Hot Seat #160: The Case of the Agitated Patient

Posted on: November 1, 2020, by :

HPI: 15 y/o F with history of conduct disorder presents to an outside hospital community emergency department in police custody for a screening exam. The referring provider is calling for recommendations. You learn that the patient was involved in a high speed MVC, with +airbag deployment and it is unclear if she was restrained.  She has been arrested and is currently in CFSA custody.  Vital signs and exam per referring provider:

Initial vital signs: BP 80/40, HR 60s, RR 14, SpO2 100% on RA

Primary survey: airway intact, bilateral BS, strong and equal peripheral pulses with good cap refill; GCS 15 with equal pupils (3 -> 2mm).

Secondary survey: chest wall tenderness to palpation, suprapubic and right pelvic tenderness to palpation that follows a seat-belt distribution but no seat-belt sign. She complains of left sided neck pain, but no c-spine tenderness. She also complains of mid-line thoracic spine tenderness.

The referring provider planned for trauma labs and x-rays, however patient became aggressive and combative. BP spontaneously improved to 100/60, but then drifted back down to 80/40s. Her heart rate remained in 60s with good capillary refill. She is described as somnolent at times, but becomes more alert and combative when interventions are attempted. The referring provider suspects intoxication and has low suspicion for intracranial injury.  CFSA consented for all necessary treatment and transfer for trauma evaluation. She is well known to your ED.

Four hours after arrival to OSH ED she was transported to your pediatric trauma center as a “trauma transfer.”

On arrival her exam is unchanged. Blood pressures continue to be 80s/40s, (lowest 70/30) with heart rates of 60-70s and good perfusion. She continues to refuse all medical care and to be combative – biting off BP cuffs, swatting away and spitting at staff. It is noted by the ED social worker and charge nurse that this behavior is typical for her and has occurred during her prior ED visits.

You attempt to obtain trauma labs given the persistent hypotension, but she refuses an IV.  With police and security assistance, you administer 10mg of haloperidol intramuscularly to help calm her down. After 20 minutes she is still combative and refusing all labs and imaging. Her vital signs are unchanged.

After an hour of care in the trauma bay, she agrees to go to the CT scanner, but will not allow placement of an IV for contrast. You obtain CT Head, CT Cervical Spine and CT Abdomen/Pelvis without contrast. All images are normal, but radiology comments that they cannot rule-out an active intra-abdominal bleed given that she did not receive contrast. Her vital signs continue to show BPs in 80s/40s and HRs in the 60s. She continues to refuse placement of an IV.

The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.

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2 thoughts on “Hot Seat #160: The Case of the Agitated Patient

  1. Sedate with IM ketamine at the referring facility, intubate, IV access, stabilize hypotension post-trauma, and transfer to a Trauma Center.

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