Efficient Evaluation of the Patient with Agitation

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Efficient Evaluation of the Patient with
Agitation

• Marc L. Martel, MD

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Learning Objectives

• Understand the process and expectations of
  medical clearance of the agitated patient.
• Recognize the limitations and controversy
  surrounding medical evaluation of the psychiatric
  patient.
• Evaluate the patient with acute agitation
  according to ED protocol to determine the
  underlying etiology and appropriate interventions.

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Efficient Evaluation

• aka Medical Clearance
• Definition
• Purpose
• 3 Categories
• No physical illness
• Known co-morbid condition(s) not acute
• Acute medical condition stabilized

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Expectations

• Psychiatrists
• Medically evaluated
• Minimal risk of deterioration in the patient /
  patients condition
• EPs
• Psychiatric evaluation

5
Reality

• Absolution
• Psychiatric physical examination
• 13-17 routinely perform PEs
• ED evaluation
• Lack of documentation

6
Medical Clearance

• Significant disparity
• Conservative evaluation
• 4-12 incidence of important medical disorders
• Self reporting 92 specific 91 sensitive
• Liberal evaluation
• SMA-34 abnormal in 60/100 patients
• ED patients with new ? CC, 63 organic

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Standard Approach

• Call for standardization
• Evaluation Tool
• Prospective protocols
• Patient specific
• History
• Physical examination
• MSE

8
ED Evaluation

• Behavioral Issue THEN
• Prior Psychiatric History
• No
• Medical Evaluation
• Normal
• Admission versus Psych Evaluation
• Abnormal
• Treatment versus Medical Admission

9
ED Evaluation

• Behavioral Issue
• Prior Psychiatric History
• Yes
• Is presentation similar
• Yes
• Meet Psychiatric Admission Criteria?
• No
• ED Intervention Necessary Outpatient psych
  versus discharge home