Principles of management

1. Examine for signs of (i) infection (e.g. pyrexia, purulent sputum, catheter sites, neutrophilia, falling platelet count, CXR, meningism), (ii) cardiovascular instability (hypotension, increasing metabolic acidosis, oliguria, arrhythmias), (iii) covert pain, particularly abdominal and lower limbs (e.g. compartment syndrome, DVT), (iv) focal neurological signs (e.g. meningism, unequal pupils, hemiparesis), (v) respiratory failure (arterial blood gases), (vi) metabolic derangement (biochemical screen). If any of the above are found, treat as appropriate. Psychosis should not be assumed until treatable causes are excluded.

2. Reassure and calm the patient. Maintain quiet atmosphere and reduce noise levels. Attempt to restore day-night rhythm, e.g. by changing ambient lighting and use of oral hypnotic agents.

3. Consider starting, changing or increasing dose of sedative or major tranquilliser to control the patient. If highly agitated and likely to endanger themselves, rapid short term control can be achieved by a slow IV bolus of sedative. Consider propofol, a benzodiazepine, haloperidol or chlorpromazine in the smallest possible dose to achieve the desired effect; observe for hypotension, respiratory depression, arrhythmias and extra-pyramidal effects. Opiates may be needed, especially if pain or withdrawal is a factor. An ethanol infusion can be considered for delirium tremens resulting from alcohol withdrawal.

4. Sedation can be maintained by continuous infusion or intermittent injection, either regularly or as required. The less agitated patient may respond to IM injections of a major tranquilliser, though these should be avoided with concurrent coagulopathy.

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