A 24-year-old man is brought to the emergency department by his friend due to disorientation and restlessness. His friend says, "He's gone crazy. I had a tough time bringing him in. He kept moving from side to side in the car, banging his body against the door. Then he started pushing me while I was driving. I almost ran off the road." The patient is well known from past emergency department admissions for similar behavior of agitation; he often becomes coherent in 7-8 hours. He is homeless and has a history of using multiple illicit substances. He was also hospitalized a month ago for opioid overdose with subsequent aspiration pneumonia. The patient has no other active medical illnesses except for injuries due to trauma while intoxicated. He does not have any other psychiatric disorders. Temperature is 37.2 C (99 F), blood pressure is 160/100 mm Hg, and heart rate is 120/min. He is not oriented to time and place but recalls his name and date of birth. Examination shows prominent nystagmus as well as multiple cuts and abrasions of the shoulders and extremities. The patient is restless and paces in his room. He then stops, sits down, stands up again, bangs his body against the wall, and yells, "They're pushing a rock on me." Which of the following is the best next step in management of this patient?

Question

A 24-year-old man is brought to the emergency department by his friend due to disorientation and restlessness.  His friend says, "He's gone crazy.  I had a tough time bringing him in.  He kept moving from side to side in the car, banging his body against the door.  Then he started pushing me while I was driving.  I almost ran off the road."  The patient is well known from past emergency department admissions for similar behavior of agitation; he often becomes coherent in 7-8 hours.  He is homeless and has a history of using multiple illicit substances.  He was also hospitalized a month ago for opioid overdose with subsequent aspiration pneumonia.  The patient has no other active medical illnesses except for injuries due to trauma while intoxicated.  He does not have any other psychiatric disorders.  Temperature is 37.2 C (99 F), blood pressure is 160/100 mm Hg, and heart rate is 120/min.  He is not oriented to time and place but recalls his name and date of birth.  Examination shows prominent nystagmus as well as multiple cuts and abrasions of the shoulders and extremities.  The patient is restless and paces in his room.  He then stops, sits down, stands up again, bangs his body against the wall, and yells, "They're pushing a rock on me."  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient has signs and symptoms suggestive of phencyclidine (PCP) intoxication and is at risk of harming himself and others. PCP is a hallucinogen that is primarily an NMDA receptor antagonist. Typical symptoms include agitated, combative, or bizarre behaviors usually lasting 8 hours and leading to traumatic injuries, hypertension, tachycardia, ataxia, and prominent nystagmus (including horizontal, vertical, or rotary nystagmus). At high doses, severe agitation, hallucinations, and violent behavior can occur and require immediate management. Intoxicated patients may have delusions of strength and diminished pain perception. They may become violent in response to believing that they are being attacked. In these cases, rapid control of agitation with adequate chemical sedation is the primary intervention. Benzodiazepines (eg, lorazepam) are typically used as a first-line treatment. Physical restraints may also be needed if the patient cannot be redirected verbally. In contrast, mildly intoxicated patients commonly have dissociative symptoms, including detachment and withdrawal. In these patients, providing a low-stimulation environment is likely to be the primary treatment (Choice E). (Choice A) Assuming that airway, breathing, and circulation are intact, secondary physical injuries can be addressed once severe agitation has been managed and the patient is no longer at an acute risk of harming himself or others. (Choice B) Antipsychotics (eg, haloperidol) are typically used as adjunctive therapy when benzodiazepines fail to adequately control agitation. (Choice D) Some hospital urine toxicology screens test for PCP, but false positives are common. Although a toxicology screen is an appropriate step in assessing substance abuse, the results would not be available quick enough to be helpful during acute management of agitated behavior. Educational objective: PCP intoxication leading to severe agitation and violent behavior should be treated immediately with benzodiazepines to provide sedation. A low-stimulation environment (with or without benzodiazepines) is more appropriate for patients with milder symptoms of PCP intoxication. References: Emergency department visits involving phencyclidine (PCP). (http://www.ncbi.nlm.nih.gov/pubmed/27656747)

A 24-Year-Old Man Is Brought to the Emergency Department by His