2 x 20+ y.o. males transferred from rural ED 30 miles away.

Brought to Rural ED by ‘friends’ who had recently ejected Mr X and Mr Y from a party 30 minutes before. They were ejected from party because of uncontrolled destructive behaviour – broke furniture, assaulted partygoers. Largely incoherent but complained that TV was disturbing them in some way – jumped on TV.

Reported to have consumed alcohol +++. Friends suggested they may have consumed other recreational drugs including several possibilities: Datura tea, Benztropine, Chlorpromazine.
No amphetamines, cocaine or opioids as far as known by friends.
Both usually in good health, neither works, both have extensive alcohol and other recreational drug experience. No IV drug use known.

At the Rural ED: Loud but difficult to understand (dysarthria), assaulted staff, trashed the ED furniture and fittings.

Tried to leave the ED

Tackled by staff, physically restrained with wrist and ankle manacles. Each was given IMI Midazolam 15mg. Placed in ambulance with nursing escort. Whilst in transit to your Metropolitan ED Rural Ed staff notify of transfer. ETA 0100 Saturday.

Similar examination findings on both patients. Still restrained.
Dehydrated – 5%
Dysarthric +++
Hostile combative, making strenuous efforts to leave the ED
Easily startled, hypervigilant, over-responsive to all external stimuli.
Cognitively impaired – severe, global (limited exam)
Afebrile PR 105 BP 138/105
Chest clear. HS dual Abdomen soft
Flushed, Dilated pupils – reactive to light. Dry axillae. No bowel sounds
ECG sinus tachycardia QRS 90 msec
FBC NAD. Elec /Ur NAD. Breath alcohol 0.09 on one and the other non-compliant.
O2 sats on both > 97%

• 1. Diagnostic thoughts?
• 2. Suggested initial ED management goals?

ED staff decide to keep restraints on. 2nd hourly observations T/P/BP/UO.
No additional sedation given.

At 0600 friends come to visit. Friends ask the nurse (at change of shift) if they can visit, which is allowed. At the urging of Mr X the friends “loosen” the wrist manacles of Mr X and Mr Y…both immediately extricate themselves fully, push friends aside, attempt in a disorganised way to leave the ED and renew the physical assaults on the friends and staff trying to prevent them leaving.
Security is summoned and in addition to the ED nurses, doctors and “friends” another 4 bodies are added; 2 security and 2 wardsmen. An ambulance pulls into the ambulance bay with a suspected AMI/Pulmonary oedema case.

You arrive for your Sunday 12 hour shift at the ED as ED Physician / Director.

• 3. What are your suggested management goals…prioritise these?

You decide that sedation of these two patients is a management priority.
Acute sedation of the hostile aggressive delirious patient who cannot be safely contained by interpersonal strategies and requires physical restraint.

• 1. What is the desired endpoint of acute sedation?
• 2. Which drug will you choose?
• 3. Choose route of administration
• 4. Choose dose
• 5. What other equipment and services do you need before you attempt to administer your chosen drug to the hostile, combative dangerous patient?
• 6. After your endpoint has been achieved…what are the observation requirements from nursing staff you require…what is the need and timing for medical review?
• 7. Why may you need to repeat the whole exercise after 20-40 minutes?
• 8. What do you think about the likelihood of needing a maintenance dose of sedating medications in the medium term?
• 9. What drug, dose and route of administration will you choose?
• 10. What are the non-pharmacological strategies, which need to be put into place once the patient is safely controlled?