Acute Behavioural Disturbance in Emergency Departments – Guideline

Authors: Tom Bannister / Codes: EnC6, EnP3, EnvC1, MHC2, MHC5, MHP1, PC4, PhC3, PhP1, SLO2, SLO7 / Published: 17/06/2024

Scope/Reason for development

Acute behavioural disturbance (ABD) is an umbrella term used to describe a presentation which may include abnormal physiology and/or behaviour.

ABD patients pose a significant management challenge in the Emergency Department (ED) when their behavioural disturbance may put them and/or those around them at risk of physical injury, particularly when they have potentially life-threatening pathophysiology, such as a hyperadrenergic reaction, metabolic acidosis, or cardiotoxicity. This guideline has been written to support the emergency care of a patient with ABD whose presentation may affect the clinician’s ability to ensure that the patient, staff and others are safe, and to achieve appropriate clinical investigations and management.

Summary of Recommendations

1. All practitioners of Emergency Medicine should be familiar with the term Acute Behavioural Disturbance (ABD) and the recognition of potential cases.
2. The care of a patient presenting with ABD should be provided by a senior Emergency Medicine practitioner.
3. All EDs should have a locally agreed strategy for the management of cases of ABD.
4. All EDs should have an identified area suitable to provide verbal and environmental de-escalation of ABD cases when required.
5. All EDs should have 24/7 access to sufficient security staff to provide support. These staff should be appropriately trained to provide additional de-escalation and where appropriate, restraint of patients to support clinical care. Where this is not provided, the Trust should clearly describe any alternative provision and how this fulfils the requirements of the Health and Safety at Work Act 1974.
6. Early sedation should be considered in severe cases of ABD, including where prolonged activity or restraint has taken place.
7. In most cases of ABD requiring parenteral sedation, intramuscular ketamine or droperidol are recommended agents.

Ensure that you read the full Acute Behavioural Disturbance in Emergency Departments Guideline

Appendix 1 – The Sedation Assessment Tool

Appendix 2 – An example of a Rapid Tranquillisation protocol in Acute Behavioural Disturbance

Linked RCEMLearning Content