Subtype of delirium occurring during PTA characterized by excesses of behavior like aggression, akathisia, disinhibition and/or emotional lability
Usually with frontotemporal lesions (affecting arousal, attention, executive control, memory, limbic behavioral functions)
Usually occurs as patients become more responsive in early stages of recovery
Usually lasts 1-14 days but can last longer
safe, structured, low-stimulus environment
- Quiet private room, remove lines/tubes as much as possible
- Floor bed with padded side panels, sitter, avoid taking patient off unit
- One person speaking, one topic/idea at a time, maintain familiar staff
- Allow patient to pace or move in bed with supervision, tolerate some restlessness
- Antipsychotic agents: via dopamine pathways
- Could cause neuroleptic malignant syndrome (treat w/ dantrolene/beta blockers)
|block D2 receptors (and H, 𝛂1, cholinergic receptors)|
|Haldol can prolong PTA and slow motor recovery.
Avoid in TBI!
less D2 blockage, more serotonin blockage (5-HT2)
Less likely motor side effects but frequent metabolic side effects
|risperidone (Risperdal)||least anticholinergic, can be stimulating, can impede cognitive recovery after TBI|
|quetiapine (Seroquel)||sedating, less motor SEs, prolongs QT; usually start at 25-50mg qHS, can titrate up by 25-50mg every 1-2 days to 300mg/day but monitor QTc closely|
|olanzapine (Zyprexa)||sedating, metabolic SEs, acute IM form; usually start at 2.5-5mg qHS, can titrate up by 5-10mg every 1-2 days; IM can be from 5-10mg, 2h after initial dose and 4h after 2nd dose should be allowed to evaluate response (max 20mg/day|
|Can impair motor recovery, cause transient recurrence of hemiparesis or paradoxical agitation, increase confusion in those emerging from PTA|
|midazolam, lorazepam (short acting)||lowest dose possible, only if necessary|
Have best evidence for efficacy in treating post-traumatic agitation
No effect on motor recovery, can cause lethargy/depression at high doses
|propranolol||10-20 mg q6-8h|
|valproic acid (Depakote, Depakene)||1250-1800 mg/day|
|carbamazepine (Tegretol)||400-800 mg/day|
|amitriptyline (Elavil)||25-150 mg/day|
|sertraline (Zoloft)||25-300 mg/day|
Elovic E, Baerga E, Galang GF, Cuccurullo SJ, Reyna M, Malone RJ. Physical Medicine and Rehabilitation Board Review. 3rd ed. New York, NY: Demos Medical; 2015. Chapter 2, Traumatic Brain Injury. P.96-146.
Wagner AK, Arenth PM, Kwasnica C, Rogers EH, Braddom RL. Physical Medicine and Rehabilitation. 4th ed. Philadelphia, PA: W.B. Saunders Company; 2011. Chapter 49, Traumatic Brain Injury. P.1133-1175.
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