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Managing Disturbed In-Patients
These guidelines have been prepared to help duty doctors make safe and effective decisions
about the management of patients who are so disturbed that they represent a danger to
themselves or others. The instructions set out below are not intended to be rigidly
applied, but set out the principles of good practice.
Three principles should guide anyone dealing with these difficult situations.
1.When you are asked to attend a severely disturbed inpatient, the staff and patient may
be frightened, and you may well become frightened too. Always take your time in thinking
through your course of action: don’t panic.
2.Making decisions about the management of these patients should always be a collaborative
effort between senior nursing staff and medical staff. If you are uncertain how to
proceed, take advice. There is always a senior doctor on-call available to talk things
through and their skills are there to be used. Taking advice is a sign of maturity, not
weakness.
3.Always remember that these situations carry dangers for the patient. Patients can die
under emergency psychiatric treatment.
The Law
Although many disturbed patients are held in hospital under the Mental Health Act, in fact
the authority to treat under these circumstances arises primarily from the common law duty
of care. This involves our responsibility to make sure that even emergency treatment is
humane and not out of proportion to the patient’s degree of disturbance. It is
important that you familiarise yourself with the Mental Health Act Code of Practice and
the authority to treat under various sections of the Mental Health Act. If you have any
doubts about the legality of the situation, contact a more senior doctor.
Assessment
You should never embark upon any treatment plan without having taken responsible steps to
understand what is wrong with the patient. This is particularly important when you are
asked to see patients on a medical or surgical ward. Bear in mind the possibility that
there may be organic factors and the patient’s physical state may need to be
reassessed by senior doctors of the referring team. For instance, post-operative confusion
(disorientation in time, place or person, often with misidentification) may be due to
infection, hypoxia, internal haemorrhage and many other causes. In particular, consider
the possibility of an alcoholic withdrawal state such as delirium tremens; this is a
medical emergency not a psychiatric one. You may advise on sedation, but remember - large
doses of a neuroleptic alter the epileptic threshold and in a patient with alcohol
withdrawal may precipitate an epileptic fit
Before prescribing, always work out exactly what medication the patient has already
received in the previous forty eight hours, including any PRN medication and any recent
depot-tned~n. Always consider advice from nursing or other colleagues.
Oral Medication Regimes
Usually psychotic patients become disturbed because they are frightened or frustrated It
is possible to persuade a reluctant patient to accept medication if you are sufficiently
patient and firm.
If oral medication is accepted, Chlorpromazine syrup or Haloperidol liquid are the
medications of choice, as they are rapidly absorbed. If you choose Haloperidol consider
giving an additional anticholinergic agent as a dystonic reaction can arise. Suggested
doses include 100-200 mg of Chlorpromazine or 5-10 mg of Haloperidol
Parenteral Medication Regimes
If an intramuscular regime is to be used, the drug of choice is Clopixol Acuphase, which
is oil based and released over a seventy two hour period. The dosage regime is between 50
and 150 mg IM. Some patients may need an additional injection one to two days after the
initial dose. Further doses can be given every two or three days up to a maximum of four
injections and a cumulative dose of 400 mg. Oil based injections should not be given to
patients who are actively struggling. Fortunately, most patients stop struggling once
effectively restrained.
NEVER use intravenous chlorpromazine.
Pause to assess the effect on the patient’s mental state and level of consciousness.
This can be followed by Diazepam 10 mg (as Diazemuls) or Lorazepam 4 mg. Pause again to
assess the effects of this. If the patient is still very disturbed, the entire regime can
be repeated once. Restraint should continue until it is clear whether the patient has
responded to the medication or not. Lorazepam has a wide safety margin with minimal risk
of hypertension or accumulation of drug.
If this regime is ineffective, take advice. In many cases the patient will fall asleep. If
possible they should be left in the recovery position and you should bear in mind the
possibility of the aspiration of stomach contents. Always be aware of the risk of
respiratory arrest.
After Care
It is now necessary to make a plan for the next twenty four hours with the nursing staff.
This includes provision for further medication and for regular medical review. A period in
seclusion may be necessary with regular medical and nursing reviews. All patients who have
been forcibly medicated to the point of somnolence should be observed according to the
protocol for nursing such patients and be reviewed regularly.
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Version 4.0
October 2000