Acute agitation in the emergency department: least restrictive care, rapid tranquillisation and the law
A 34-year-old man is brought to the emergency department of a divisional railway hospital by the Railway Protection Force at 23:40. He is shouting, pacing, and has pushed over a dressing trolley; he says "they are poisoning the water supply". He will not sit or answer questions coherently. Temperature 37.9 °C, pulse 118/min, BP 138/86 mmHg, SpO2 97% on room air, random blood glucose 104 mg/dL, pupils equal and reactive, no scalp injury or focal weakness. There are no needle marks, though his breath smells of alcohol, which he denies. His brother says he stopped risperidone 10 days ago and has not slept for three nights. On duty are two nurses, one security guard and a doctor who is 15 minutes away. The department has a quiet side-room but no staff to provide continuous one-to-one observation there, and the general ward beds are full.
1. Set out, in order, the assessment and non-pharmacological steps you would take before any sedation is considered, and name the medical causes you must exclude with reasons.
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Order: staff safety, then medical assessment, then de-escalation, then - only if these fail - medication.
- Make the environment safe: move other patients and relatives away, remove the trolley, scissors, hot drinks and anything throwable, keep a clear exit route for staff, and call the security guard and the on-call doctor. Never assess an agitated patient alone in a closed room; at least four trained staff are needed before any hands-on intervention.
- Exclude a medical cause before labelling this as functional psychosis. The brother's history of stopped risperidone is suggestive, but the following must be ruled out: hypoglycaemia (already 104 mg/dL), hypoxia, head injury or intracranial bleed, meningitis or encephalitis (temperature, neck stiffness, rash), alcohol or benzodiazepine withdrawal, anticholinergic or stimulant toxicity, thyrotoxicosis, and delirium from infection or metabolic derangement. Request a repeat glucose, temperature, neurological observation, urine drug screen and basic biochemistry.
- Verbally de-escalate: one staff member speaks, slowly and calmly; use his name; acknowledge his fear without agreeing with the delusion; offer simple choices (sit here or there, water or tea); keep distance, avoid touching him, and avoid confrontation or crowding.
- Reduce stimulation: move him to the quiet side-room with the door open and a staff member present, dim the lights, and offer oral medication and fluids.
- Document observations, behaviour and every intervention, and hand over to the doctor for a capacity assessment.
2. De-escalation fails and the doctor authorises parenteral sedation. What would you expect to be prescribed, what would you question, and how would you monitor?
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Expected order: rapid tranquillisation with an intramuscular antipsychotic, with or without a benzodiazepine - commonly haloperidol 5 mg with promethazine 25–50 mg, or lorazepam 2 mg IM - given into the deltoid or gluteal muscle, by trained staff, with resuscitation equipment, oxygen and suction immediately available.
What I would question:
- IM olanzapine given together with a parenteral benzodiazepine. The combination causes excessive sedation, hypotension, bradycardia and respiratory depression and is a recognised cause of collapse.
- A benzodiazepine alone in an undifferentiated patient who may have taken alcohol or another sedative, because of additive respiratory depression.
- Any instruction to sedate and leave him unobserved, or to use restraint as a substitute for observation.
- Repeated doses given too soon before the first dose has had time to act - this is a common route to over-sedation.
Monitoring: continuous pulse oximetry; pulse, BP, respiratory rate, temperature and conscious level every 15 minutes for the first hour and every 30 minutes thereafter until he is fully alert. Watch for acute dystonia (treat with promethazine or an anticholinergic), for akathisia, and for neuroleptic malignant syndrome - fever, rigidity, fluctuating consciousness and raised creatine kinase. Record everything, because the record is what shows the least restrictive option was genuinely tried first.
3. He refuses examination and says he wants to leave. Discuss capacity, restraint and your duties under the Mental Healthcare Act 2017 and professional conduct regulations.
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Refusal in an emergency: first judge whether he can understand the information, retain it, weigh it and communicate a choice. Agitation is not the same as incapacity, and a diagnosis of mental illness does not by itself remove a person's right to refuse treatment. If he lacks capacity and there is immediate risk to himself or others, the doctor may treat him in his best interests, using the least restrictive option, and this must be documented with the reasons.
Under the Mental Healthcare Act 2017: every person has the right to make an advance directive, to nominate a representative, to give informed consent, to confidentiality and dignity, and to treatment with the least restrictive option; seclusion is prohibited. Physical restraint may be used only when it is the least restrictive option and only with the authorisation of a psychiatrist, for a defined period, with the reasons recorded and continuous monitoring - never as punishment or for staff convenience.
Your duties: explain in simple language, involve the nominated representative or brother, protect privacy and dignity, keep a contemporaneous record of every intervention and observation, report any restraint to the psychiatrist and nursing supervisor, and escalate if the setting cannot nurse him safely. A general emergency department with two nurses and no continuous observation is the wrong place for an acutely psychotic, potentially absconding patient; a psychiatric unit or a medical bed with a dedicated sitter is the safer and more lawful plan.