CPCP on Agitation and Aggression in TBI by Medical Student Dwijavanthi Kumar

Coming at you with yet another great Clinical Problems in Consult Psychiatry (CPCP) presentation. CPCP is the ongoing quality improvement program in consultation psychiatry that is my answer to the Maintenance of Certification (MOC) Performance in Practice (PIP). This week one of our talented 3rd year medical students, Dwijavanthi Kumar, put together a game-changer on how consultation psychiatrists can improve on their ability to provide practical, evidence-based recommendations to help colleagues provide safe, humanistic, and excellent medical care to patients suffering from the behavioral challenges associated with acute traumatic brain injury (TBI). The issue with patients who have traumatic brain injuries is that they can be irritable, agitated, and aggressive. It’s not always appropriate to give them the usual antipsychotics that we often recommend for managing agitated and aggressive behavior that we might see in patients who are delirious for other medical reasons. Conceptually, psychiatric consultants frequently think of acute brain injury as being one of the many medical causes of delirium. Not all medical specialists think of acute TBI that way.

The challenge is to collaborate with physiatrists, rehabilitation specialists,  and physical therapists based on the medical literature regarding the use of benzodiazepines and antipsychotics like haloperidol. Haldol is not the treatment for delirium; you’ve heard me say that here many times. However, the reason antipsychotics are often used is because patients who are disruptive and disorganized may behave in ways that make it difficult for the medical team to find and treat the underlying causes of delirium. And benzodiazepines can cause delirium by themselves, unless the cause of the delirium is alcohol or benzodiazepine withdrawal. What Dwijavanthi discovered is that the literature suffers from a dearth of controlled studies (there are actually none available) and that haloperidol and by extension other antipsychotics may impede recovery from TBI while prolonging post traumatic amnesia. Benzodiazepines can paradoxically disinhibit patients with TBI and make them even more aggressive.

As always, the main thing we can do is be there for patients struggling with their emotions, scattered thoughts, and impulsive behavior. They’re not always completely unaware of how their remarks, outbursts, and hurtful actions affect those around them, even to the point of alienating those who love them most. Loving them may not always seem like it’s enough. Caring for them may sometimes seem pointless. Don’t just do something… sit there. Sometimes just this can go a long way toward easing their pain.

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