Psychiatric Emergencies — SAQ

Stem

Mr K, a 30-year-old man with a 5-year history of paranoid schizophrenia, is brought to the emergency department by police under a Section 136 hold after threatening his mother with a knife. He is acutely agitated, pacing and shouting that "the FBI have planted a chip in my brain" and that he "has to kill them before they kill me." De-escalation by the psychiatric liaison team and an offer of oral lorazepam and oral olanzapine are refused. He postures aggressively and approaches a member of nursing staff with a clenched fist. He weighs 80 kg; observations are pulse 110, blood pressure 148/92, respiratory rate 18, SpO2 98% on air, temperature 36.8 °C, and his ECG shows QTc 440 ms. There is no history of cardiac, respiratory or renal disease and no recent depot.

^{[5] [17] [16] [28]}

Questions

a) Lay out, in sequence, your immediate management of this acute agitation. (3 marks)

The cardinal principle is safety first → de-escalation → oral → IM rapid tranquillisation, applied stepwise.

^{[28] [5] [17]}

1. Scene safety — trained staff in locally defined numbers (NICE NG10 requires organisations to specify staff:patient ratios and numbers for restrictive interventions; it does not quote a universal four-to-five person team), removal of any weapon, a clear exit, panic alarm, and police present given the weapon history. Never approach alone or turn one's back on the patient.
2. ABCDE primary survey — airway patent; respiratory rate 18, SpO2 98% on air; pulse 110, blood pressure 148/92; GCS 15; blood glucose (BM) checked early to exclude hypoglycaemia; temperature 36.8 °C makes a hyperthermic rigidity syndrome unlikely at this moment.
3. De-escalation — already attempted by psychiatric liaison and failed. An oral offer has been refused (Project BETA: engage, collaborate, verbally de-escalate; oral before parenteral).
4. Rapid tranquillisation is indicated because de-escalation has failed, oral has been refused and there is imminent risk to staff. NICE NG10 first-line parenteral options in adults are IM lorazepam alone or IM haloperidol combined with IM promethazine. With a recorded ECG (QTc 440 ms is not a sourced “safe/unsafe” cut-off — NICE still prefers lorazepam if cardiovascular disease or no ECG), IM lorazepam is the better NG10 choice here. BAP/NAPICU 2018 also lists IM olanzapine and IM aripiprazole as effective IM monotherapy; IM olanzapine must not be given concurrently with IM benzodiazepines (wait at least 1 hour; hypotension). Battaglia reported eight fatalities with IM olanzapine and advised against simultaneous CNS depressants. I would not use IM midazolam (TREC 2003 showed faster sedation but BAP does not recommend IM midazolam because of respiratory depression) and would not use IM haloperidol monotherapy (TREC 2007: all 10 dystonias in the haloperidol-alone arm; BAP does not recommend haldol monotherapy).
5. Post-IM monitoring — NICE NG10: pulse, blood pressure, respiratory rate, temperature, hydration and consciousness at least every hour until there are no further physical-health concerns; every 15 minutes if BNF maximum exceeded, asleep/sedated, illicit drugs/alcohol, pre-existing physical health problem, or harm from restrictive intervention. BAP medium-level after IM RT: NEWS-equivalent every 15 minutes for a minimum of 1 hour.
6. Identify and treat any underlying driver — non-adherence, substance use, missed organic cause.

^{[28] [5] [1] [18] [19] [17] [16]}

(1 mark for safety and ABCDE with glucose; 1 mark for NG10/BAP IM choice and the olanzapine/benzodiazepine separation; 1 mark for sourced post-IM monitoring.)

^{[28] [5]}

b) One hour after IM lorazepam, Mr K remains agitated and aggressive. Describe your next steps. (2 marks)

If there is no response to IM lorazepam, NICE NG10 1.4.41 is IM haloperidol combined with IM promethazine. That is also the TREC 2007 regimen: IM haloperidol 5–10 mg plus IM promethazine up to 50 mg, which left more patients tranquil or asleep by 20 minutes than haloperidol alone (RR 1.30, NNT 6) with all 10 acute dystonias in the monotherapy arm. BAP: baseline ECG before haloperidol because of QTc prolongation. ^{[28] [5] [18]}

If still refractory: reassess for an organic cause; seek senior review; BAP: IM olanzapine only if no concurrent IM benzodiazepine (wait ≥1 hour). Do not invent daily-maximum milligram limits that are not in NG10/BAP recs. Restraint is last resort: NG10 — do not obstruct airway/breathing/circulation; do not routinely restrain more than 10 minutes; consider RT or seclusion as alternatives to prolonged restraint.

^{[28] [5]}

(1 mark for NG10/TREC second-line combination with ECG; 1 mark for reassessment/escalation and sourced restraint limits.)

^{[28] [5]}

c) Mr K lacks capacity to make decisions about admission and treatment. Outline the lawful basis on which you can detain and treat him. (2 marks)

This is jurisdiction statute, not a PubMed trial result.

^{[5] [28]}

In England & Wales: capacity under the Mental Capacity Act 2005 — two-stage test (impairment of mind/brain plus inability to understand, retain, weigh/use or communicate). Treatment of mental disorder may proceed under the Mental Health Act 1983 (amended 2007). After a Section 136 police place-of-safety hold, assessment can lead to Section 2 (28-day assessment) or Section 3 (treatment). Emergency community admission: Section 4 (72 hours, one doctor). Inpatient holding: Section 5(2) 72 hours (doctor), Section 5(4) 6 hours (nurse). Common law covers immediate life-threatening intervention with minimum force until formal authority is in place. NICE NG10 requires seclusion in detained patients (or immediate MHA assessment if seclusion is used in an emergency in a non-detained person).

^{[28] [5] [16]}

In India under the Mental Healthcare Act 2017, Section 115 creates a presumption of mental illness after a suicide attempt and a duty to provide care (decriminalisation of attempted suicide).

^[16]

(1 mark for MCA two-stage test and MHA sections; 1 mark for emergency/Section 4 or 5 route and MHCA 2017.)

^{[16] [28]}

d) Forty-eight hours later, on the psychiatric intensive care unit on risperidone 4 mg daily plus lorazepam 2 mg tds, Mr K develops a fever of 39.5 °C, lead-pipe rigidity in all four limbs, a tachycardia of 120, labile blood pressure, profuse diaphoresis and drowsiness. Creatine kinase is 5,200 U/L, white cell count 17 × 10⁹/L and alanine aminotransferase 220 U/L. What is the diagnosis and outline your immediate management. (3 marks) ^{[4] [7]}

This is neuroleptic malignant syndrome (NMS) against the Gurrera 2011 international consensus: recent dopamine-antagonist exposure; hyperthermia >38.0 °C on at least two occasions; rigidity; mental-status alteration; creatine kinase elevation (at least 4× ULN); sympathetic lability; tachycardia plus tachypnea; negative work-up for other causes. Lead-pipe rigidity without clonus/hyperreflexia and a slower (days) onset distinguish NMS from serotonin toxicity (Hunter criteria). Low serum iron, raised CK, LDH/AST and white cell count support NMS over serotonin toxicity (Perry).

^{[4] [7] [10]}

Immediate management:

^{[5] [28]}

1. STOP the antipsychotic immediately — failure to discontinue independently predicted death (Guinart: OR 4.39), as did respiratory problems, more severe hyperthermia and older age.
2. Supportive care — cooling, IV fluids, intensive monitoring of rigidity, temperature, renal and respiratory status.
3. Dantrolene is the most effective evidence-based drug treatment for NMS (Perry); benzodiazepines and dopamine agonists (for example bromocriptine) are described for more severe cases. Specific milligram regimens for bromocriptine/dantrolene are not quoted from those papers here.
4. Do not reintroduce any antipsychotic for a 2-week neuroleptic washout (Perry) to minimise recurrence.
5. ICU for severe cases (airway, rhabdomyolysis, haemodynamic instability).

^{[4] [8] [7] [16]}

(1 mark for diagnosis with Gurrera 38.0 °C ×2 / CK ≥4× ULN; 1 mark for stopping the drug and supportive care; 1 mark for dantrolene as best-evidenced drug and 2-week washout — without unsourced milligram protocols.)

^{[4] [7]}

References11ShowHide

1. [1]Battaglia J. Pharmacological management of acute agitation Drugs, 2005.PMID 15916448
2. [4]Gurrera RJ, Caroff SN, Cohen A, et al. An international consensus study of neuroleptic malignant syndrome diagnostic criteria using the Delphi method J Clin Psychiatry, 2011.PMID 21733489
3. [5]Patel MX, Sethi FN, Barnes TR, et al. Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: De-escalation and rapid tranquillisation J Psychopharmacol, 2018.PMID 29882463
4. [7]Perry PJ, Wilborn CA. Serotonin syndrome vs neuroleptic malignant syndrome: a contrast of causes, diagnoses, and management Ann Clin Psychiatry, 2012.PMID 22563571
5. [8]Guinart D, Misawa F, Rubio JM, et al. A systematic review and pooled, patient-level analysis of predictors of mortality in neuroleptic malignant syndrome Acta Psychiatr Scand, 2021.PMID 34358327
6. [10]Dunkley EJ, Isbister GK, Sibbritt D, et al. The Hunter Serotonin Toxicity Criteria: simple and accurate diagnostic decision rules for serotonin toxicity QJM, 2003.PMID 12925718
7. [16]Bush G, Fink M, Petrides G, et al. Catatonia. II. Treatment with lorazepam and electroconvulsive therapy Acta Psychiatr Scand, 1996.PMID 8686484
8. [17]Richmond JS, Berlin JS, Fishkind AB, et al. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup West J Emerg Med, 2012.PMID 22461917
9. [18]Huf G, Coutinho ES, Adams CE; TREC Collaborative Group. Rapid tranquillisation in psychiatric emergency settings in Brazil: pragmatic randomised controlled trial of intramuscular haloperidol versus intramuscular haloperidol plus promethazine BMJ, 2007.PMID 17954515
10. [19]TREC Collaborative Group. Rapid tranquillisation for agitated patients in emergency psychiatric rooms: a randomised trial of midazolam versus haloperidol plus promethazine BMJ, 2003.PMID 14512476
11. [28]National Institute for Health and Care Excellence Violence and aggression: short-term management in mental health, health and community settings NICE guideline NG10, 2015.Source