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Introduction
Acute behavioural disturbance (ABD) is
a clinical emergency most likely to be seen
in the emergency department (ED) or police
custody suite in overweight men in their midthirties
who chronically misuse illicit stimulants
(Gonin et al 2018, Sliwicka et al 2019). It
is not a diagnosis, but rather a spectrum of
behavioural disturbance ranging from overt
physical or verbal activity, where the person
responds to verbal de-escalation techniques, to
extreme and continuous aggression for which
the person requires rapid tranquillisation
(Paton et al 2019). Figure 1 illustrates the
acute behavioural disturbance spectrum. In its
most extreme form the condition is sometimes
referred to as excited delirium syndrome
(Royal College of Emergency Medicine
(RCEM) 2022), however in the UK the
preferred term is ABD.
This article discusses the more extreme
part of the spectrum, which requires early
recognition and intervention to prevent
death. While ABD is relatively rare, the
incidence is becoming more frequent and with
greater recognition among the police there is
a likelihood of increased hospital attendance of
those presenting with the condition.
Acute behavioural disturbance
In 1985 the term ‘excited delirium’ was
coined by doctors Wetlie and Fishbain who
noted an increase in sudden deaths among
cocaine users on the east coast of the US
following rapid onset of agitation and
violence for which they required restraint
(Strommer et al 2020). Post-mortems noted
non-lethal levels of cocaine and no anatomic
cause of death (Strommer et al 2020). The
term is controversial, in part because it has
been used to explain the deaths of healthy
young men during or immediately following
police restraint (Sliwicka et al 2019). There
have been suggestions that its use in this
context is to ‘cover up’ excessive police
force, therefore it has become a politically
Citation
Peel MR (2022) Acute
behavioural disturbance:
recognition, assessment and
management. Emergency Nurse.
doi: 10.7748/en.2022.e2126
Peer review
This article has been subject
to external double-blind
peer review and checked
for plagiarism using
automated software
Correspondence
mattpeel@nhs.net
\@mattpeel1980
Conflict of interest
None declared
Accepted
8 February 2022
Published online
March 2022
Abstract
Acute behavioural disturbance (ABD) is a clinical emergency which typically affects overweight
men in their mid-thirties who chronically misuse illicit stimulants. People with ABD are most likely to
be seen in police custody or emergency departments, therefore nurses working in these areas must
be able to recognise the signs and symptoms and know how to respond appropriately. Presentation
varies, but the signs and symptoms commonly include extreme agitation, hyperthermia, hostility
and exceptional strength without fatigue. Further, it is important to recognise that people with
ABD are at risk of developing metabolic acidosis, hyperkalaemia, rhabdomyolysis or disseminated
intravascular coagulation. This article gives an overview of ABD and describes the main elements of
management and treatment.
Author details
Matthew Peel, advanced clinical practitioner, Leeds Community Healthcare NHS Trust, Leeds, England
Keywords
aggression, control and restraint, emergency care, mental health, patients, patient behaviour,
pre-hospital care, professional, substance misuse
Why you should read this article:
● To recognise the signs and symptoms of acute behavioural disturbance
● To learn about the pathophysiology of acute behavioural disturbance
● To understand the principles of assessment and management of people with acute behavioural disturbance
Acutebehaviouraldisturbance:recognition,
assessmentandmanagement
Matthew Peel
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charged term (Strommer et al 2020) which
some major organisations, including the
World Health Organization, the American
Psychiatric Association and the American
Medical Association, do not recognise
(Gonin et al 2018).
In the UK the preferred term is acute
behavioural disturbance (ABD) which is
used to describe a life-threatening condition
characterised by extreme physical agitation
and altered mental status, which require
recognition and treatment (Joint Royal
Colleges Ambulance Liaison Committee and
Association of Ambulance Chief Executives
2019, Royal College of Psychiatrists and
Faculty of Forensic and Legal Medicine 2020,
College of Policing 2021, RCEM 2022).
Wetli and Fishbain’s (1985) initial
definition of excited delirium described
a state of extreme mental and physiological
excitement characterised by extreme agitation,
hyperthermia, hostility, exceptional strength
and endurance without fatigue. ABD describes
a combination of psychological agitation and
severe metabolic and haemodynamic changes
(Hall 2016) and it is this combination that
poses the risk of sudden, unexpected collapse
and death (RCEM 2022). The mortality rate is
difficult to determine, in part because most of
the literature on the topic relates to the most
severe cases where an individual has died, but
is believed to be less than 10% (Byard 2018).
Signs and symptoms and differential
diagnoses
Signs and symptoms of ABD are listed
in Box 1. The more signs and symptoms
a person experiences, the greater the risk of
developing complications and subsequent
collapse or death.
ABD should be considered for any extremely
aggressive individual, particularly when the
aggression is associated with hyperthermia,
apparent lack of fatigue and demonstration
Matthew Peel
Figure1. Acute behavioural disturbance spectrum
Violent behaviour Inappropriately dressed / naked
Glass attraction-destruction Rapid breathing
Sweating profusely
Increased pain tolerance Does not tire Hot to touch
Superhuman strengthNear constant activity
Acute behavioural disturbance
of excessive strength (Gonin et al 2018). One
of the challenges of recognising the condition,
however, is that the signs and symptoms
overlap with those of other conditions,
therefore there is a wide range of differential
diagnoses (see Box 2).
It is essential to be able to differentiate
between aggressive, violent individuals who
are not experiencing ABD and those who are.
Misidentification of ABD by police officers
could result in the inappropriate transfer
of violent or aggressive individuals to EDs
and the ‘medicalisation’ of a police matter.
Equally, nurses must be able to recognise
and understand the signs and symptoms of
ABD as this is a life-threatening condition
for which patients require immediate
treatment (RCEM 2022).
Pathophysiology
The pathophysiology of ABD is not
fully understood, but it is a complicated
physiological and psychological condition with
multifactorial predisposing and stimulating
factors (Baldwin et al 2018, Kunz et al
2021). Illicit substances, typically cocaine,
are often reported as a cause (Byard 2018,
Gerdtz et al 2020), however drug levels
reported in people who develop ABD are
similar to those in recreational users, therefore
it cannot be attributed solely to drug use
(Byard 2018). Drugs associated with ABD are
shown in Box 3.
A common hypothesis for
the pathophysiology of ABD is
a hypercatecholaminergic state which relates
to excessive levels of the body’s catecholamines
– adrenaline (epinephrine), noradrenaline
(norepinephrine) and dopamine (Gonin et al
2018, Waugh 2018).
Adrenaline and noradrenaline are
responsible for the sympathetic nervous system
– ‘fight or flight’ – response to a perceived
life-threatening situation (Peate and Nair
Key points
	● People with ABD
tend to present as
extremely agitated,
hyperthermic, hostile,
exceptionally strong
and without fatigue
	● Assessment and
management of patients
with ABD is time
critical but can be
challenging because of
the person’s behaviours
	● In police custody,
the priority for
management of
individuals with ABD
centres on containment,
de-escalation and
possible pre-rapid
tranquillisation
	● The priority for
management of patients
with ABD in the
emergency department
is rapid tranquillisation,
cooling and fluid
resuscitation
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2015). The release of these chemicals leads
to sympathetic nervous system overactivity,
which results in increased heart rate, blood
pressure, respiratory rate, blood flow to the
muscles, sweating and dilation of the coronary
arteries (Peate and Nair 2015, Levy and
Gleeson 2017). In part, this overactivity and
life-threatening ‘fear’ response accounts for the
excessive strength and near-constant activity
seen in people with ABD (Kunz et al 2021).
According to this hypothesis, some individuals
develop high levels of catecholamines as
a response to stress, physical activity and/or
stimulant use (Gonin et al 2018).
Dopamine is a major neurotransmitter
(Waugh 2018) and increased levels are
associated with symptoms of psychosis and
hyperthermia (Baldwin et al 2018, Mash
2016). All stimulant drugs increase levels of
dopamine therefore it is likely that ingestion
of these, or ingestion combined with an
individual’s genetic susceptibility, or the
effect of chronic stimulant misuse, results in
unregulated dopamine levels (Mash 2016,
Gonin et al 2018). This hyperdopaminergic
state results in deterioration of a person’s
psychological state by increasing their agitation
and paranoia (Mash 2016). This then leads to
aggression which further increases adrenaline
and noradrenaline levels through conversion
of extreme emotional distress into autonomic
toxicity (Mash 2016).
As the person’s condition deteriorates they
may develop hyperthermia, leading to further
metabolic disturbance (Kunz et al 2021). It
has been suggested that continuous physical
activity, such as restlessness, agitation, running
or fighting – or resisting restraint – can lead to
life-threatening metabolic acidosis (Kunz et al
2021). When an individual is experiencing
metabolic acidosis, they hyperventilate as
a compensatory mechanism which reduces the
carbon dioxide in the blood in an attempt to
keep the blood pH as close to normal levels as
possible. However, if the person becomes tired,
or is restrained, the ability to hyperventilate
may be impeded, resulting in uncompensated
metabolic acidosis which can lead to cardiac
arrest (Kunz et al 2021).
ABD has also been associated with
withdrawal from or sudden cessation of illicit
drugs (Corstens 2018, RCEM 2022), although
importantly not always in people who are
drug dependent. Corstens (2018), for example,
detailed the case of a 51 year old man who
took gamma hydroxybutyrate, a psychoactive
drug also known as GHB, ‘recreationally’ for
10 days while on holiday, despite not normally
taking the drug. He developed ABD shortly
after returning from holiday, but his drug
screen was negative.
Complications
Rhabdomyolysis, hyperkalaemia and
disseminated intravascular coagulation are
potential complications of ABD (RCEM 2022).
Rhabdomyolysis occurs when there is extensive
skeletal muscle injury caused by muscle
overexertion; this releases myoglobin which in
turn results in acute kidney injury (Yaqoob and
Ashman 2017). The condition is characterised
by massively elevated creatine kinase levels and
results in hyperkalaemia and hypovolaemia
(abnormally low extracellular fluid) (Yaqoob
and Ashman 2017). It is suspected that the
hyperthermia and near-constant physical
Box 2. Differential diagnoses for acute
behavioural disturbance
	» Substance misuse (intoxication or withdrawal)
	» Hypoglycaemia
	» Neuroleptic malignant syndrome
	» Heatstroke
	» Serotonin syndrome
	» Head injury
	» Thyrotoxicosis and/or thyroid storm
	» Seizures
	» Sepsis
	» Electrolyte abnormalities
	» Hypoxia
	» Akathisia (movement disorder)
	» Psychiatric conditions
	» Anticholinergic syndrome
	» Brain tumour
(Byard 2018, Linder et al 2018, Faculty of Forensic and Legal Medicine
2019, Royal College of Emergency Medicine 2022)
Box 1. Signs and symptoms of acute
behavioural disturbance
	» Hyperthermia or ‘hot to touch’
	» Does not tire
	» Naked or inappropriately dressed
	» Rapid breathing (tachypnoea)
	» Tachycardia
	» Profuse sweating
	» Excessive strength and/or continues to struggle despite
restraint
	» Increased threshold and/or tolerance for pain
	» Constant or near-constant activity
	» Glass or mirror attraction and/or destruction
	» Unresponsive to the presence of others (for example,
police or security officers)
	» Extremely aggressive and/or violent behaviour
	» Symptoms of acute psychosis with fear of impending
doom
(Jauchem 2011, Baldwin et al 2018, Faculty of Forensic and Legal
Medicine 2019, Royal College of Emergency Medicine 2022)
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Box 3. Drugs associated with acute
behavioural disturbance
	» Cocaine
	» Methamphetamine
	» Amphetamine
	» Lysergic acid diethylamide (LSD)
	» Phencyclidine (PCP)
	» 3,4-methylenedioxymethamphetamine (MDMA), ecstasy
	» Cannabis
	» Synthetic cathinones
	» Synthetic cannabinoids
	» Synthetic psychedelics such as N-methoxybenzyl
(NBOMe)
	» Opioids
(Byard 2018, Gonin et al 2018, Strommer et al 2020)
© RCN Publishing Company Limited 2022
activity combined with increased adrenaline
has a role in skeletal muscle injury and
rhabdomyolysis (Mash 2016).
Hyperkalaemia involves an elevated
serum potassium level (≥ 5.4 mmol/l), which
can lead to arrhythmias or cardiac arrest
(Alfonzo et al 2020). Hyperkalaemia may
result from rhabdomyolysis or from use of
illicit drugs such as cocaine, methamphetamine
or 3,4-methylenedioxymethamphetamine
(MDMA) (Jauchem 2011).
Disseminated intravascular coagulation is
a condition characterised by microvascular
thrombosis, which typically affects the
skin, brain and kidneys and can result
in haemorrhage, which may be occult or
frank (Murphy et al 2017). Disseminated
intravascular coagulation results from
hyperthermia or use of illicit drugs such
as synthetic cathinones, N-methoxybenzyl
(NBOMEs) or cocaine (Jauchem 2011,
Scott-Ham and Stark 2016, Wills 2016,
Zawilska et al 2020).
Management of individuals with
acute behavioural disturbance
in police custody
The College of Policing (2021) states that
police officers who suspect that an individual
has ABD should not bring them into custody.
However, the condition may not be apparent
immediately, so those experiencing ABD
may have been brought into custody or their
condition may deteriorate while in custody.
The focus for nurses and other healthcare
professionals working in police custody is
to intervene at the early stages of ABD to
try to prevent the person’s condition from
deteriorating (Faculty of Forensic and Legal
Medicine 2019). Individuals with advanced
ABD, or ABD that is unresponsive to oral
lorazepam (see below), are not fit to be
detained in custody and should be transferred
to an ED (Faculty of Forensic and Legal
Medicine 2019).
The Faculty of Forensic and Legal
Medicine (2019) advocates a low threshold
for suspecting ABD, in part because of the
potential life-threatening complications and
the limited healthcare resources available in
police custody suites to manage these. It also
states that immediate transfer to an ED is
mandatory if an individual shows any of the
signs illustrated in Figure 2.
Management of people with ABD in
police custody is limited to de-escalation,
containment, pre-rapid tranquillisation and
transport to hospital (Faculty of Forensic and
Legal Medicine 2019).
De-escalation
If the person is not exhibiting the signs
illustrated in Figure 2, attempts should be
made to try to de-escalate the person, identify
a cause of their agitation and mitigate this
cause if it is safe and appropriate to do so
(Faculty of Forensic and Legal Medicine 2019).
De-escalation can be carried out by a nurse or
other healthcare professional, but if a police
officer has established some rapport with the
individual, then they might be the best person
to do this. Mitigation might involve reassuring
the person or adjusting restraints to make them
more comfortable.
Containment
Containment rather than restraint is the most
crucial intervention when managing agitated
people in custody, given the dangers of
restraint to the person concerned or to those
restraining them. The main danger of restraint
Figure2. Signs of acute behavioural disturbance
that require immediate transfer of patient to an
emergency department
Faculty of Forensic and Legal Medicine (2019)
Near constant
physical activity
Extreme agitation
or aggression
Tactile
hyperthermia
Transfer to emergency
department
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is to the person concerned; if they continue
to struggle alongside deteriorating agitation,
this increases the release of catecholamines
which in turn increases the risk of cardiac
arrest (Mash 2016, Faculty of Forensic and
Legal Medicine 2019, College of Policing
2021). Restraint by police must be reserved for
a definitive objective, such as moving a person
to a cell or exercise yard or transporting them
to hospital (Faculty of Forensic and Legal
Medicine 2019); restraining someone to
stop them being violent, when containment
is available, should be avoided at all costs
(Faculty of Forensic and Legal Medicine
2019, College of Policing 2021). Custody
officers may be concerned that containment
might increase the risk of a person harming
themselves, however it must be stressed that
restraint is dangerous and has significant risks
(Faculty of Forensic and Legal Medicine 2019,
College of Policing 2021). People are unlikely
to de-escalate while being restrained.
Custody can be an ideal environment for
containment because the cells are relatively
bare and without stimuli. The lights should be
dimmed, and the person should be monitored
via CCTV technology at a short distance from
the cell to reduce their interaction with other
people and to avoid deterioration in their
agitation. If possible, the cell should be cooled
to avoid the risk of over-heating; alternatively,
the person could be contained in a secure
exercise yard if they are sweating or hot to
touch (Kent Police 2021).
The purpose of containment is to give the
person a chance to de-escalate and provide
time to arrange transport to a hospital if
required. Ideally, an ambulance should take
the person to hospital, but an alternative
strategy is for the ambulance to follow a police
van if the person remains very aggressive.
A police van also offers an area of containment
whereas in an ambulance the person might
require restraint. If the person requires urgent
transfer to hospital and an ambulance is not
available, police should consider transporting
the person using ‘blue lights’ (Faculty of
Forensic and Legal Medicine 2019, College of
Policing 2021).
Pre-rapid tranquillisation
If de-escalation fails, the Faculty of
Forensic and Legal Medicine (2019)
recommends administration of oral
lorazepam, a benzodiazepine, for pre-rapid
tranquillisation. The aim is three-fold; to
reduce suffering and harm, reduce the risk
of harm to others and facilitate transfer
to hospital (Faculty of Forensic and Legal
Medicine 2019). Administration of oral
lorazepam may be achievable and appropriate
at the lower end of the ABD spectrum, but
those at the extreme end are unlikely to accept
the medicine, and even if they do it is less likely
to achieve the desired effect (Gonin et al 2018).
People at the extreme end of the ABD
spectrum are most in need of pre-rapid
tranquillisation to prevent further deterioration
and to de-escalate them enough to facilitate
safe transfer to an ED without the need
for restraint. In this scenario, intranasal
midazolam may be of benefit as it can enable
rapid control of the person and has an
adequate duration of action to facilitate safe
transfer to an ED by ambulance (Hall 2016,
Gonin et al 2018, Martel et al 2021). It is also
non-invasive, painless and reduces stimuli
and there is no risk of needlestick injury
(Teleflex 2021). However, at present in the UK
the Faculty of Forensic and Legal Medicine
(2019) only recommends administration of
oral lorazepam in police custody. Table 1
summarises the medicines used for pre-rapid
tranquillisation.
Management of patients with acute
behavioural disturbance in the
emergency department
Patients who present to the ED with
ABD are likely to be highly agitated and
aggressive unless they have received pre-rapid
tranquillisation before arriving. However,
this is unlikely because those working
in custody are limited to using only oral
lorazepam (Faculty of Forensic and Legal
Medicine 2019), while paramedics are only
authorised to administer sedative agents in
certain circumstances, for example for patients
experiencing seizures or symptomatic cocaine
toxicity (Joint Royal Colleges Ambulance
Liaison Committee and Association of
Ambulance Chief Executives 2019).
If not already present in the ED, police
or security should be summoned to assist if
needed. Consideration should be given to
placing the patient in the safest area of the ED,
ideally with 360° access to the bed and enough
space for all those involved, such as nurses,
doctors and police and/or security staff. Nurses
Table 1. Summary of medicines used for pre-rapid tranquillisation
Drug Route Typical dose Onset Duration
Lorazepam Oral 1-2mg 20-30 minutes 6-8 hours
Midazolam Intranasal 5mg 3-5 minutes 30-60 minutes
(Vilke et al 2012, Faculty of Forensic and Legal Medicine 2019, NHS 2020)
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must also consider the security and welfare
of other patients when deciding in which part
of the ED to place the patient. Regardless of
where the patient is placed, monitoring and
resuscitation equipment must be available
(RCEM 2022). Where possible, the lights
should be dimmed and noise such as alarms,
phones and voices should be reduced to avoid
unnecessary stimuli which might increase the
patient’s agitation (Gonin et al 2018).
Assessment
Patients should be seen immediately by
a senior clinician because of the potential lifethreatening
complications of ABD. Collateral
history must be gathered from police, family or
witnesses to establish the patient’s behaviours
and activities before the current episode
(RCEM 2022). It is unlikely that a full history
can be obtained from the patient while they
remain agitated.
Assessment and monitoring depends initially
on the patient’s ability to cooperate, therefore
some elements of the assessment may need
to be reserved until rapid tranquillisation
has been administered and taken effect
(Vilke et al 2012). Box 4 lists the main
elements of assessment and monitoring
of patients who present with ABD, once
tranquillisation has enabled this.
Management
The recommended management of patients
with ABD is to ‘treat the triad’ (see Figure 3)
of symptoms – that is, agitation and exertion,
acidosis and rhabdomyolysis and hyperthermia
(Vilke et al 2012).
Agitation and exertion
Stopping the patient’s agitation and continued
exertion is the primary goal to enable further
assessment and management and is essential
before withdrawing physical restraints
(Gonin et al 2018). Nurses should attempt to
determine the duration of restraint used before
the patient arrived in the ED and record this in
the nursing notes.
Seclusion is not recommended – and is not
available – in the ED, therefore patients with
ABD often require rapid tranquillisation if
de-escalation has failed (National Institute for
Health and Care Excellence (NICE) 2015).
NICE (2015) recommends administration of
intramuscular (IM) rather than intravenous
(IV) rapid tranquillisation except in
exceptional circumstances, for example
for people who are extremely aggressive,
critically unwell or with established IV access.
Additionally, IV access is likely to be difficult
to obtain in a highly agitated and aggressive
individual (RCEM 2022).
There is no ideal sedative agent to use for
rapid tranquillisation because they all have
benefits and drawbacks (RCEM 2020).
NICE (2015) recommends IM lorazepam
when there is little patient history available.
Box 4. Main elements of assessment and
monitoring of patients who present with
acute behavioural disturbance, once
tranquillisation has enabled this
	» Airway
	» Breathing
	–Respiratory rate and pattern
	–Oxygen saturation
	–Chest auscultation
	–End-tidal carbon dioxide monitoring
	» Circulation
	–Cardiac monitoring
	–Blood pressure
	–Capillary refill
	–12-lead electrocardiogram
	–Arterial blood gas, including a point-of-care testing
assessment of the metabolic state, lactate and
haematological and electrolyte panel
	–Venous samples for formal laboratory testing,
including full blood count, clotting screen, urea and
electrolytes, troponin and creatine kinase
	» Disability
	–Glasgow Coma Scale and sedation scoring
	–Pupillary response
	–Capillary blood glucose
	–Note degree and positioning of restraints (if in use)
	» Exposure
	–Temperature
	–Head-to-toe examination
	» Fluids
	–Fluid balance
(NHS England 2015, Royal College of Emergency Medicine 2022)
Matthew Peel
Acidosis and
rhabdomyolysis
Hyperthermia
Agitation and
exertion
Treat the
triad
Figure3. Management of patients with acute
behavioural disturbance: ‘treat the triad’
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The benefits of IM lorazepam include a long
half-life, a wide safety profile and a readily
available reversal agent (flumazenil), as well
as a record of common use and familiarity in
the ED (Martel et al 2021, National Center
for Biotechnology Information 2021, RCEM
2022). However, lorazepam has a slower and
unpredictable onset time when administered
IM, making titration difficult (RCEM 2022).
Additionally, as a benzodiazepine lorazepam is
associated with some respiratory depression,
which may impede the person’s ability to
hyperventilate as a compensatory mechanism
for metabolic acidosis (Linder et al 2018).
The RCEM (2022) recommends ketamine
as a first-line agent for rapid tranquillisation.
Some studies have shown that ketamine
sedated 98% of patients with ABD effectively,
while other benefits include rapid onset,
a wide dose range that can deliver the
desired effect with no toxic side-effects
and consistent effects at predictable doses
(Isoardi et al 2021, RCEM 2022). Ketamine
also preserves airway reflexes and rarely
affects the patient’s respiratory effort (RCEM
2022). It can however inhibit the reuptake of
catecholamines, further increasing the heart
rate, blood pressure, cardiac output and
myocardial oxygen demands (RCEM 2022).
Ketamine has also been associated with more
side effects than lorazepam, including
hypersalivation, and has been shown to
increase intubation rates (Linder et al 2018).
Table 2 shows a summary of medicines used
for rapid tranquillisation in the ED.
Regardless of the sedative used, oxygen
should be administered, the patient should
be monitored and their sedation score
measured regularly using a validated
sedation assessment tool (Calver et al
2011, RCEM 2022).
The RCEM (2022) recommends a safety
brief to ensure everyone involved in the
person’s care, including police and security
staff, is aware of the plan to deliver rapid
tranquillisation. This is usually led by a senior
ED clinician. The main elements include:
	» Roles and responsibilities.
	» Intended plan for rapid tranquillisation,
including method of administration and
what will happen post-administration.
	» Anticipated problems and complications
of rapid tranquillisation and how these
will be managed.
	» Restraint considerations.
	» IV access plan.
	» Plan for moving the patient to
a resuscitation environment.
	» Responsibility for decision to relax restraint.
Hyperthermia
Patients who are hyperthermic (temperature
> 37.7°C) should be passively cooled by
removing their clothing and reducing
the environmental temperature, aiming
for normothermia (36.5°-37.5°C) (NICE
2013). Active cooling measures, such as
administration of cooled IV fluids or placing
ice packs in the axilla and groin areas, may
be needed if the patient is critically ill, has
an extremely high temperature (> 40.1°C)
or is not responding to passive cooling
techniques (Hughes and Cruickshank
2011). The patient’s temperature should be
monitored closely.
Acidosis and rhabdomyolysis
Patients will typically require fluid
resuscitation to treat metabolic acidosis and
reverse the dehydration and hypovolaemia
caused by hyperthermia, hyperventilation and
sweating (Vilke et al 2012). Fluid resuscitation
is also a core treatment for rhabdomyolysis
(Patel and Kadiyala 2019).
Conclusion
Although ABD is connected to the
controversial term excited delirium, there is
a consensus that the condition exists in the
context of people who present as extremely
agitated, hyperthermic, hostile, exceptionally
strong and without fatigue. The assessment
and management of patients with ABD
is complex and time critical and can be
more challenging because of the person’s
behaviours. Nurses must be conscious of the
patient’s safety as well as their own and that
of other patients and colleagues. In police
custody, the priority for management centres
on containment rather than restraint and
involves de-escalation and possible pre-rapid
tranquillisation. In the ED, the priority for
management is rapid tranquillisation, cooling
and fluid resuscitation.
Table 2. Summary of medicines used for rapid tranquillisation in the
emergency department
Drug Route Typical dose Onset (minutes) Duration (minutes)
Lorazepam Intramuscular 4mg 15-30 60-120
Intravenous 2-4mg 2-5 60-120
Ketamine Intramuscular 4-5mg/kg 3-5 60-90
Intravenous 2-4mg/kg 1 20-30
(Hall 2016)
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