New RCEM Guidelines – Acute Behavioural Disturbance


The Royal College of Emergency Medicine in the UK has today published new guidelines (PDF) on the management of acute behavioural disturbance (ABD) in the emergency department. This follows a year after NICE guidance was released on the management of violence and aggression, but focuses specifically on ABD. The guidelines have been published in conjunction with the Faculty of Forensic and Legal Medicine.

ABD is a medical emergency, comprising acute delirium in conjunction with autonomic dysfunction. Sudden death occurs in around 10% of presentations. It can be challenging clinically as there is no definitive diagnostic investigation, and symptoms can overlap with multiple severe and life-threatening presentations such as serotonin syndrome and heat stroke.

The main recommendations in the guidelines are:

  • Restraint measures should commence with verbal calming and de-escalation techniques. Physical restraint should be kept to a minimum and used as a last resort option to facilitate chemical sedation.
  • Sedation should ideally be administered intravenously, however this comes with safety considerations and clinicians should keep these in mind. Dynamic risk assessment may prompt intramuscular (IM) sedation followed by cannulation.
  • Intramuscular lorazepam is recommended for first line use by NICE, however benzodiazepines have a variable response between patients and may require active titration. Onset time is also slow and can be unpredictable when given IM. Ketamine has a more consistent profile and has the benefits of airway reflex and respiratory drive preservation, though could theoretically worsen any cardiac instability. Clinicians should use sedatives that they are familiar with, full patient monitoring should be used, and early anaesthetic input should be sought.
  • Patients should be closely monitored for development of hyperkalaemia, rhabdomyolysis and disseminated intravascular coagulation (DIC), both clinically and by utilising appropriate blood tests.
  • Active cooling should be undertaken early and aggressively to treat hyperthermia.
  • Intravenous fluids should be used early to treat hypovolaemia and correct metabolic acidosis.
  • Patients are likely to require ongoing management in a critical care environment. This should be decided on an individual basis.

This is a summary of the guidance. The full document can be read here together with references and a table of dose, onset and duration for commonly used sedatives and tranquillisers.

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