Agitation

Author: Elizabeth DeVos MD, MPH, FACEP, University of Florida College of Medicine—Jacksonville

Editor: Nur-Ain Nadir MD, University of Illinois College of Medicine—Peoria

Last Updated: November 2019

Case Study

A 45 year-old male presents to the emergency department with police and EMS. The patient was found at a party combative and disruptive.  During transport, the patient continued to yell and struggle and ultimately struck his head on the ground while police attempted to restrain him.  He is now at the triage desk on an EMS stretcher in handcuffs writhing around yelling and spitting and threatening to bite anyone who comes near him.  The patient’s vitals are HR 126, BP 150/88, RR 20, SpO2 100% RA. The patient has a right forehead hematoma with a 2 cm laceration that is actively bleeding.  The charge nurse and chief resident attempt to speak to the patient in a calm tone and ask for the patient’s complaints and account of the situation. The patient continues to threaten staff and lunge in the bed and security and additional assistance are called.  Nursing staff prepares 400mg Ketamine IM at the attending’s order and the team prepares to place the patient in restraints using a 5-point technique. 

Objectives

Upon finishing this module, the student will be able to:

1. Recognize the agitated and potentially dangerous patient.
2. Describe the initial evaluation of an agitated patient.
3. Define agitated behavior and differentiate delirium, dementia and psychosis.
4. Describe appropriate methods for de-escalation and restraint.
   

Introduction

Agitation complicates the presentation of many ED patients. Examples of agitation include changes in mood, orientation, and level of consciousness and may present as violence. Agitation may be a symptom of delirium, dementia or psychosis. The duty of the emergency physician is to ensure safety for the patient and staff while distinguishing underlying medical causes from those that are functional or psychiatric in nature.

Initial Actions and Primary Survey

After assessment of the ABCs, focus on attempting to calm the patient to facilitate further evaluation. De-escalation while avoiding sedation is preferred to allow gathering of further history. Vital signs, measures to assure the safety of the patient and others, and early containment (including physical or chemical restraint, as appropriate) are the first steps. A good history, including one from collateral sources, is essential. Blood glucose and pulse oximetry should be attained as soon as is safe to do so as hypoglycemia and hypoxia can be fatal causes of altered mental status. Whenever head and neck trauma is a possibility, the provider should also consider safely placing a cervical collar on the patient. Always consider the safety of both the patient and examiner before approaching a potentially dangerous patient.

Presentation

An agitated patient may present anywhere on the spectrum from slightly anxious to combative. Clinically significant agitation may include explosive and unpredictable anger; intimidating behavior; physical or verbal abusiveness; or signs of impatience like restlessness, pacing and excessive movement. Violent actions do not usually occur without warning. Watch for signs of anxiety including pacing, clenching of fists, pressured or angry speech, defensiveness, verbal threats, or yelling. Patients may have any range of vital signs, however tachycardia and hypertension may be frequently associated with acute agitation. Agitated behavior may occur in the context of substance abuse, personality disorder, and psychiatric or physical illness. Below we will discuss key features of delirium, dementia and psychosis.

Delirium is an acute confusional state due to an organic disturbance in the brain. These patients require evaluation for a medical cause of the agitation. Key features include change in level of consciousness (agitation to drowsiness) and change in cognition (memory, orientation, attention or speech). Usually, the course is acute but fluctuates in severity. Patients are often elderly and usually hallucinations are non-auditory. An example would be a newly combative elderly patient sent for evaluation from a nursing home found to have a UTI.

Dementia is an organic brain disturbance with progressive mental status changes including intellectual abilities, behavior and personality. Onset of dementia is typically slow and progressive. Dementia may present with an acute delirium in a patient with a chronic, progressive decline.

Psychosis is a dysfunction in processing of information or thought capacity that may present as a feature of a personality disorder, schizophrenia, mania, acute stress reactions, or depression with psychotic features. Patients may have delusions, hallucinations, disorganized speech or behavior and negative symptoms. Patients with acute psychosis are usually not disoriented. 

Differential Diagnosis

The patient with acute agitation, may be suffering from delirium, psychosis or dementia. It is the job of the clinician to determine what is the cause of the altered mental status.

The differential diagnosis for delirium can be remembered with the mnemonic DIMTOPS:

• Drugs-intoxication, poisoning, or withdrawal
• Infections-UTI, pneumonia, meningitis, encephalitis, and others
• Metabolic Disturbance-Glucose and other endocrine derangements, electrolyte disorders
• Trauma-Head injury
• Oxygen-Hypoxia
• Postictal State
• Space Occupying Lesion-Intracranial Tumor

Table 1 below notes some of the features that helps differentiate psychiatric from organic etiologies of agitation.

Table  1. Features of Patient Presentation Differentiating Psychiatric form Organic Etiology. 

Diagnostic Testing

Investigations should focus on identifying and treating life-threatening diagnoses presenting as agitated behavior and general medical conditions causing these symptoms. A complete set of vital signs and blood glucose should be acquired for all agitated patients and additional workup tailored based upon the patient’s presentation. After ensuring respiratory and hemodynamic stability, the next steps are to obtain a complete history and physical. Collateral information from family members, witnesses, paramedics, and other providers is essential. Often, a PCP or psychiatrist can attest to the patient’s baseline behavior or provide additional information about precipitants of patients’ agitation. Physical exam should include a complete neurological exam including assessment mental status and evaluating for meningeal signs, signs of trauma, evidence of toxidromes (assess pupils, heart, bowel sounds, skin) or intoxication. Sepsis can also affect mental status—consider a thorough assessment of the neck, skin, lungs, abdomen and potentially genitalia. 

Tailor the diagnostic testing based upon history, physical, and vital signs. Consider head CT for patients with significant agitation after trauma and investigate potential sources of infection in patients with immune compromise or fever with agitation. Consider urinalysis as UTI may be frequent a source of mental status change in elderly and chronically ill patients. When history is limited, keep a low threshold to order diagnostic tests.

Treatment

Management relies on controlling agitation for the safety of the patient and others in the department. Calming an agitated patient allows the provider to establish a more normal patient-physician relationship and obtain informed consent where needed. When approaching an agitated patient, it is essential to remain composed and to approach with adequate assistance (including security or police if needed). The patient should be evaluated in a safe place with a clear escape route for the examiner. (Do not position the patient between yourself and the door.) Leave the room immediately if you feel in any danger. Do not be embarrassed to ask for help and do not trivialize any threats. It is essential for medical students to communicate with the supervising team before evaluating a potentially dangerous patient. 

Verbal De-Escalation 

Verbal de-escalation should be used whenever possible. The physician must convey professional concern and respect for the patient. Avoid threatening the patient by speaking in a calm and reassuring manner and respecting personal space. Pay attention to your body language and avoid potentially threatening stances such as crossed arms or waving a finger. Acknowledge the patent’s discomfort but speak in a controlled manner and put clear limits on disrupted and dangerous behaviors. The patient should be advised of the consequences for such continued behavior. Often, verbal de-escalation is all that is needed to calm an agitation. In some cases, approaching as a group with a show of force may calm an agitated patient.

Non-Pharmacological Restraint

When attempts at de-escalation are unsuccessful, restraints may be used alone or in conjunction with other interventions. Physical restraints restrict freedom of movement of one’s body including soft wrist or ankle restraints or torso vests attaching to the patient’s gurney. The team should continuously explain what is happening to the patient without threats. The patient should be placed in a calm, quiet area. Always use physical restraints for the briefest possible time until less restrictive measures are effective.

Restrained patients cannot move to protect themselves and sedated patients are at particular risk. For their safety, restrained patients should have a provider in the room constantly and have continual monitoring of vital signs. Seclusion should be initiated only in consultation with a senior emergency physician and in an area without hazards for the patient and where staff can see the patient at all times. 

Whenever placing a patient in restraints, it is essential to comply with safety procedures, monitoring, and documentation standards in compliance with all local hospital and national policies. An attending should evaluate the patient soon after restraints are placed. A plan for removal of the restraints should be communicated with the team with endpoints including establishing of a safe environment for the patient and staff.

Five Point Immobilization is employed to ensure patient and team safety utilizing at least 5 team members. Restraints should be soft and easy to remove if needed (e.g. in case of seizure). Never apply restraints over neck, chest or head and do not use gags.

• Team leader talks to the patient and may control the head
• One person per limb at a major joint
• Grasp all extremities at the same time
• Place the patient supine on the bed
• Apply restraints to each ankle and wrist—attach to bedframe, not rails

Chemical Restraint (Rapid Tranquilization)

In patients who are agitated to the degree that they are unable to participate in less restrictive alternatives, medications may be used to rapidly allow for evaluation of the patient. Chemical restraint is used to control violent and potentially dangerous behavior rather than confining bodily movement. The decision to utilize chemical restraint is clinical. It is never acceptable to initiate its use for staff convenience or patient punishment. When choosing a therapy, consider the objective of reducing agitation with minimal sedation to allow for timely assessment and treatment of any underlying condition requiring immediate medical intervention.

A variety of options are available and should be weighed based on the patient’s history and presentation. Vital signs should be monitored frequently until the patient is ambulatory. Historically, benzodiazepines and antipsychotics are the most common pharmacotherapeutic options. Table 2 shows common choices for chemical restraint. Emergency physicians should be familiar with the use of these medications, their side effects and how to address complications of their use. Anticholinergic medications such as benztropine and diphenhydramine may be used for prophylaxis against extrapyramidal symptoms caused by some antipsychotic administrations.

Table 2: Commonly Used Medications Used in the Chemical Restraint of the Agitated Patient

Some advocates for the use of Propofol in the acutely agitated patient though there is not yet sufficient literature on its use in the Emergency Department for acute agitation. Droperidol is also favored by some due to a shorter duration of sedation than some benzodiazepines. The FDA has placed a black box warning on the drug because, like many other medications, it can cause QT prolongation and an increased risk for the development of torsades de pointes and other serious dysrhythmias, though some studies show it to have similar rates of adverse events to other ED treatments for acute agitation. Any plans to use these drugs should be discussed with an attending, preferably prior to the acute need for use on a patient.

Pearls and Pitfalls

• Utilize collateral history and always attempt to gather additional history from patient after the acute agitation is controlled.
• Always ensure your own safety and make staff aware of any potentially violent patient.
• Obtain finger stick glucose and pulse oximetry as soon as it is safe to do so.
• Consider trauma (and the need for C-spine protection), toxidromes and infection.
• Do not ignore agitation and potential for violence.
  

Case Study Resolution

The patient presented acutely agitated with signs of trauma.  When verbal de-escalation techniques were not successful, the team quickly moved to utilizing chemical and physical restraint for the safety of the patient and the treating team.  The patient was placed on a monitor, remained in direct visual observation of the treating team and a full trauma assessment was completed. Vital signs were repeated and were HR 102, BP 120/80, RR 14, SpO2 98% RA, Temperature 97.4F orally. Blood glucose was 98. Police relayed that they were called to the party for a fight but do not have any further information about the patient or what occurred prior to their arrival and no family could be identified. The patient remained sedated but arousable for the next 2 hours while a CT of his head, lab evaluation, and laceration repair were completed.  When the patient no longer required physical restraints, they were removed. A complete history was taken when the patient was able to participate which revealed no other significant history other than use of drugs that evening. No other complaints or injuries were identified, and the patient was discharged in police custody. 

References

1. Bak M, Weltens I, Bervoets C, et al. The pharmacological management of agitated and aggressive behaviour: A systematic review and meta-analysis. Eur Psychiatry. 2019;57:78-100. DOI: 10.1016/j.eurpsy.2019.01.014 PMID: 30721802
2. Coburn VA, Mycyk MB. Physical and chemical restraints. Emerg Med Clin North Am. 2009 Nov;27(4):655-67, ix. DOI: 10.1016/j.emc.2009.07.003. Review. PubMed PMID: 19932399.
3. Downes MA, Healy P, Page CB, Bryant JL, Isbister GK. Structured team approach to the agitated patient in the emergency department. Emerg Med Australas. 2009 Jun;21(3):196-202. DOI: 10.1111/j.1742-6723.2009.01182.x. PubMed PMID: 19527279.
4. Garris S and Hughes C. Acute Agitation. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cling DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill; 2016.  http://accessmedicine.mhmedical.com/content.aspx?sectionid=109448152&bookid=1658Accessed March 21, 2019.
5. Isaacs ED, Rossi J, Swan MC. The violent or agitated patient. Emerg Med Clin N Am. 2010 (28); 235-256. DOI: 10.1016/j.emc.2009.10.006 PMID: 19945609
6. Isbister GK, Calver LA, Page CB, Stokes B, Bryant JL, Downes MA. Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: the DORM study. Ann Emerg Med. 2010;56(4):392-401.e1. DOI: 10.1016.j.annemergmed.2010.05.037 PMID: 20868907
7. Klein LR, Driver BE, Horton G, Scharber S, Martel ML, Cole JB. Rescue Sedation When Treating Acute Agitation in the Emergency Department With Intramuscular Antipsychotics. J Emerg Med. 2019; Feb 8. DOI: 10.1016/j.jemermed.2018.12.036 PMID: 30745194
8. Le Cong M, Gynther B, Hunter E, Schuller P. Ketamine sedation for patients with acute agitation and psychiatric illness requiring aeromedical retrieval. Emerg Med J. 2012;29(4):335-7. DOI: 10.1136/emj.2010.107946. Epub 2011 May 12. PMID: 21565879
9. Lukens TW, Wolf SJ, Edlow JA, et al. Clinical policy: Critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med. 2006 Jan;47(1):79-99. DOI: 10.1016/j.annemergmed.2005.10.002  PMID: 16387222
10. Mason J, Colwell CB, Grock A. Agitation Crisis Control. Ann Emerg Med. 2018;72(4):371-373. DOI: 10.1016/j.annemergmed.2018.08.004 PMID: 30236325
11. Martel M, Sterzinger A, Miner J, Clinton J, Biros M. Management of acute undifferentiated agitation in the emergency department: a randomized double-blind trial of droperidol, ziprasidone, and midazolam. Acad Emerg Med. 2005;12(12):1167-72. DOI: 10.1197/j.aem.2005.07.017  PMID: 16282517
12. Nazarian DJ, Broder JS, Thiessen MEW, et al. Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department. Ann Emerg Med. 2017;69(4):480-498. Doi: 10.1016/j.annemergmed.2017.01.036 PMID: 28335913
13. Zun LS. 2005. Evidence Based Evaluation of Psychiatric patients. Journal of Emergency Medicine. 28(1):35–39. DOI: 10.1016/j.jemermed.2004.10.002  PMID: 15657002