An Uncontrollable, Aggressive Patient at a Free-Standing Emergency Department

We present the case of an aggressive male patient who was unable to be successfully sedated with conventional medications in the ED and ultimately required intubation to ensure the safety of the patient himself and the staff. After admission to the ICU, he was found to have atrophy of the frontal and bilateral lobes secondary to a traumatic brain injury (TBI) 19 years prior. Managing the patient required collaboration with the intensivist, hospitalist, and psychiatry and neurology teams for 10 months, and he was refused admission to multiple psychiatric facilities due to safety concerns because of his high level of aggression and unpredictability. An out-of-state, high-security facility eventually accepted the patient. The second challenge was finding a highly trained medical team willing to transport the patient. This case illustrates the difficulty and safety concerns with regard to managing an aggressive patient with previous TBI when the commonly used medications do not produce the desired effect. A literature search did not reveal a standard protocol or consensus on managing these types of patients in emergent situations.