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During a late shift in the emergency department, a 22-year-old non-binary patient was brought in by EMS for chest tightness, shortness of breath, and severe anxiety. The patient is pacing in triage at this time. The patient has a history of anxiety and panic attacks. They have previously been treated with medication and CBT.

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Heart rate: 103 bpm

Blood pressure: 138/89 mmHg

Respiratory rate: 24

Temperature: 37.5°C

Oxygen saturation: 100% on room air

The patient is obviously distressed, visibly trembling, sweating profusely, and crying. They are having difficulty following directions, won’t sit down, and are chewing on what’s left of their fingernails.

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The Patient should be referred to psychiatry from the ED. While still in the ED, they should be kept in a low-stimulus environment. The patient should be considered a candidate for 1:1 due to severe anxiety, particularly the inability to stay grounded. Medications should be ordered, including possible PRN sedatives if the condition escalates. 12-lead EKG and labs should be done to rule out potential cardiac causes.

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Complication #1: The patient may go into respiratory alkalosis

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Complication #1: The patient may go into respiratory alkalosis

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1. Encourage slow deep breathing for the patient.

This will allow for the patient to breathe out excess carbon dioxide and reduce their chances of respiratory alkalosis.

2. Calm the patient and reduce anxiety.

It is imperative to attempt to calm the patient and reduce their external stimuli for the patient to be safe.

3. Assess and treat the underlying cause.

Although initially it is important to calm the patient for their safety; to prevent a state like this again it is important for the nurse to assess and treat the underlying cause of this panic.

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Complication #2: The patient may become aggressive due to not receiving adequate care

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Complication #2: The patient may become aggressive due to not receiving adequate care

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1. Establish trust with the patient through therapeutic communication.

Therapeutic communication is key in deescalating a patient. This trust and ease that the nurse develops may prevent the patient from becoming aggressive as well.

2. Ensure a safe environment for all.

If the patient seems to be becoming violent, it is important to place them in a safe environment. This can include placing them close to the nurse's station, having one-to-one precautions, and removing items that may be used as a weapon to others or self.

3. Involve interprofessional help early.

The patient is experiencing a panic attack that has underlying causes. It is important to gain other healthcare professionals on this patient's team quickly to prevent him from escalating to forms of aggression.

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Complication #3: The patient may develop an infection while admitted because of nail biting

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Complication #3: The patient may develop an infection while admitted because of nail biting

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1. Encourage the patient to regularly bathe and inform them of the importance of hand hygiene

The patient will likely remain in the hospital for a prolonged period of time following this crisis. Due to this, they are at a higher risk of infection. To decrease the chances of acquiring these, it is important to encourage regular bathing and hand hygiene.

2. Obtain regular lab testing and monitoring

Regular lab testing allows for the nurse to monitor the patients' WBC count to prevent an infection. This is important because stress can weaken the immune system.

3. Maintain skin integrity

The nurse should regularly check the patient's skin integrity and educate about nail-biting leading to infection.

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What is the highest priority complication? 

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What is the highest priority complication? 

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Respiratory Alkalosis is the highest priority, as the patient is hyperventilating, which can lead to lightheadedness, dizziness, and tingling in the extremities. Although there are other complications, this is an immediate threat that can lead to potentially life-threatening events such as dysrhythmias and seizures in severe cases.

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Benzodiazepines such as lorazepam and diazepam for anxiety. This medication works by enhancing GABA activity which inhibits the CNS, leading to a lower respiratory rate and restoring breathing patterns.

Labs: ABGs and BMP to confirm respiratory alkalosis while also assessing electrolyte imbalances that could also cause hyperventilation. Hypocalcemia and hypokalemia could also result in respiratory alkalosis.

1:1 supervision to ensure the safety of the patient and staff due to his agitation. This would get the patient into a low-stimulus room with constant supervision.

Consult Psychiatry. This is crucial as the patient has a history of anxiety/panic attacks and was previously treated with medication.  Patient needs to be assessed by a psychiatrist to evaluate medication adjustments and/or other possible interventions to reduce the likelihood of further anxiety episodes.

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Despite your best effort, the patient has exhibited physical and mental decompensation. 

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Despite your best effort, the patient has exhibited physical and mental decompensation. 

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After about 10 minutes, the patient paused and asked quietly, “Can I use the bathroom?” Their voice was low, and their energy seemed to shift. They seemed more withdrawn. The nurse gave them permission and remained just outside the door, assuming it would be a brief moment for them to regroup. What no one knew was that the patient had a small safety razor blade hidden in the seam of their hoodie pocket. This was something triage had missed. No one asked about self-harm or suicidal thoughts. It was a backup plan they had carried for weeks just in case the anxiety ever became too much. And in that moment, it was.

Minutes passed with no sound. The nurse knocked. No answer. When she opened the door, the patient was on the floor, knees tucked to their chest, wrist bleeding. Blood had pooled on the floor next to them. The patient looked up, pale and trembling, and said, “I didn’t want to die. I just needed it to stop.” The staff did their best to monitor and support the patient, and the nurse never left the room, but no one had asked the one question that could’ve changed everything.

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1 🫂 Stabilize the patient physically and emotionally 

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1 🫂 Stabilize the patient physically and emotionally 

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Provide wound care and assess the severity of injuries.

Administer ordered medications (IM lorazepam) for acute anxiety and distress.

Offer therapeutic presence and emotional reassurance.

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2 ✂️ Ensure immediate patient safety and initiate suicide precautions 

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2 ✂️ Ensure immediate patient safety and initiate suicide precautions 

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Secure the environment by removing harmful objects and placing the patient on 1:1 observation.

Notify the provider and behavioral health team about the incident.

Prioritize life-saving safety interventions to prevent further self-harm.

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3 📋Coordinate transfer to a higher level of psychiatric care 

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3 📋Coordinate transfer to a higher level of psychiatric care 

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Initiate an emergency involuntary psychiatric hold.

Arrange transfer to an inpatient psych facility.

Complete documentation and ensure a warm, safe handoff.