Acute Behavioural Disturbance (ABD)
Table of contents
Red Flags
At all times consider the danger to yourself, your partner and bystanders. Have no hesitation in requesting police involvement and communicate clearly the urgency with which you need them based on the threat the patient or environment poses.
Non-pharamacological management
A focus should be placed on non-pharmacological management approaches in line with a least restrictive approach to management of patients reflecting the aims of the Mental Health Act 2014 (WA) and also general good practice.
Ensure space is given, both for the patient and to allow you to withdraw if required
Predicting danger
Patients who presented with alcohol intoxication, substance misuse or mental health issues including anxiety and delirium were identified as the groups at greatest risk for potential violence with themes around alcohol reflected in internal violence and aggression reports also (Pich et al., 2017).
Sedation Assessment Tool
The Sedation Assessment Tool (SAT) is an objective method for assessing a patient’s agitation state and is used by Queensland Ambulance Service and the in-hospital environment and is a modified version of the Altered Mental Status Score. In research it has been shown to have excellent interrater reliability (Kappa of 0.87) and is straight forward to use with median time to allocate a score of 10 seconds (Calver et al., 2011).
| Score | Responsiveness | Speech |
|---|---|---|
| +3 | Combative, violent, out of control | Continual loud outbursts |
| +2 | Very anxious and agitated | Loud outbursts |
| +1 | Anxious/restless | Normal / talkative |
| 0 | Awake and calm/cooperative | Speaks normally |
| -1 | Asleep but rouses if name is called | Slurred or prominent slowing |
| -2 | Responds to physical stimulation | Few recognisable words |
| -3 | No response to stimulation | Nil |
Note. From Calver, L. A., Stokes, B., & Isbister, G. K. (2011). Sedation assessment tool to score acute behavioural disturbance in the emergency department. Emergency Medicine Australasia, 23(6), 732–740. doi:10.1111/j.1742-6723.2011.01484.x
Pharmacological management
Research has shown that patients sedated using Midazolam also often require additional sedation to achieve therapeutic effects (Isbister et al., 2010). In addition to efficacy, the safety profile of Midazolam compared to other available options is also of note with concerns around respiratory depression (resulting in hypoventilation and hypoxaemia) and hypotension (Australian Medicines Handbook Pty Ltd, 2019), especially where patients are alcohol intoxicated (Yap et al., 2019).
Isbister et al. (“Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: the dorm study,” 2010) framed these concerns quite nicely when they stated:
“The unpredictable response to intramuscular midazolam is most likely due to differences in individual patient tolerance and is particularly important in patients with violent and acute behavioural disturbance who have an increased use of drugs and alcohol. This makes intramuscular midazolam, at least, and potentially other benzodiazepines, a problematic choice of drug in a setting in which rapid sedation is required, usually with little knowledge of the patient.”
In addition, doses of Ketamine less than 200mg have shown to be associated more frequently with treatment failure (Isbister et al., 2016).
References
- Calver, L. A., Stokes, B., & Isbister, G. K. (2011). Sedation assessment tool to score acute behavioural disturbance in the emergency department: The sedation assessment tool. Emergency Medicine Australasia, 23(6), 732–740. https://doi.org/10.1111/j.1742-6723.2011.01484.x
- Yap, C. Y. L., Taylor, D. M. D., Kong, D. C. M., Knott, J. C., Taylor, S. E., & the Sedation for Acute Agitation in Emergency Department Patients: Targeting Adverse Events (SIESTA) Collaborative Study Group. (2019). Risk factors for sedation‐related events during acute agitation management in the emergency department. Academic Emergency Medicine, 26(10), 1135–1143. https://doi.org/10.1111/acem.13826
- Isbister, G. K., Calver, L. A., Page, C. B., Stokes, B., Bryant, J. L., & Downes, M. A. (2010). Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: the dorm study. Annals of Emergency Medicine, 56(4), 392–401.e1. https://doi.org/10.1016/j.annemergmed.2010.05.037
- Isbister, G. K., Calver, L. A., Downes, M. A., & Page, C. B. (2016). Ketamine as rescue treatment for difficult-to-sedate severe acute behavioral disturbance in the emergency department. Annals of Emergency Medicine, 67(5), 581–587.e1. https://doi.org/10.1016/j.annemergmed.2015.11.028