Behavioural presentations get triaged to psychiatry and the physiological screen never happens. The patient is restrained or sedated, admitted to a mental health unit, and the hypoglycaemia, hypoxia, sepsis or subdural haematoma driving the agitation is found hours later or not at all.
Four numbers can be obtained on almost anyone, however combative: capillary glucose, temperature, oxygen saturation and pulse. If a finger is impossible, an ear or forehead probe and a tympanic temperature will do. Add pupils and a look for head injury while you are close. These take under a minute and exclude most of the immediately reversible causes.
The pattern that should always stop you is new agitation in someone with no psychiatric history, particularly over 65 or with any fever, focal sign or fluctuating conscious level. That is delirium until proven otherwise, and delirium has a cause. Sedation given without those four numbers does not just delay the diagnosis — it removes the conscious level that would have shown you the deterioration.
- Get glucose, temperature, saturations and pulse before or immediately after sedating anyone
- New agitation with no psychiatric history is delirium until proven otherwise
- Check the pupils and look for head injury while you are at the bedside
- Record a conscious level before sedation so that later changes mean something
- Ask about alcohol, benzodiazepines and anticholinergics — withdrawal and toxidromes are both common and both reversible
Why it matters
Sedation removes the only sign — conscious level — that would have revealed the medical cause you did not look for.
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