Behavior

Agitated Patient

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Agitated Patient, Agitation

  • See Also
  1. Agitation Management
  2. Agitated Delirium
  3. Agitation in Dementia
  4. Violent Behavior
  5. Calming the Agitated Patient
  6. Physical Restraint
  7. Emergency Psychiatric Evaluation
  8. Delirium
  • Definitions
  1. Agitation
    1. Behavior that is loud, hyperactive, disruptive, threatening or disruptive
  2. Agitated Delirium (Excited Delirium)
    1. Psychomotor Agitation, Delirium and sweating often with Violent Behavior, increased strength, hyperthermia
  • Precautions
  1. See Agitated Delirium
  2. Patient Agitation is highly dangerous for both patients and staff
    1. Assaults by patients against nurses and physicians in the Emergency Department is common
      1. Schnapp (2016) West J Emerg Med 17(5): 567-73 [PubMed]
      2. Omar (2018) Ann Emerg Med 72(4): s144 [PubMed]
    2. Follow established protocols for deescalation, Physical Restraint and Sedation of the Violent Patient
      1. Employ acute intensive management to prevent injury to patients and staff
    3. Agitation is frequently associated with secondary causes (see below) as well as injuries (e.g. Closed Head Injury)
      1. Ensure patient and staff safety, and then evaluate red flags (see below)
      2. Psychiatric causes of acute Agitation are a diagnosis of exclusion
  3. Red Flags for Underlying Medical Causes
    1. See Delirium
    2. Extremes of age (young children, elderly)
    3. Abnormal Vital Signs (e.g. fever, significant Tachycardia, Hypoxia)
    4. Trauma
    5. Delirium
    6. Visual Hallucinations
    7. Neurologic Abnormalities
    8. Acute Intoxication
    9. Unknown Ingestion
    10. Signs of Substance Withdrawal
    11. Serious comorbidities (e.g. Immunosuppression)
    12. Lack of prior mental illness
  • Causes
  1. See Agitated Delirium
  2. See Altered Mental Status Differential Diagnosis
  3. See Psychosis
  4. See Delirium
  5. Neurologic
    1. Cerebrovascular Accident
    2. Intracranial Hemorrhage (Acute Subdural Hematoma, Subarachnoid Hemorrhage)
      1. Agitation is a key presentating finding in 10% of severe Traumatic brain injuries
      2. Brooke (1992) Arch Phys Med Rehabil 73(4): 320-23 [PubMed]
  6. Toxicology
    1. Serotonin Syndrome
    2. Neuroleptic Malignant Syndrome
    3. Sympathomimetic Toxicity
    4. Anticholinergic Toxicity
    5. Alcohol Withdrawal
    6. Benzodiazepine Withdrawal
    7. Stimulant Abuse (e.g. Cocaine, Methamphetamine)
    8. Hallucinogen (PCP)
    9. Wernicke's Encephalopathy (Alcohol Abuse)
    10. Opioid Withdrawal
  7. Metabolic
    1. Hypoglycemia
    2. Hyperglycemia
    3. Thyrotoxicosis
    4. Hypercalcemia
  8. Thermoregulation
    1. Heat Stroke
    2. Hypothermia
  9. Infection
    1. Encephalitis
    2. Meningitis
    3. Sepsis
  10. Respiratory
    1. Hypoxia
    2. Hypercarbia
  11. Psychiatric Disorder with Psychosis
    1. Major Depression
    2. Bipolar Disorder
    3. Schizophrenia
  12. Dementia
    1. See Agitation in Dementia
    2. Often related to physical discomfort or illness
  • History
  1. Review medical record including recent emergency visits and hospitalizations
  2. Obtain history from EMS staff on arrival
  3. Obtain history from family
  • Exam
  1. See Emergency Psychiatric Evaluation
  2. Agitation rating scales
    1. Agitated Behavior Scale
    2. Behavioral Activity Rating Scale
    3. Broset Violence Checklist
  3. Evaluate for secondary causes
    1. Trauma Exam
    2. Emergency Neurologic Exam
  4. Evaluate for Decision Making Capacity
    1. See CURVES Capacity Assessment Tool
  • Evaluation
  1. See Agitated Delirium
  2. See Altered Mental Status
  3. See Unknown Ingestion
  4. See Psychosis
  5. See Delirium
  6. Evaluate for easily reversible causes
    1. Bedside Glucose (Hypoglycemia)
    2. Hypoxia (Oxygen Saturation)
  7. Diagnostics to consider
    1. Electrocardiogram
    2. Comprehensive Metabolic Panel
    3. Complete Blood Count
    4. Urinalysis
    5. Thyroid Stimulating Hormone
    6. Toxicology Screening
      1. Urine Drug Screen
      2. Blood Alcohol Level
      3. Acetaminophen Level
      4. Salicylate Level
    7. Neurologic Testing
      1. Head CT
      2. Lumbar Puncture
  • Management
  1. See Agitation Management
  2. See Agitated Delirium
  3. See Agitation in Dementia
  4. See Physical Restraint
  5. See Chemical Restraint
  • References
  1. Roppolo, Klinger, Leaf (2019) Crit Dec Emerg Med 33(2): 3-10
  2. Shanks, Ginsburg and Leaf (2023) Crit Dec Emerg Med 37(9): 4-10