When “Agitation” is a Medical Crisis: A Case Series of Barriers to Best Practice Guidelines for Evaluation of Medical Illness in Patients with Reported Agitation

Abstract:
Background

The Best practices in Evaluation and Treatment of Agitation (BETA) published by the American Association for Emergency Psychiatry (AAEP), influenced The Expert Consensus in 2016. Both described symptoms concerning for underlying medical etiology of agitation (“abnormal vital signs”, “abnormal physical exam findings”) that require further evaluation to exclude medical conditions.

Methods

The following case series from a large county and academic medical center demonstrates remaining barriers between guidelines and implementation. These three patients seen between September 2023 and March 2024 were in 4-point restraints with delayed recognition of medical emergencies because of attribution of their symptoms to agitation or agitation medications.

Results

1. 43-year-old Black woman admitted for rhabdomyolysis, AKI and altered mentation with agitation. Day 3 of hospitalization, the C-L team entered to find nurses tightening restraints for “repeated headbanging” and tensing of extremities. She was diaphoretic, minimally responsive with abnormal movements, febrile, hypertensive, tachycardic, and tachypneic and deemed acute epilepticus.

2. 18-year-old Guatemalan, K’iche speaking, man admitted for altered mentation and agitation with catatonia was in the ICU with 4-point restraints. Nursing reported increased agitation. He was febrile, hypertensive, tachycardic, tachypneic, diaphoretic, speaking nonsensically with severe muscle rigidity and opisthotonos. While the primary team continued to suspect psychiatric etiology, the infectious disease team, consulted after urging from C-L, diagnosed tetanus with no further episodes of “agitation” after treatment.

3. 53-year-old Black man brought in by police from a group home for “agitation” (later revealed to be secondary to a sexual assault) was placed in 4-point restraints and received emergent intramuscular haloperidol and midazolam. Vitals were not taken at admission due to agitation. 15 minutes later he became diaphoretic, bradycardic, and hypotensive presumed to be a reaction to haloperidol. In 2 hours he received benztropine, solumedrol and two doses of epinephrine without improvement. Eventually, repeat workup showed an NSTEMI requiring cardiac catheterization.

Discussion

Possible discrepancies between consensus guidelines and clinical practice for medical evaluation in agitation include the following:

a) Failure of guidelines to define abnormal vitals or physical exam findings


b) Failure of the guidelines account for mild vital or physical exam abnormalities seen in agitated patients without medical emergency, thereby making abnormalities seem less noteworthy to medical staff


c) Lack of recommendations for medical reevaluation of patients already in restraints

Conclusion:

In this submission we will address discrepancies by proposing a rating scale of objective data and severity to establish risk of medical etiology to aid in the evaluation of medical emergencies in patients presenting with agitation.