What is the workup for a patient presenting with increased agitation?

Workup for Increased Agitation

The management of acute agitation requires a systematic approach beginning with verbal de-escalation techniques, followed by identification of underlying causes, and pharmacological intervention only when necessary.

Initial Assessment and Safety Measures

• Ensure safety of patient, staff, and others in the area 1, 2
• Implement verbal de-escalation strategies:
  • Respect personal space (maintain two arms' length distance)
  • Minimize provocative behavior (calm demeanor, visible unclenched hands)
  • Establish verbal contact with one designated staff member
  • Use concise, simple language
  • Identify patient's goals and expectations
  • Practice active listening
  • Set clear limits and expectations
  • Offer choices and optimism 1

Diagnostic Workup

Screen for underlying reversible causes:

1. Metabolic disturbances:

   • Point-of-care glucose testing (mandatory for all agitated patients) 3
   • Electrolyte abnormalities
   • Renal/hepatic dysfunction

2. Infectious causes:

   • Urinary tract infection (especially in elderly)
   • Pneumonia
   • Sepsis
   • CNS infection 1

3. Neurological causes:

   • Stroke/TIA
   • Seizure (including post-ictal states)
   • CNS lesions/trauma 1

4. Toxicologic/medication-related:

   • Medication effects or withdrawal (especially benzodiazepines, opioids, anticholinergics)
   • Substance intoxication or withdrawal
   • Polypharmacy (particularly in elderly) 1

5. Hypoxia - Check oxygen saturation 1

6. Other causes:

   • Bowel obstruction/constipation
   • Bladder outlet obstruction
   • Pain 1

Pharmacological Management

If verbal de-escalation fails and medication is necessary:

First-line options:

1. For unknown etiology or psychiatric cause:

   • Haloperidol 5-10 mg IM (2-5 mg for elderly/debilitated patients) 4, 5
   • Can repeat as often as hourly, though 4-8 hour intervals may be sufficient 5

2. For alcohol withdrawal or sedative-hypnotic withdrawal:

   • Lorazepam 2-4 mg IM/IV 1, 4
   • Diazepam 5-10 mg IM/IV initially, then 5-10 mg in 3-4 hours if necessary 6

3. For cooperative patients:

   • Oral medications preferred: risperidone, olanzapine, or lorazepam 4

Combination therapy:

• Haloperidol + lorazepam for more rapid sedation than monotherapy 4, 7
• For refractory agitation despite high doses of neuroleptics, consider adding lorazepam 0.5-2 mg every 4-6 hours 1

Special populations:

• Elderly patients:

  • Lower doses (haloperidol 0.5-1 mg bid)
  • Consider atypical antipsychotics: risperidone (0.5-1 mg bid), olanzapine (2.5-15 mg daily), or quetiapine (50-100 mg bid) 1

• Children/adolescents:

  • Haloperidol 0.5-1 mg may be used, with repetition as needed 4
  • For tetanus in infants over 30 days, 1-2 mg IM/IV slowly, repeated every 3-4 hours 6

Monitoring

• Monitor vital signs and mental status continuously
• Watch for extrapyramidal symptoms with antipsychotics
• Monitor for QT prolongation with haloperidol
• Watch for respiratory depression with benzodiazepines 4

Common Pitfalls to Avoid

1. Mistaking agitation for pain - can lead to inappropriate opioid administration which may worsen delirium 1

2. Overlooking delirium - agitation may be the presenting symptom of delirium, which has high morbidity and mortality if untreated 1

3. Excessive sedation - can mask underlying conditions and lead to respiratory depression 7

4. Premature physical restraint - should be used only as a last resort when other measures fail 1, 2

5. Failing to transition to oral medication - switch to oral therapy as soon as practicable to maintain control 5, 7

By following this systematic approach to the agitated patient, clinicians can effectively manage symptoms while identifying and treating the underlying cause, ultimately improving patient outcomes and reducing the risk of adverse events.