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Emergency and Acute Medicine – Agitation
Overview and Definition
Agitation is a state of extreme restlessness marked by increased verbal activity, motor activity, or both. It represents a broad clinical spectrum ranging from excessive talkativeness to aggressive, threatening, or violent behavior. Agitation may be the presenting feature of numerous medical (organic) or psychiatric (functional) conditions and therefore requires careful and systematic evaluation in the emergency setting.
Clinical Significance and Special Forms
Agitation varies widely in severity and includes life-threatening entities such as excited delirium syndrome. This condition is characterized by severe agitation, metabolic acidosis, and hyperadrenergic autonomic dysfunction, and is associated with a risk of sudden cardiac death, particularly following prolonged physical struggle or restraint. Early recognition and intervention are critical to reduce morbidity and mortality.
Epidemiology
Behavioral disturbances account for approximately 6% of all emergency department visits, translating to an estimated 1.7 million visits annually in the United States. Agitated patients frequently require significant ED resources and pose safety challenges for staff and other patients.
Etiology
Agitation has a wide differential diagnosis. Medical causes include infections such as meningitis, encephalitis, and sepsis-related delirium; metabolic disturbances including hypoglycemia, electrolyte abnormalities, renal or hepatic failure, and acid–base disorders; endocrine emergencies such as thyroid storm; pulmonary causes including hypoxia and hypercapnia; toxicologic causes such as intoxication or withdrawal states; and neurologic disorders including stroke, intracranial hemorrhage, postictal states, or brain tumors. Psychiatric causes include mood disorders (mania or agitated depression), psychotic disorders such as schizophrenia, and severe anxiety disorders.
History and Clinical Assessment
A detailed history and physical examination are essential in distinguishing organic from functional causes of agitation. The history of present illness alone has high sensitivity for detecting underlying medical illness in patients presenting with psychiatric symptoms. When the patient is unable to provide a reliable history, collateral information should be obtained from family, friends, emergency medical services, or caregivers. Key historical points include trauma, recent infection, medication use, substance exposure, psychiatric history, and neurologic symptoms.
Physical Examination
A comprehensive physical examination is mandatory. Abnormal vital signs should prompt an aggressive search for medical causes. Hyperthermia may suggest infection, neuroleptic malignant syndrome, serotonin syndrome, or excited delirium. A toxidrome-oriented examination should include pupillary size, skin findings, sweating patterns, and urinary retention. A focused but thorough neurologic examination is critical, as focal deficits mandate evaluation for structural or metabolic disease. Cognitive testing is particularly important, as impaired attention, memory, or orientation suggests delirium rather than a purely psychiatric disorder.
Diagnostic Evaluation
The extent of diagnostic testing should be guided by clinical suspicion. At a minimum, all agitated patients require a full set of vital signs, a complete physical and neurologic examination, and bedside blood glucose testing. Additional laboratory studies, imaging, or procedures should be tailored to suspected etiologies. Head CT imaging is indicated in patients with trauma or neurologic deficits, while lumbar puncture should be considered when CNS infection is suspected and no source is otherwise identified.
Prehospital and Initial Management
Prehospital providers should follow established protocols for physical and chemical restraint and provide advance notification to the receiving facility. Initial emergency department management focuses on airway, breathing, and circulation, with prompt treatment of any life-threatening conditions. Severely agitated patients may pose immediate danger and should be placed in a controlled environment, changed into hospital attire, and searched for weapons to ensure safety.
Management of Agitation
Treatment should be directed at the underlying cause whenever possible. Verbal de-escalation techniques are first-line therapy for mild to moderate agitation. When pharmacologic intervention is required, benzodiazepines are preferred for alcohol withdrawal, while antipsychotics are first-line for agitation due to primary psychiatric disorders. Combination therapy may be necessary for severe agitation. Physical restraints should be used only when necessary and always in conjunction with chemical sedation to minimize complications.
Disposition and Follow-Up
Disposition depends on the etiology and resolution of agitation. Admission is indicated when an underlying medical or psychiatric condition requires inpatient management. Discharge should be reserved for patients whose agitation has resolved and who can be safely managed as outpatients. Appropriate psychiatric or substance-use referrals should be arranged, and follow-up tailored to the underlying diagnosis.
Pearls and Pitfalls
Clinicians must maintain a high index of suspicion for medical causes of agitation, particularly in patients with new onset after age 45, abnormal vital signs, focal neurologic deficits, acute onset, visual hallucinations, or impaired cognition. Common pitfalls include failure to undress and search patients for weapons, inadequate sedation, prolonged or poorly monitored restraint use, and insufficient documentation of clinical decision-making and restraint justification.
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