Agitated Adolescent in the Emergency Department
Tomas, 16, is brought to the emergency department by police after he was found on a bridge railing at 02:00. He is pacing, shouting that 'everyone would be better off,' and has punched a wall, causing abrasions on his right hand. He smells of alcohol, and his speech is slurred but he is oriented to place and person. He denies hallucinations. He refuses to sit and says he will leave. His mother arrives and reports he has been withdrawn for weeks and stopped attending school. There is no medical history on file. The department is at capacity.
1. How do you balance immediate safety, legal authority, and therapeutic engagement in the first 30 minutes?
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Immediate safety: Tomas has expressed suicidal ideation and was found in a potentially lethal situation, and he is intoxicated and agitated. Safety comes first. Keep him in a visible, low-stimulus area with staff nearby; remove hazards; assign a consistent nurse. Do not physically restrain unless less restrictive measures fail and policy permits; use calm, short sentences, offer choices, and maintain distance.
Legal authority: A minor with suicidal ideation and intoxication requires emergency evaluation and likely an emergency hold under local mental health law, plus notification of a guardian. Confirm with the attending and document the basis. Do not let him leave before evaluation; if he attempts to leave, follow policy and involve security.
Therapeutic engagement: Acknowledge his distress without arguing: 'You're having a really hard night; I want to keep you safe while we figure this out.' Offer food, a blanket, and a quiet space. Avoid confrontation over his refusal to sit; negotiate small steps.
Assessment: Screen for medical causes of agitation (hypoglycemia, head injury, intoxication, withdrawal) and obtain vitals. Ask directly about suicide plan and means. Involve his mother as support with his assent where possible.
2. What assessment data and disposition plan should you gather and communicate to the psychiatric team?
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Assessment data to gather:
- Suicide risk: ideation, intent, plan, means, prior attempts, protective factors, and access to firearms or medications.
- Substance use: what and how much he drank, last use, withdrawal risk, and other drugs.
- Medical: vitals, glucose, hand injury assessment, neuro exam, and any signs of head trauma.
- Mental status: mood, affect, thought content, sleep, appetite, and school withdrawal.
- Social: family support, bullying, abuse, or stressors; mother's observations.
- Collateral from mother and any records.
Disposition planning: He is not safe for discharge home from the emergency department. Recommend inpatient psychiatric evaluation or crisis stabilization, with medical clearance for intoxication. Ensure 1:1 observation until transfer. Communicate a concise handoff: presenting event, statements, risk factors, medical findings, legal hold status, family contact, and interventions tried.
Follow-up: Provide the mother with crisis resources and a safety plan framework, and document all findings and decisions.