Acute Agitation and Psychosis with Limited Resources
At 19:00, a 30-year-old man is brought to a health center by his brother. He has not slept for three days, is shouting that neighbors are poisoning him, and has torn his shirt. His family tied his wrists with rope after he broke a window. He is sweating, but his temperature is 37.2°C, pulse 104/min, and random blood glucose is 5.4 mmol/L. There is no history of head injury, seizures, or known substance use, and he has never been seen at the health center. He refuses to sit and threatens to hit staff. The health center has oral diazepam, injectable diazepam 10 mg, injectable haloperidol 5 mg, and a quiet immunization room. There is no psychiatrist; the referral hospital is two hours away.
1. Describe your de-escalation and safety plan before giving any medicine.
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First ensure safety for the patient, staff and other patients. Clear the area, remove dangerous objects, and have a second staff member present. Ask the family to loosen the rope carefully and explain that restraint is causing pain and fear; do not remove it abruptly if he is still violent. Use one calm speaker, short sentences, a low voice and open body posture. Offer food, water and a quiet place to sit. Do not argue with the belief that neighbors are poisoning him; say, "You are safe here and we want to help you feel calmer." Check vital signs, glucose, hydration, temperature and any wounds. His glucose is normal and temperature is not raised, but ask about drugs, alcohol withdrawal, recent head injury and medication. These help distinguish psychosis from delirium. Keep the immunization room quiet and dim. If he remains threatening, call for additional help and plan a controlled physical intervention only as a last resort, with enough trained people to avoid injury. Document what was tried before medication.
2. If medication is needed for severe agitation, what would you choose and what must you monitor?
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Because he is severely agitated and threatening staff, urgent sedation may be needed to allow assessment and safe transfer. A reasonable choice is haloperidol 5 mg IM, or diazepam 10 mg IM if psychosis is less clear and extreme arousal is the main problem. Avoid combining both unless a doctor directs it, because the combination can cause excessive sedation and respiratory depression. Haloperidol can cause acute dystonia, so monitor for neck stiffness, tongue protrusion or eye rolling and have an anticholinergic available if stocked. Avoid haloperidol if there is suspected stimulant intoxication, head injury or severe dehydration until reviewed. After injection, place him in a safe, observed area and monitor BP, pulse, respiratory rate, sedation level and temperature every 15 minutes until stable. Do not leave him alone. Continue to investigate causes such as infection, hypoglycemia, withdrawal or head injury. Because there is no psychiatrist, arrange transfer once he is calm enough; sedation is not a substitute for diagnosis and definitive care.
3. What are the consent, legal and referral issues in this situation?
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Seek the patient's consent for examination and treatment whenever possible. If his agitation makes him unable to decide, involve his brother and follow national mental health policy and facility protocol for emergency treatment. Use the least restrictive option and the shortest necessary sedation. Physical restraint must be supervised, released regularly, and documented; it is not a punishment and must never be used because the family or staff are angry. Document the reasons for emergency treatment, the risks explained, the medicines and doses, monitoring, and the family's involvement. Protect confidentiality and avoid discussing his beliefs in public. Arrange referral to the provincial hospital for psychiatric assessment, medical review and social support; confirm transport and an escort. Give the family clear instructions not to tie him again and to return if he becomes drowsy, feverish, unable to drink or more confused. Report the case according to local regulations and follow up after discharge.