How do you differentiate agitation from emergence in a patient?

Differentiating Agitation from Emergence

Agitation during emergence from anesthesia is a distinct clinical entity characterized by psychomotor excitation that occurs specifically during the recovery period from general anesthesia, while agitation in other contexts represents a broader behavioral disturbance with numerous potential causes.

Key Distinguishing Features

Emergence Agitation

• Timing: Occurs specifically during awakening from general anesthesia 1
• Duration: Self-limited state confined to the emergence period as consciousness is restored 1
• Context: Always follows administration of general anesthesia
• Presentation: Psychomotor excitement that may include violent behavior as consciousness returns 1
• Risk factors: Young adults, otolaryngology procedures, volatile anesthetic maintenance, PTSD in veterans 1
• Mechanism: Theoretical underblunted sympathetic activation in response to internal stimuli (flashbacks, anxiety) or external stimuli (surgical pain) during return of consciousness 1

General Agitation

• Timing: Can occur at any time, not specifically tied to anesthesia recovery
• Duration: May persist for extended periods until underlying cause is addressed
• Context: Multiple potential causes including medical, psychiatric, and substance-related 2
• Presentation: Behavioral features such as destructiveness, disorganization, or dysphoria 3
• Risk factors: Medical illness, drug ingestions, psychiatric disorders, substance abuse 3
• Mechanism: Varies based on underlying etiology - may be due to medical conditions, psychiatric disorders, or substance-related causes 2

Assessment Algorithm

1. Determine context:

   • Was the patient recently under general anesthesia? → Consider emergence agitation
   • No recent anesthesia? → Evaluate for other causes of agitation

2. If emergence agitation suspected:

   • Assess timing in relation to anesthesia emergence
   • Look for self-limited nature confined to emergence period
   • Consider preventive measures for future anesthesia (dexmedetomidine, ketamine) 1
   • For veterans, implement patient-centered rapport tactics and identify/avoid PTSD triggers 1

3. If general agitation suspected:

   • Rule out medical causes first:
     • Obtain point-of-care glucose test for all patients 4
     • Evaluate for signs of medical illness, drug toxicity, or substance intoxication 3
     • Consider infectious, metabolic, neurologic, or toxicologic etiologies 4
   • Assess psychiatric factors:
     • History of psychiatric illness
     • Presence of psychotic symptoms
     • Evidence of mood disorders

Management Considerations

Verbal De-escalation (First-Line for General Agitation)

• Engage the patient verbally
• Establish a collaborative relationship
• Verbally de-escalate out of the agitated state 5
• Respect personal space (maintain two arms' length distance) 3
• Create a calming physical environment with decreased sensory stimulation 3

Pharmacological Management (When Verbal De-escalation Fails)

For undifferentiated agitation requiring rapid control:

• First choice: Droperidol 5 mg IM or midazolam 5 mg IM (achieves sedation in approximately 18.3 minutes) 6
• Alternative: Lorazepam 2-4 mg IM (longer duration, approximately 217 minutes to arousal) 6
• For known psychiatric illness: Haloperidol 5-10 mg IM (onset approximately 28.3 minutes) 6
• For severe agitation not responding to initial treatment: Combination of haloperidol 5-10 mg + lorazepam 2 mg IM 6

Common Pitfalls to Avoid

1. Failing to rule out medical causes: Always consider that agitation may be a symptom of an underlying medical condition, especially delirium masquerading as a psychiatric condition 3

2. Premature use of restraints: Physical restraints should be used as a last resort after verbal de-escalation and pharmacologic interventions have failed 5

3. Overlooking substance intoxication: Cognitive function should be assessed individually rather than relying on specific blood alcohol levels 3

4. Medication side effects: Be aware that antipsychotics and medications used to manage extrapyramidal symptoms can potentially exacerbate agitation due to anticholinergic side effects 3

5. Inadequate monitoring: Always monitor vital signs, level of consciousness, and respiratory status after administering sedative medications 6

By systematically evaluating the context, timing, and clinical presentation, clinicians can effectively differentiate between emergence agitation and other causes of agitation, leading to appropriate management strategies that prioritize patient safety and comfort.