TBI Agitation

[zenman]

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29 yr old male with hx of heroin and cocaine abuse with new TBI due to ATV accident (no helmet). I saw him on med/surg floor and started Depakote 500 mg twice a day. He was mostly staying under the covers but was inappropriate and agitated at times.

He was then dumped on PM&R unit which is not equipped to handle TBI. He's now strolling around the unit, pulling fire alarms, eloping, threatening staff. The unit is on lockdown and patient is on 3:1 staff. PM&R doc started Buspar 5 tid. Depakote level was 53. Pt refused further lab draws but I increased Depakote to 500 mg am and 1,000 QHS. PM&R doc getting more frustrated so my psychiatrist came over and suggested scheduled Klonopin. PM&R doc thought Seroquel would be better. I think he would up yesterday getting 50 mg bid. She then switched to scheduled Klonopin. She called us again late yesterday and I brought over our new locums psychiatrist. He suggested a cocktail of Haldol 10 mg, Ativan 2 mg and Benedryl 50 mg. PM&R doc was leery of Haldol as she thought it was not conducive to brain healing but the locums guy told her the patient needed to be under control. I see the PM&R doc went with less Haldol (5 mg) and more Benedryl (100 mg). We'll see the patient again this morning.

Any suggestions? PM&R doc is at her wit's end.

 

[SuperSoccer19]

your PM&R doc seems to have been given advice by a psychiatrist and she seems to not take that advice.

 

[OldPsychDoc]

How much "brain healing" is he going to get in his present state? 🙄

I'd personally be a bit less excited about the benzo in brain injury just because of the risk of disinhibition, but if you trust your attendings...

Depakote and risperidone are my go-to meds for broken brains.

(Oh--and a PM&R unit that's not equipped to deal with brain injury???? Find a new PM&R unit!)

 

[nitemagi]

1. Eval for delirium.
2. Up the depakote
3. Make sure he's sleeping
4. Minimize benzo's unless there's direct evidence it's helping not disinhibiting
5. I'd minimize benadryl as anticholinergics are a big concern if confusion is a factor. If you have to use an antihistamine, go with vistaril (minimal anticholinergic effects)

 

[Encephalopathy]

I learned from a neuropsychiatrist that beta-blockers are first-line for TBI-associated aggression. There's some evidence for propranolol titrated up to 420 mg/day:

http://www.ncbi.nlm.nih.gov/pubmed?term=14660233

 

[zenman]

How much "brain healing" is he going to get in his present state? 🙄

I'd personally be a bit less excited about the benzo in brain injury just because of the risk of disinhibition, but if you trust your attendings...

Depakote and risperidone are my go-to meds for broken brains.

(Oh--and a PM&R unit that's not equipped to deal with brain injury???? Find a new PM&R unit!)

I'd have rolled my eyes too at "brain healing" if I wasn't looking directly at her. I also like Depakote and risperidone...perhaps I should buy stocks. And the PM&R unit is in a small general hospital so they are limited.

 

[vistaril]

29 yr old male with hx of heroin and cocaine abuse with new TBI due to ATV accident (no helmet). I saw him on med/surg floor and started Depakote 500 mg twice a day. He was mostly staying under the covers but was inappropriate and agitated at times.

He was then dumped on PM&R unit which is not equipped to handle TBI. He's now strolling around the unit, pulling fire alarms, eloping, threatening staff. The unit is on lockdown and patient is on 3:1 staff. PM&R doc started Buspar 5 tid. Depakote level was 53. Pt refused further lab draws but I increased Depakote to 500 mg am and 1,000 QHS. PM&R doc getting more frustrated so my psychiatrist came over and suggested scheduled Klonopin. PM&R doc thought Seroquel would be better. I think he would up yesterday getting 50 mg bid. She then switched to scheduled Klonopin. She called us again late yesterday and I brought over our new locums psychiatrist. He suggested a cocktail of Haldol 10 mg, Ativan 2 mg and Benedryl 50 mg. PM&R doc was leery of Haldol as she thought it was not conducive to brain healing but the locums guy told her the patient needed to be under control. I see the PM&R doc went with less Haldol (5 mg) and more Benedryl (100 mg). We'll see the patient again this morning.

Any suggestions? PM&R doc is at her wit's end.

well I mean this is not 'high level' management......you are limited in what you can do and what will work. We see these patients all the time, and it's pretty straightforward management. You use sedating antipsychotics and probably with Depakote as well, and in his current state on the inpt unit just titrate the injectible antipsychotic up to whatever is required. He's pulling firearms and stuff and required sitters, so you're primary mode of management at this point is to get that under control at pretty much any cost, which you are going to do with sedating antipsychotics primarily......just pick one and if it doesn't work so great increase the dose or try another.

 

[vistaril]

I'd have rolled my eyes too at "brain healing" if I wasn't looking directly at her. I also like Depakote and risperidone...perhaps I should buy stocks. And the PM&R unit is in a small general hospital so they are limited.

regarding AP selection in this sort of patient, there is no real "right" choice.....ask 50 different academic C-L psychiatrists and maybe 7 would use Haldol, 7 risperdal, 7 zyprexa IM, etc.....just pick one and go from there.