Controlling the Milieu

This is our 3rd of 3 cases exploring the care of patients with altered mental status in the Emergency Department.  Similar to our "Out on a Limb" and "Sepsis Smackdown" case series, the case presented is followed by a series of questions, with a discussion in the comment section facilitated by the post authors.  In approximately 1 month, the authors of the post will conduct a combined simulation/small group session reinforcing the learning points from the posts during Grand Rounds.  Around this time, they will also curate the comments from the discussion and publish a post highlighting these learning points.  Looking forward to a great discussion!

It is a cold, blustery winter night in the ED.  You are the on-duty flight physician as well as ED physician for your particular patient care area, and you get toned out for a scene in a nearby county.  Having arrived on scene, you enter the ambulance to find a middle aged man belted to the backboard with cervical collar on, verbally and physically struggling with the paramedics who are trying to restrain him.  

By report, he was found at the bottom of a deer stand, presumably having fallen out. Initial GCS was 11 (3- 3-5) with a R parietal cephalohematoma and abrasions to his arms and  face.  

Your brief assessment amidst his yelling and fighting is the following:

HR 115 BP 110/60 SpO2 91% (on RA as he has ripped the nasal cannula out)

GCS now 4-4-5 (13), moving all extremities and localizing, not following commands, yelling and grunting, PERRL 4-2 symmetric but slowly reactive

Minimal wheezing throughout

His skin is pale and mildly jaundiced, he has bruising to his arms and chest in various stages, and his abdomen is rotund.  

He smells of alcohol and cigarettes.

Question 1

Why is this patient agitated?  How are you going to manage his mental status? What unique aspects of this patient and this environment go into your decision making process? Are there particular means of controlling his agitation that might be contraindicated?

You successfully manage this patient’s mental status and transport him safely back to the ED, handing him off to the ED and Trauma teams in the SRU.  You proudly saunter back to your Pod, head held high.  Much to your chagrin, several minutes later EMS providers bring in a young, physically fit man screaming on the back of the stretcher. They report he is well known to them as a poorly controlled paranoid schizophrenic.  You do a quick chart review seeing several psychiatric admissions for “intentional drug overdose.”  You can’t find an accurate or current med list, however…

The milieu in your pod is quickly spinning out of control...

Question 2

What is your differential diagnosis for this patient’s agitation?  How do you manage this patient’s mental status?  Do you have an algorithm you follow for acute management of excited delirium?  What considerations are unique in this case?  

Question 3

What if he had no known medical or social history, does that change your approach to evaluation and management?  

Seemingly instantaneously after regaining control of the milieu, the nurse comes to you saying she “needs something” to give to the woman in bed 40.  You, having forgotten who this woman in fact is, look to see that there is a thin elderly female admitted to the general medicine team for urosepsis.  She has been boarding in your ED for ~8 hours.  The nurse hasn’t been able to get in contact with the admitting team for ~30 minutes, and the woman has managed to pull out her peripheral IV and Foley catheter.  You hear from the nurse manager that there has been a code blue on one of the inpatient floors, and the team will be occupied for the near future.

Question 4

What management steps do you take in this instance?  What are your goals of managing her delirium? If chemically sedating, how and by what route?  What factors go into your decision making when choosing a particular agent?  Does her age, sex, status, or current care environment alter your plan?

Written by Tim Loftus, MD PGY-4 Resident

Posted by Jeffery Hill, MD MEd