Restless state

Does the thought of an agitated patient make you feel a little on edge? Take 10 minutes to work through this module and leverage your AMBOSS resources!

You are the internal medicine night float. It's 4 am, and you've finally found a peaceful moment to lie down in the call room. Now that you're trying to rest, you realize that you've had 6 cups of coffee and probably half a pound of graham crackers this shift. Some might say you're jittery. You prefer to call it hyperkinetic. Regardless, you jump out of your skin when the pager goes off just 2 minutes after you assume the supine position.

Click the pager icon to reveal the message.

Perhaps the lion sleeps tonight, but it appears that nobody else will. Now you have a decision to make.

Question: How urgently should you assess the patient?

Make your choice, then click on the explanation bubble to reveal the answer.

• Right now
• After resting your eyes for 10 minutes
• Leave the issue for the primary team; it will either resolve itself or the team can address it when they preround in a couple of hours.

You head over to assess the patient. While you're in the elevator, you have a moment to collect your thoughts.

Question: What information is most crucial to know, and how are you going to find it?

Read on to see the bits of information you should collect quickly, as well as how to find them.

Signout sheet review

Review your signout sheet for clues to the etiology of the patient's agitation. Inherent biases can predispose clinicians to attribute agitation to mental health issues, but some life-threatening medical conditions can also cause agitation.

• Age
• Admission diagnosis or reason for hospitalization
• Past medical history, procedures, and interventions
• Medications
• Allergies
• Recent laboratory results

Unless patient and/or staff safety is at immediate risk, investigate medical causes for acute agitation before escalating interventions (e.g., administering a parenteral calming medication).

More information, please...

The signout sheet often provides relatively static information about the patient (e.g., how they were at 4 pm), but dynamic changes are usually more important in determining the etiology of agitation. Prioritize the following information so you can collect it as quickly as possible from the patient's nurse.

• Onset and progression of symptoms
• Other associated signs or symptoms

The elevator doors open, and the calming effect of the piped-in Muzak immediately dissipates as you encounter frenetic activity at the nurses' station, intensified by the flickering fluorescent lighting overhead. At least you're wide awake thanks to that 6th cup of coffee.

The unit clerk, who is simultaneously talking on the phone and entering information into a computer, points you vaguely toward a nurse at the back of the station. The nurse waves half-heartedly.

Question: What do you do next?

Make your choice, then click on the explanation bubble to reveal the answer.

• Ask the nurse your questions, then evaluate the patient by yourself to keep things calm.
• Ask the nurse if she noted any risk factors for violence.
• Activate the behavioral emergency response team.

Know if your hospital has a behavioral emergency response team and how to activate it. If your hospital does not have one, know how to contact security.

Reading the signs

The following signs portend increased risk of violence.

• Verbal signs
  • Expression of frustration or anger
  • Loud, threatening, or insulting speech
  • Repetitive mumbling
• Behavioral signs
  • Suspicious or angry affect
  • Staring or avoidance of eye contact
  • Pacing and/or restlessness
  • Threatening gestures
  • Signs of anxiety or agitation
• Other patient factors
  • Evidence of drug or alcohol use
  • Presence of a weapon or something that could be used as a weapon

Do not approach patients alone if there are signs of potential for violence and/or multiple risk factors for violent behavior.

You take a deep breath. Evaluating an agitated patient is stressful! You remind yourself to be objective...and to not take anything personally.

Question: What red flags can you immediately assess from the doorway?

Make your choices, then click on the explanation bubbles to reveal the answers.

• Signs of potential for violence
• Abnormal vital signs
• Clinical features of respiratory distress
• Neurological abnormalities
• Clinical features of psychosis

That's right—all of the above!

Begin your evaluation at a distance. Summon additional help immediately if there is potential for violence. Approach the patient only when it is safe to do so.

“The hardest choices require the strongest wills.”

Question: Which clinical scenario would you like to explore?

Choose an option to continue the module:

• Option 1: Severe agitation with signs of potential violence
• Option 2: Restless but no imminent signs of violence

Your patient is calmer now, and so are you. Maybe you can even go settle down in the call room again...

You did a great job:

• Ensuring patient and staff safety and obtaining appropriate safety support when necessary
• Assessing the patient's level of agitation
• Reviewing appropriate pharmacological therapy for severe agitation (Option 1)
• Implementing de-escalation techniques (Option 2)
• Ordering appropriate initial diagnostic tests (Option 2)
• Considering critical medical causes of agitation and tailoring management accordingly (Option 2)

Congratulations on completing this module. Hopefully you now feel more comfortable assessing a patient with agitation!

Personal story from an AMBOSS clinician

I was on a psychiatry elective rotation. One day, while rounding on inpatient psych consults, our team was assessing a patient's decision-making capacity and recommending treatment for her psychiatric condition. She had a diagnosis of bipolar disorder and was in an active manic episode, displaying pressured speech and irritability. Her primary team was treating her for tuberculosis infection, and she had tried to leave against medical advice but was prevented from doing so because of the public health concern. Being held against her will, she was understandably agitated and distrustful of the medical staff. But as a result of her manic state, she had also been making verbal threats of physical harm toward the staff.

Because the patient was being treated for active tuberculosis, she was in an airborne infection isolation room with a double door. To evaluate her, our entire team of five donned our PPE and entered the room, closing both doors behind us. Our soft-spoken attending took the lead and began to speak with the patient to get a better sense of her current mental state. Despite our attending's calm voice and nonthreatening demeanor, things quickly took a turn for the worse. The patient's agitation escalated and, before we could intervene, she punched our attending square in the face.

We quickly exited the room and called security to assist us. Fortunately, our attending did not sustain any long-term injuries. But the memory stayed with me throughout residency. In hindsight, it was a mistake to have the entire team present for the attending's interview, given the patient's distrust of medical personnel at the time. In addition, we should have been wary of entering the patient's room without security backup, since she had made recent threats of harm toward the staff and the isolation room required closing not one, but two, doors behind us and prevented a quick exit.

The lesson I learned: Situations involving patients with agitation can escalate to violence quickly and unexpectedly. Avoid placing any barriers between yourself and a safe exit, and have a low threshold for taking backup with you.