Agitated Patient

Aka: Agitated Patient, Agitation

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II. 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

III. Precautions: Red Flags for underlying medical causes

  1. See Delirium
  2. Extremes of age (young children, elderly)
  3. Abnormal Vital Signs
  4. Trauma
  5. Delirium
  6. Visual Hallucinations
  7. Neurologic Abnormalities
  8. Acute Intoxication
  9. Unknown Ingestion
  10. Signs of Substance Withdrawal
  11. Serious comorbidities

IV. Causes

  1. See Agitated Delirium
  2. See Altered Mental Status Differential Diagnosis
  3. See Psychosis
  4. See Delirium
  5. Head Trauma
    1. Intracranial Hemorrhage (Acute Subdural Hematoma, Subarachnoid Hemorrhage)
  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)
  7. Metabolic
    1. Hypoglycemia
    2. Hyperglycemia
    3. Thyrotoxicosis
  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

V. Exam

  1. Emergency Psychiatric Evaluation
  2. Agitation rating scales
    1. Agitated Behavior Scale
    2. Behavioral Activity Rating Scale
    3. Broset Violence Checklist

VI. 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

VII. Management

  1. See Agitated Delirium
  2. See Calming the Agitated Patient
  3. See Physical Restraint

VIII. References

  1. Roppolo, Klinger, Leaf (2019) Crit Dec Emerg Med 33(2): 3-10

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