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Agitation, Emergency Medicine

Basics

Description

- 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

- Metabolic derangements: - Electrolyte derangement - Hyponatremia - Hypocalcemia - Hypoglycemia

- Renal failure - Acid/base disturbances - Hepatic encephalopathy - Wernicke encephalopathy - Wilsons disease

- Endocrinopathies: - Thyroid storm - Hyperparathyroidsism

- 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

- 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

- 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

- 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

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 severityFrom excessive talkativeness to threatening or violent behaviorIncludes excited delirium syndromeCharacterized by agitation, acidosis, hyperadrenergic autonomic dysfunctionAssociated with sudden cardiac death, particularly after a violent struggle

Epidemiology

Incidence and Prevalence Estimates

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

Etiology

Medical (organic) etiologies:

  • Infectious:CNS infectionsEncephalitisMeningitisNeurosyphilisAbscessHyperactive or mixed delirium secondary to sepsis
  • Metabolic derangements:Electrolyte derangementHyponatremiaHypocalcemiaHypoglycemiaRenal failureAcid/base disturbancesHepatic encephalopathyWernicke encephalopathyWilsons disease
  • Endocrinopathies:Thyroid stormHyperparathyroidsism
  • Pulmonary etiologies:
  • Toxicologic causesToxidromes:SympathomimeticAnticholinergicCholinergicAlcohol intoxicationAlcohol withdrawalNeuroleptic malignant syndrome (NMS)Serotonin syndrome (SS)
  • Neurologic causes:TumorsCNS infections (see above)Huntington diseaseIschemic cerebrovascular accidentTraumatic intracranial hemorrhageSubarachnoid hemorrhagePostseizure
  • Psychiatric (functional) etiologies:
  • Mania/agitated depression
  • Psychotic illnesses such as schizophrenia
  • Anxiety disorders

Diagnosis

Signs and Symptoms

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

History

  • 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:TraumaRecent illness and feverHeadache, loss of consciousness, neurologic deficits, or visual hallucinationsCurrent medicationsHistory of:Psychiatric illnessSubstance abuseHIV/immunosuppressed stateCancerNeurologic disorders, including epilepsy

Physical Exam

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

  • Vital sign abnormalities should prompt a full evaluation for an organic causeHyperthermia may indicate an infectious etiology, NMS, SS, or excited delirium syndrome
  • Perform a toxidrome-oriented exam, includingPupillary assessmentSkin evaluation for diaphoresis or absence of sweatEvaluation for urinary retention
  • A detailed neurologic exam is mandatoryAny neurologic deficit requires a full evaluation for an underlying medical illnessOrientation, memory, and attention should be intact for patients with a functional cause of agitationAlterations in orientation and memory are seen in delirium and dementiaInattention, such as inability to recite the days of the week backward, should raise suspicion of deliriumMuscle tone and reflexes should be assessedMuscle rigidity may indicate NMSHyperreflexia and clonus may indicate SS

Diagnosis Tests & Interpretation

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

Essential Workup

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

Diagnosis Tests & Interpretation

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

Imaging

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

Diagnostic Procedures/Surgery

  • Lumbar puncture should be considered in patientswith meningeal signswhere infection is suspected as etiology of agitation but no source is identified

Differential Diagnosis

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

Treatment

Pre-Hospital

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

Initial Stabilization/Therapy

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

Ed Treatment/Procedures

  • 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 includeBenzodiazepines1st line therapy for alcohol withdrawalMay precipitate or worsen delirium in geriatric patientsAntipsychotics1st line for patients with functional etiology of agitation/psychosisLow dose can be used in delirious geriatric patient when verbal de-escalation is unsuccessfulMonitor for QTc prolongation and extrapyramidal symptomsCombination therapy of parenteral benzodiazepines and haloperidolMay produce more rapid sedation than monotherapyShould 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:HyperthermiaRhabdomyolysisNerve injury if extremities are kept in same position for prolonged timeExcited delirium syndrome

Follow-Up

Disposition

Admission Criteria

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 Criteria

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

Issues for Referral

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

Followup Recommendations

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

Pearls and Pitfalls

Search for potential medical illnesses causing the agitation

  • Factors suggestive of organic causes include:New onset at age >45Abnormal vital signsFocal neurologic abnormalitiesAcute onsetVisual hallucinationsAbnormalities of memory or attention on cognitive testingTrauma 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

Additional Reading

  • 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.

See Also (Topic, Algorithm, Electronic Media Element)

  • Alcohol Withdrawal
  • Poisoning, Toxidromes
  • Delirium

Codes

ICD9

307.9 Other and unspecified special symptoms or syndromes, not elsewhere classified

ICD10

R45.1 Restlessness and agitation

SNOMED

  • 24199005 Feeling agitated (finding)
  • 47295007 Psychomotor agitation (finding)