - Management

Answer 6

Management

• ongoing risk assessments
• psych referral if has features of psych illness
• manage any underlying causes
• likely discharge once calmed down if no underlying medical illnesses