542 Emergency Medicine
490.The answer is e.(Tintinalli, p 1812.)Violent behavior requires
immediate restraint.Hospital security and the police are best trained to
subdue violent patients with the least chance of staff or patient injury.
Patients who are threatening or who demonstrate violent behavior should
be disrobed, gowned, and searched for weapons. Patients whose behavior
suggests the potential for violence should be approached cautiously with
adequate security force nearby. The physician should stand in a location
that neither threatens the patient nor blocks the exit of the patient or the
physician from the room. Physical restraints are frequently required for the
violent or severely agitated psychotic, delirious, or intoxicated patient who
is a danger to themselves or others. Pharmacologic restraints (haloperidol,
lorazepam) are also useful in obtaining behavior control and should be
considered once the initial evaluation has been completed.
(a)The patient should not be allowed to leave the hospital prior to a
medical and psychiatric evaluation. (b)No staff member should be alone with
a patient who is violent or threatens violence. (c)Although using calming
techniques are useful to assuage many patients, it is important not to delay
the medical evaluation and prolong detection of a life-threatening process.
(d)Giving the patient a sedating medication is useful; however, you should
try to first medically evaluate the patient. In addition, you should not enter
the patient’s room alone with a needle in your hand.
491.The answer is a.(Tintinalli, pp 1816-1817.)Rapid tranquilization is a
method of pharmacologic management of acute agitation or psychosis using
high-potency neuroleptics and benzodiazepines. The most common regimen
used is the combination of haloperidolandlorazepam,which can be admin-
istered via parenteral, intramuscular, or oral routes. There is a synergistic effect
between the two medications. Moreover, the benzodiazepine may prevent the
potential extrapyramidal affects that occasionally occur with neuroleptic use.
(b)Etomidate and succinylcholine are used for rapid sequence intubation,
which is not indicated in this patient. (c)Chlorpromazine is a low-potency
antipsychotic that may cause significant hypotension and is rarely used in
the ED setting. (d)Ketamine is a dissociative agent that is not typically
used in psychotic patients. (e)Clozapine is an atypical antipsychotic that is
used in schizophrenics when other neuroleptics are ineffective. It is not an
agent of choice for acute sedation or psychosis.
492.The answer is b.(Rosen, pp 1549-1583.)Amajor depressive episode
is characterized by two or more of the following symptoms over a 2-week