• Failure to recognise ABD as a medical emergency that requires immediate management. Prolonged physical restraint worsens metabolic acidosis and is likely to increase the risk of sudden death.
  • Failure to have sufficient personnel (medical (ED +/- anaesthetic)/nursing/security/police) present to safely sedate the patient. An inefficient attempt to sedate the patient may result in needlestick or physical injuries to healthcare professionals and is likely to result in prolonged physical restraint of the patient with its inherent consequences.
  • Failure to exclude underlying medical or surgical causes for the patient’s altered mental status. Although cocaine use is the most common cause for ABD there are numerous other medical causes that must be excluded as timely management of these conditions may be required.
  • Failure to acknowledge flaws in urinary toxicology screening tests. These tests may not detect novel psychoactive drugs (false negative result) or may detect previous but not clinically relevant use of such substances (false positive). Treat the patient clinically.
  • Choosing an inappropriate agent with which to sedate the patient. Ketamine or droperidol are the agents of choice, whilst benzodiazepines may also be used. As previously mentioned, use of an agent with which the sedating clinician is familiar is essential. Haloperidol has been used but needs consideration of its potential to increase the QTc, and may exacerbate symptoms of ABD.