🚨 Acute Behavioural Disturbance
Overview
Acute Behavioural Disturbance (ABD) is a state of altered consciousness and/or behaviour that poses a risk to the patient, staff, or others. It requires rapid assessment to identify underlying causes and de-escalation or sedation to ensure safety and facilitate further management.
Recognition
Recognise ABD by sudden onset of agitation, aggression, confusion, paranoia, or violence. Patients may be disorientated, verbally abusive, physically threatening, or resisting care. Consider underlying causes such as hypoxia, hypoglycaemia, head injury, sepsis, drug intoxication/withdrawal, or acute psychosis.
Initial Assessment (ABCDE)
Prioritise safety for all. Perform an ABCDE assessment from a safe distance initially. Look for signs of trauma, track marks, or medical alert jewellery. Assess vital signs, GCS, and capillary blood glucose. Attempt verbal de-escalation. Gather collateral history from paramedics or family regarding baseline mental state and recent events.
Red Flags
Red flags include rapid deterioration in GCS, respiratory compromise, haemodynamic instability, seizures, signs of head injury, or severe hyperthermia. Any patient who is unresponsive to verbal de-escalation and poses an immediate threat requires urgent intervention.
Investigations
Bedside: Capillary blood glucose, vital signs, ECG. Bloods: FBC, U&Es, LFTs, CRP, ABG, toxicology screen (if drug involvement suspected). Imaging: CT head (if head injury suspected, new neurological deficit, or unexplained reduced GCS).
Immediate Management
Prioritise safety and de-escalation. If verbal de-escalation fails and there is an immediate risk, consider rapid tranquilisation with appropriate medication (e.g., benzodiazepines, antipsychotics). Ensure adequate staff presence and a clear escape route. Treat any immediately reversible causes identified (e.g., hypoglycaemia, hypoxia). Provide a safe, quiet environment once the patient is calm.
Escalation Triggers
Escalate to a senior registrar or consultant immediately for severe, unmanageable agitation, rapid deterioration in physiological parameters, or suspicion of a serious underlying medical cause. Involve mental health liaison teams for suspected primary psychiatric causes. Consider critical care referral if requiring high-dose sedation or advanced organ support.
MLA High-Yield Notes
Always consider and rule out organic causes before attributing ABD to a primary psychiatric condition. Hypoxia and hypoglycaemia are common, treatable causes. Rapid tranquilisation is a last resort to ensure safety. Documentation of de-escalation attempts and rationale for sedation is crucial. Safeguarding considerations are important.
References
- Royal College of Emergency Medicine (RCEM) Guidelines on Management of Acute Behavioural Disturbance
- NICE Guideline NG10: Violence and aggression: short-term management in mental health, health and community settings
- Resuscitation Council UK Guidelines