Agitation

Chief complaint: You have been asked to see a 43-year-old male with a traumatic brain injury who is currently admitted to an inpatient rehabilitation unit. His nurse states that the patient is agitated and asks for your assistance.

DOMAIN A: DATA ACQUISITION

+ What are the key components of this patient’s history and physical examination?

Relevant History:

  • Is the patient currently a danger to himself or others?
  • How long ago was his TBI?
  • What severity was his TBI?
  • Are his current symptoms worse than his typical symptoms of agitation? How does his agitation typically manifest?
  • What is the patient’s neurologic baseline and has there been any recent change from this baseline?
  • Are there any stimuli or circumstances which worsen his agitation or improve it?
  • Is he prescribed any medications to address his agitation? Has he been taking them?
  • Does the patient appear to be in pain?
  • Past Medical and Surgical History?
  • Family history?
  • Current medications?

Relevant Physical Examination:

  • Vital signs
  • General appearance and current behaviors
  • Mental status examination
  • Cranial nerve examination
  • Manual muscle testing
  • Brief sensory examination if tolerated
  • Additional examination: heart, lungs, abdomen, extremities, skin - emphasis on looking for any pain generators or signs of other underlying etiology
 

DOMAIN B: PROBLEM SOLVING

The patient’s recent baseline is described as Ranchos Level 4: he is confused, disoriented, and agitated. You learn that over the past 24 hours he has become more irritable and has been refusing therapies, vital checks, and other care. On examination he is pacing his room and yells at you as you enter. While no new neurologic deficits are noted, your examination is limited by extremely poor participation.

+ What is your differential diagnosis for this change in status?

  • The differential diagnosis is broad, especially given the limited examination. New intracranial pathology (especially intracranial bleed, hydrocephalus, seizures) should be considered. I would also consider infection (especially UTI, pneumonia, meningitis). Hunger, pain, thirst, drug intoxication or withdrawal, medication toxicity, hypoxia, endocrine changes, metabolic disturbance, or other electrolyte disorders are also on my differential. Finally, the patient may just be overstimulated.

+ Would you order any labs or imaging at this time? If so, which specific tests?

  • In the patient’s current state it may be difficult to obtain labs or vitals. I would try to deescalate the patient before any labs or imaging. I would like to obtain at least a CT head and basic labs to start (CBC, BMP, and UA).

+ Challenge Question

  • In general, what are the pros and cons of obtaining a CT head without contrast vs an MRI brain without contrast in a brain injured patient?

+ Challenge Answer

  • CT studies can be done much more quickly and are less sensitive to patient motion. CTs without contrast show bone and intracranial bleeding better than MRIs, while MRIs show the brain tissue and other soft tissue in more detail. CTs can be safely done in patients with metal foreign bodies, implantable medical devices, etc, while the magnetic fields in MRIs could affect these devices or potentially cause patient harm. Unlike CTs, MRIs do not use ionizing radiation.
 

DOMAIN C: PATIENT MANAGEMENT

Your workup, including CT head and labs, has been unremarkable and the patient has actually improved on his own. He remains confused and agitated but is tolerating therapies and appears much calmer. You suspect that his earlier aggression was due to his post-traumatic amnesia and confusion.

+ What steps would you take to prevent further episodes of aggression in the future?

  • I would start with environmental modifications, including creating a quiet environment by turning off televisions and limiting visitors, reorientation as appropriate, adjusting lighting to promote appropriate sleep/wake cycles, and permitting a degree of psychomotor restlessness as part of the recovery process.
  • I would make sure that evening medications are ordered to promote sleep, such as melatonin or trazodone.
  • If other pharmacologic measures are needed to control dangerous behaviors, I would consider both scheduled and PRN medications. Scheduled medications may include propranolol, valproic acid, antidepressants, or atypical antipsychotics (among others). PRN medications may include atypical antipsychotics, trazodone, and potentially short-acting benzodiazepines.
 

DOMAIN D: SYSTEMS-BASED PRACTICE

You notice that the patient had to wait over three hours to be transported down to his stat CT head at your hospital’s radiology department.

+ How would you attempt to improve this process?

  • A three-hour wait for a stat CT is unacceptable so I would want to find out how to prevent this in the future. I would start by collecting data on average wait times for CTs - I could potentially do this by looking at the times that orders are placed in the EMR and comparing them to when the CTs are actually recorded in the EMR. If a trend is noted, I would bring this to hospital administration and would ask if it is something that they are already aware of. It is likely that there is some “weakest link” in the process - potentially transport personnel availability, CT scanner availability, order processing time in the EMR, etc. I would strongly encourage them to address these deficiencies in order to provide the best possible patient care.
 

DOMAIN E: INTERPERSONAL AND COMMUNICATION SKILLS

This is our role-playing portion of the case.

Your patient has been doing well. Your co-worker, another physician, approaches you one morning and says that he saw the patient’s face in the evening news for circumstances surrounding his firearm-related TBI. Your co-worker asks you about his recovery.

+ What is your response?

  • “I need to respect HIPAA for my patients, so I can’t share any information about his care with you, but thank you for letting me know that this individual was in the news. ”
  • Note: You should not share any information about the patient. You should remain respectful in all of your interactions, even if you feel that someone else has made a mistake.