Rosen & Barkin's 5-Minute Emergency Medicine Consult (36 page)

Agitation, a state of extreme restlessness

• Characterized by increased verbal and motor activity
  
• Can be the presenting symptom of a variety of medical (organic) and psychiatric (functional) disorders
  
• Broad spectrum of severity
  
  • From excessive talkativeness to threatening or violent behavior
    
  • Includes excited delirium syndrome
    
    • Characterized by agitation, acidosis, hyperadrenergic autonomic dysfunction
      
    • Associated with sudden cardiac death, particularly after a violent struggle
      

• 6% of emergency visits are for behavioral disturbances
  
• ∼1.7 million emergency visits annually in US involve agitated patients
  

Medical (organic) etiologies:

• Infectious:
  
  • CNS infections
    
    • Encephalitis
      
    • Meningitis
      
    • Neurosyphilis
      
    • Abscess
      
  • Hyperactive or mixed delirium secondary to sepsis
    
• Metabolic derangements:
  
  • Electrolyte derangement
    
    • Hyponatremia
      
    • Hypocalcemia
      
    • Hypoglycemia
      
  • Renal failure
    
  • Acid/base disturbances
    
  • Hepatic encephalopathy
    
  • Wernicke encephalopathy
    
  • Wilsons disease
    
• Endocrinopathies:
  
  • Thyroid storm
    
  • Hyperparathyroidsism
    
• Pulmonary etiologies:
  
  • Hypoxemia
    
  • Hypercarbia
    
• Toxicologic causes
  
  • Toxidromes:
    
    • Sympathomimetic
      
    • Anticholinergic
      
    • Cholinergic
      
    • Alcohol intoxication
      
    • Alcohol withdrawal
      
  • Neuroleptic malignant syndrome (NMS)
    
  • Serotonin syndrome (SS)
    
• Neurologic causes:
  
  • Tumors
    
  • CNS infections (see above)
    
  • Huntington disease
    
  • Ischemic cerebrovascular accident
    
  • Traumatic intracranial hemorrhage
    
  • Subarachnoid hemorrhage
    
  • Postseizure
    
• Psychiatric (functional) etiologies:
  
• Mania/agitated depression
  
• Psychotic illnesses such as schizophrenia
  
• Anxiety disorders
  

DIAGNOSIS

A detailed history and physical exam are critical in differentiating between medical and psychiatric causes of agitation.

• The HPI has a sensitivity of 94% in detecting medical illness in psychiatric patients.
  
  • If a detailed HPI is unattainable from the patient seek collateral information from family, friends, and pre-hospital providers
    
• Inquire about:
  
  • Trauma
    
  • Recent illness and fever
    
  • Headache, loss of consciousness, neurologic deficits, or visual hallucinations
    
  • Current medications
    
  • History of:
    
    • Psychiatric illness
      
    • Substance abuse
      
    • HIV/immunosuppressed state
      
    • Cancer
      
    • Neurologic disorders, including epilepsy
      

A thorough exam is critical to differentiate between organic and functional causes

• Vital sign abnormalities should prompt a full evaluation for an organic cause
  
  • Hyperthermia may indicate an infectious etiology, NMS, SS, or excited delirium syndrome
    
• Perform a toxidrome-oriented exam, including
  
  • Pupillary assessment
    
  • Skin evaluation for diaphoresis or absence of sweat
    
  • Evaluation for urinary retention
    
• A detailed neurologic exam is mandatory
  
  • Any neurologic deficit requires a full evaluation for an underlying medical illness
    
  • Orientation, memory, and attention should be intact for patients with a functional cause of agitation
    
    • Alterations in orientation and memory are seen in delirium and dementia
      
    • Inattention, such as inability to recite the days of the week backward, should raise suspicion of delirium
      
  • Muscle tone and reflexes should be assessed
    
    • Muscle rigidity may indicate NMS
      
    • Hyperreflexia and clonus may indicate SS
      

The diagnostic work up is directed by the history, physical exam, and underlying suspicion of for an organic etiology of the agitation.

At minimum all patients should have:

• A full set of vital signs
  
• A complete physical exam, including a detailed neurologic exam and tests of cognition and attention
  
• Blood glucose testing
  

Diagnostic tests should be directed on the basis of the suspicion of an organic etiology for the patient’s agitation, and history and physical exam findings.

Head CT should be considered in trauma patients or those with neurologic deficits.

• Lumbar puncture should be considered in patients
  
  • with meningeal signs
    
  • where infection is suspected as etiology of agitation but no source is identified
    

Agitation may be the presenting symptom of an underlying medical illness, substance abuse or withdrawal, or a psychiatric illness.

TREATMENT

Pre-hospital providers frequently encounter agitated or violent patients and should:

• Follow regional protocols regarding physical and chemical restraints
  
• Provide prenotification when transporting an agitated or violent patient so that the receiving hospital can mobilize necessary resources
  
• Obtain a fingerstick glucose if feasible
  

• ABCs
  
• Treat life-threatening medical/traumatic conditions as appropriate
  
• Severely agitated patients may become violent and pose harm to staff and other patients
  
  • Patients should change into hospital gowns and be searched for weapons
    
  • Physical and parenteral chemical restraints should be used when necessary to ensure safety of patient(s) and staff
    

• When an organic etiology is suspected or diagnosed
  
• Treatment should be directed at underlying cause
  
• When a functional etiology is suspected or diagnosed
  
• Emergency psychiatric referral is indicated
  
• Management of agitation
  
• Verbal de-escalation techniques are 1st line for mild or moderate agitation
  
• Chemical restraint options include
  
  • Benzodiazepines
    
    • 1st line therapy for alcohol withdrawal
      
    • May precipitate or worsen delirium in geriatric patients
      
  • Antipsychotics
    
    • 1st line for patients with functional etiology of agitation/psychosis
      
    • Low dose can be used in delirious geriatric patient when verbal de-escalation is unsuccessful
      
    • Monitor for QTc prolongation and extrapyramidal symptoms
      
  • Combination therapy of parenteral benzodiazepines and haloperidol
    
    • May produce more rapid sedation than monotherapy
      
    • Should be consider in highly agitated/violent patient
      
• Physical restraint use:
  
• Chemical sedation should be used to facilitate early discontinuation of physical restraints
  
• Physician and nurses must document use and rationale for usage
  
• Prolonged use can result in:
  
  • Hyperthermia
    
  • Rhabdomyolysis
    
  • Nerve injury if extremities are kept in same position for prolonged time
    
  • Excited delirium syndrome
    

FOLLOW-UP

Disposition is ultimately determined by the underlying cause of the agitation and whether the condition resolves.

Admission is warranted if there is an underlying medical or psychiatric condition that requires inpatient treatment

Discharge should be limited to those individuals where the underlying cause resolves (e.g., substance use/abuse) and/or can be safely treated as an outpatient

• Psychiatric referral as appropriate
  
• Alcohol/drug treatment as appropriate
  

Follow-up is determined by the causative medical or psychiatric condition(s).

Search for potential medical illnesses causing the agitation

• Factors suggestive of organic causes include:
  
  • New onset at age >45
    
  • Abnormal vital signs
    
  • Focal neurologic abnormalities
    
  • Acute onset
    
  • Visual hallucinations
    
  • Abnormalities of memory or attention on cognitive testing
    
  • Trauma with evidence of head injury
    

Pitfalls:

• Not assessing for underlying organic cause of agitation
  
• Not undressing patients and searching for weapons
  
• Inadequate dosing of sedatives/antipsychotics
  
• Failure to adjust extremity position in restraints to prevent nerve complications
  
• Inadequate documentation of the need for restraint
  

• Lukens TW, Wolf SJ, Edlow JA, et al, from the American College of Emergency Physicians Clinical Police Subcommittee. Clinical Policy: Critical issues in the diagnosis and management of the adult psychiatric patient in the Emergency Department.
  Ann Emerg Med.
  2006;47:79–99.
  
• Nordstrom K, Zun LS, Wilson MP, et al. Medical evaluation and triage of the agitated patient: Consensus statement of the American Association for Emergency Psychiatry Project BETA Medical Evaluation Workgroup.
  West J Emerg Med.
  2012;8:3–10.
  
• Rossi J, Swan MC and Isaacs ED. The violent or agitated patient.
  Emerg Med Clin N Am.
  2010;28:235–256.
  
• Vilke GM, DeBard ML, Chan TC, et al. Excited delirium syndrome (EXDS): Defining based on a review of the literature.
  J Emerg Med.
  2012;43:897–905.