A 43-year-old man is brought to the emergency department by the police after being found walking in the middle of a busy parking lot while talking to himself and shouting at passing cars. The patient is barefoot and disheveled. He is oriented to person and place but is unable to give a coherent history. He says, "I've been in a lot of hospitals, but I won't take any medication." The patient appears tense and agitated. When the nurse attempts to take vital signs, he refuses and pulls his arm away. He glares at the nurse and shouts, "All you do is experiment on people." Which of the following is the most appropriate next step in management of this patient?

Question

A 43-year-old man is brought to the emergency department by the police after being found walking in the middle of a busy parking lot while talking to himself and shouting at passing cars.  The patient is barefoot and disheveled.  He is oriented to person and place but is unable to give a coherent history.  He says, "I've been in a lot of hospitals, but I won't take any medication."  The patient appears tense and agitated.  When the nurse attempts to take vital signs, he refuses and pulls his arm away.  He glares at the nurse and shouts, "All you do is experiment on people."  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d76f_875e_bc81_498d718157a9_MD0003_00 Initial management of agitation in the emergency department involves techniques of verbal deescalation, with chemical and physical restraints used as a last resort. This patient is agitated and uncooperative when approached by the nurse and shows signs that he is having difficulty caring for himself (barefoot, disheveled) and may suffer from a psychotic disorder (disorganized behavior, talking to himself, paranoid). However, the patient is communicating verbally and has not shown directed violence that endangers the staff's safety. As a first step, efforts should be made to calm the patient down. Offering the patient something to eat and drink can be effective in meeting the patient's basic human needs and defusing the situation. Other guidelines for managing agitation include: Respecting the patient's personal space Using a calm voice and nonthreatening demeanor Setting limits that harming oneself or the staff is unacceptable Ensuring that adequate staff and security are available if the patient should become violent and need to be restrained. Although security personnel should be on standby, confronting the patient or threatening to administer medication, to use physical restraints, or to call security risks escalating the situation (Choice C). (Choices A and B) Verbal deescalation techniques should be attempted first in this patient who is agitated but nonviolent. Immediate restraint by either chemical sedation (eg, intramuscular antipsychotic) or physical means is indicated when verbal deescalation has failed and violence by a patient is imminent or has already occurred. Prolonged use of physical restraints may result in active resistance, putting the patient at risk for electrolyte abnormalities, arrhythmias, and rhabdomyolysis. Educational objective: Verbal deescalation techniques should be used to calm agitated but nonviolent patients and may include the offer of something to eat and drink. Intramuscular antipsychotic medication and physical restraints are indicated when verbal deescalation has failed and violence by a patient is imminent. References: Improving the management of acutely agitated patients in the emergency department through implementation of Project BETA (Best Practices in the Evaluation and Treatment of Agitation). (http://www.ncbi.nlm.nih.gov/pubmed/33145538) Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. (http://www.ncbi.nlm.nih.gov/pubmed/22461917)

A 43-Year-Old Man Is Brought to the Emergency Department by the Police