Acute Behavioural

Disturbance (ABD) in ED

Mohammed Aneez
SpR ED
Wexham Park Hospital
 Outline

• Definition
• Recognition and potential cause
• Management and handling
• Investigation
• Special circumstance
• Documentation
• Reference
• Take home message
 Definition

Acute behavioural disturbance (also previously called excited delirium,

acute behavioural disorder, or agitated delirium) is an umbrella term
used to describe a presentation which may include abnormal
physiology and/or behaviour ( RCEM –Sep 2022)

It is important to recognize that ABD should not be considered a

diagnosis or syndrome, but rather a clinical picture with a variety of
presenting features and potential causes.
 Definition

• The terms 'acute behavioural disturbance' ('ABD') and 'excited delirium' ('ExD')
have been used to describe a situation in which a person is extremely agitated and
distressed, usually in a public place, and in such a state of agitation that they may
be at risk of a potentially fatal physical health emergency. ( RCPsych- Sep 2022 )

• ABD is a term which is now recognised across police, ambulance services, and
emergency control room staff
 Recognition and Potential cause

Recoginising ABD can be a distracting presentation because patients may have co-
existing toxicological problems, or traumatic injuries which may not be immediately
obvious.

• Agitation
• Constant physical activity
• Bizarre behaviour (incl. paranoia, hypervigilance)
• Fear, panic
• Unusual or unexpected strength
• Sustained non-compliance with police or ambulance staff
• Pain tolerance, impervious to pain
• Hot to touch, sweating, rapid breathing, tachycardia (Autonomic)
 Recognition and Potential cause

• Substance intoxication
• Mental health conditions
• Withdrawal ( alcohol/substance)
• Hypoxia ( Anaemia, cardiac failure, PE)
• Metabolic disorder (Electrolyte disturbance, hepatic or renal failure)
• Sepsis
• Trauma (Head injury /post operative)
• Anticholinergic syndrome/ Neuroleptic malignant syndrome/Serotonin syndrome
• Endocrinopathies (Thyroid storm, glucose, PTH, adrenal)
• Environmental (hypo/hyperthermia)
• CNS pathology (seizure, hemorrhage, tumor, hypertensive encephalopathy)
 Management and handling

MEDICAL V/S NON-MEDICAL

 Management and handling

• Assess risk to patient - Patients may lose their ability to interact with
their environment safely. Patients presenting with severe ABD are
likely to lack mental capacity which should be formally assessed and
documented to make emergency treatment decision.

• Assess risk to staff/other patients - Staff who have not had approved
training should not be asked to restrain patients. Early escalation to
on-site security services is recommended. Request police assistance if
indicated.
 Management and handling

De-escalation (Verbal/environmental)
• Respect personal space
• Do not be provocative
• Establish verbal contact
• Be concise
• Identify wants and feelings
• Listen closely
• Agree, or agree to disagree
• Set clear limits
• Offer choices and optimism – offer oral sedatives and offer kindness
• Debrief patient and staff
 Management and handling

Ideal environment
• Adequate and appropriately located exits so that staff can exit without being trapped by the
patient
• Doors which open outwards
• Quiet, low stimulus
• Not too warm
• Absence of equipment/furniture and moveable objects that could be a potential weapon or used
to barricade an exit
• Absence of potential ligature points
• Constantly observable
• Staff able to signal need for additional support easily
 Management and handling

Restraint

• Attempts should be made to remove any ongoing restraint at the earliest

opportunity.
• There is concern that in ABD, continued exertion under restraint can contribute
to poor outcomes (likely due to increasing catecholamine levels, worsening
hyperthermia, and metabolic acidosis).
• Prolonged restraint should prompt consideration of rapid tranquilisation.
• the shortest possible time necessary to aid an intervention.
• ensure that there is no obstruction to ventilation and to minimise the risk of
asphyxiation
 Management and handling

Rapid tranquilisation / Sedation

• Is this the right thing to do? Yes, to provide the patient with a safe
assessment or essential treatment.
• prevent further sympathetic over-stimulation and excessive muscular activity
from causing a metabolic storm and subsequent cardiovascular collapse.
• prevent the patient from causing physical harm to themselves or others and
facilitate investigations and treatments.
• Associated with reduce mortality.
 Management and handling

Before considering rapid tranquilsation

• Are you anticipating complication like apnoea, airway obstruction, or

a requirement for subsequent intubation.
• Right personal? Practitioner delivering rapid tranquilisation must be
trained and capable of managing complications if they arise. Do you
have appropriate trained staff?
• Do you have critical care support ?
 Management and handling

Consider a Safety Brief prior to parenteral rapid tranquilisation

• Roles
• Intended plan
• Anticipated problems
• Restraint considerations
• Intravenous access plan
• Plan for moving to resuscitation environment
• Responsibility for decision to relax restraint
 Management and handling

Sedation Assessment Tool

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, co-operative Speaks normally
-1 Asleep but rouses normally if name called Slurring or prominent slowing
-2 Responds to physical stimulation Few recognisable words
-3 No response to stimulation Nil
 Management and handling

• Oral Sedative – Lorazepam 1-2mg

• Parenteral sedation
Ketamine - 4mg/kg IM (or titrate to effect IV)
Dissociative effects reduces adrenergic features. Speed of onset, cardiovascular
stability and preservation of respiratory drive/airway reflexes.
Droperidol - 5-10mg IM.
Fewer adverse event than benzo. Concern of QT prolongation and cannot be
used in patient taking antipsychotic medication.
Midazolam- 5-10mg IM. respiratory adverse events common
Haloperidol and lorazepam – found to have longer time to be successful.
 Investigation

• Blood tests
• Blood gas (to include blood glucose)
• b. FBC, U&E, LFT, troponin, CK, coagulation profile
• c. Other tests as clinically indicated; e.g., blood cultures, trauma bloods,
overdose bloods, toxicology screen, appropriate metabolic screen
• Electrocardiogram (ECG)
• Imaging if clinically indicated (Xray/ CT )
 Special circumstances

• Frail or older patients – Feature of hyperactive delirium. Sedative

‘start low, go slow’ strategy may reduce risk.
• Paediatric patients - Adolescent / Pre-adolescent
• Patients with learning difficulties -Care plans should be checked.
 Documentation

• relevant features from the collateral history

• features supporting the decision to manage as ABD
• attempts to achieve verbal/environmental de-escalation
• assessments of mental capacity
• restraint applied, duration and indication
• security or police involvement, including use of force, controlled energy device use,
etc.
• sedative strategy and any adverse events
• involvement of other specialties
 Take home message

• Early recognisition of acute behavioural disturbance

• Get help from senior and trained staff
• Always think of underlaying medical cause
• Early and safe decision for rapid tranquilisation
• Involve critical care team if needed
 Reference

• https://www.rcpsych.ac.uk/docs/default-source/improving-care/bette
r-mh-policy/position-statements/ps02_22.pdf
• https://rcem.ac.uk/wp-content/uploads/2022/01/Acute_Behavioural
_Disturbance_Final.pdf
• https://www.rcemlearning.co.uk/reference/acute-behavioural-
disturbance/#1639499735327-28ecbab7-be9c