Acute agitation with hyperthermia in the emergency department
A 28-year-old man is brought to the emergency department of a tertiary hospital in Muscat at 02:00 by Royal Oman Police, who found him running barefoot along the carriageway shouting at passing cars. He carries no identification and no family member accompanies him. On arrival he is diaphoretic, incoherent and repeatedly tries to climb off the trolley; he spits and attempts to bite staff. Vital signs: pulse 152/min, BP 168/98 mmHg, respiratory rate 28/min, oxygen saturation 96% on air, rectal temperature 39.2 °C. He has generalised muscle rigidity and dilated pupils, and a small twist of white powder is found in his pocket. He will not answer questions and cannot give a history. There is no previous record in the hospital system. Two security staff are available; the department is simultaneously managing casualties from a road traffic collision.
1. Outline your assessment and investigation in the first 30 minutes, naming the conditions you must exclude and the specific findings that would change your management.
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Assessment runs in parallel with resuscitation: airway, breathing, circulation, IV access, point-of-care glucose, continuous cardiac and oxygen saturation monitoring, core temperature and a full set of observations, with adequate staff and a clear exit route. Sedation should not be delayed to complete history-taking.
Investigations: venous blood gas, urea and electrolytes, creatinine, creatine kinase, liver function, glucose, calcium, paracetamol and salicylate levels, alcohol, urine drug immunoassay, ECG, chest radiograph and urinalysis. CT head if there is focal neurology, a witnessed head injury, or no improvement once agitation is controlled; lumbar puncture if meningism or fever without another source.
Differential and discriminating features:
- Stimulant intoxication (cocaine, amphetamine): mydriasis, sweating, hyperthermia, rigidity, tachycardia - the leading possibility here.
- Serotonin syndrome: clonus and hyperreflexia dominate; there is no serotonergic history here.
- Neuroleptic malignant syndrome: lead-pipe rigidity, very high CK, recent antipsychotic; less acute and sweating is less prominent.
- Anticholinergic toxicity: dry skin, urinary retention, normal temperature.
- Also hypoglycaemia, sepsis or meningoencephalitis, thyrotoxicosis, head injury, alcohol withdrawal.
Findings that change management: temperature above 40 °C, CK above 5000 U/L, acidosis, hyperkalaemia or renal failure mandate intensive care and aggressive cooling; hypoglycaemia requires immediate dextrose; focal signs require imaging before any assumption of a primary psychiatric cause.
2. Describe your approach to behavioural control, including drug choice, route, dose, monitoring and combinations you would avoid, and justify each choice.
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Start with de-escalation: reduce noise and stimulation, one speaker, short simple sentences, offer oral medication and fluids, keep a visible but non-threatening staff presence. If there is an immediate risk of harm to himself or others, move to rapid tranquillisation with a planned team, not an improvised struggle.
First line is a benzodiazepine, because the presumed pathophysiology is stimulant-driven hyperadrenergic excess and benzodiazepines lower temperature, heart rate and seizure risk. Options: lorazepam 2 mg or midazolam 5 mg intramuscularly, or diazepam 10 mg rectally if no IV access; reassess after 5–10 minutes and repeat once if needed.
If an antipsychotic is required, use it alone: olanzapine 10 mg IM, or haloperidol 5 mg IM with promethazine 25–50 mg for sedation, with ECG monitoring because of QT risk and extrapyramidal effects. Avoid combining IM olanzapine with parenteral benzodiazepines, which causes excessive sedation and cardiorespiratory depression, and avoid antipsychotics as first-line monotherapy in hyperthermic stimulant toxicity because they impair heat dissipation and lower the seizure threshold.
Physical restraint is a last resort: trained team, prone position avoided, continuous observation of airway and vital signs, time-limited, released as soon as safe, with sedation score, temperature, glucose and oxygen saturation documented at intervals.
3. He cannot consent to treatment. Set out the legal and ethical basis on which you would proceed and what you would document.
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The starting position is that an adult is presumed to have capacity, but this man's agitation and delirium mean he cannot understand, retain, weigh or communicate a decision about treatment. Treatment is therefore justified under the emergency or necessity principle: it is immediately necessary to prevent serious harm and is limited to what is proportionate and least restrictive.
In Oman, emergency treatment and short-term detention of a person with a suspected mental disorder are governed by the Mental Health Law and by hospital policy; because intoxication or a medical cause may be responsible, the initial footing is medical necessity rather than formal psychiatric detention. Request an urgent psychiatric opinion and a second medical opinion as soon as the patient is safe, and involve the police officer who brought him for identification and next-of-kin tracing.
Document contemporaneously: the mental state findings supporting lack of capacity, the specific risks, each intervention with time, dose and route, who authorised it, the duration of any restraint, monitoring parameters, efforts to use less restrictive measures, and the review plan. Inform the family once identified, respect confidentiality by sharing only what is necessary, and record that the patient will be reassessed for capacity when he is lucid. If he remains psychotic after the toxic cause resolves, formal assessment under the Mental Health Law with the required second opinion and notification to the responsible body should follow.