The agitated patient is one of the most challenging encounters in emergency medicine. They may be yelling, fighting, refusing care, or creating an unsafe environment. But it’s important to remember that agitation is not a diagnosis but a symptom. Behavior is a vital sign.

In this episode, we challenge the assumption that every combative patient is intoxicated, psychiatric, or simply “difficult.” We explore the broad differential diagnosis of agitation, including hypoxia, hypercapnia, hypoglycemia, traumatic brain injury, stroke, sepsis, toxicologic emergencies, and withdrawal states.

Listeners will learn a structured approach to identifying life-threatening causes of agitation, recognizing important clinical clues, and balancing patient care, safety, and the need for rapid intervention. From the “frequent flyer” with a hidden medical emergency to the patient who appears intoxicated but is actually deteriorating, this episode reinforces a critical concept:

Before we sedate the situation, we must diagnose it.

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1. American College of Emergency Physicians (ACEP). Clinical Policy: Severe Agitation in the Emergency Department. Annals of Emergency Medicine. 2024. https://www.acep.org
2. American Heart Association. 2020 American Heart Association Guidelines for CPR and Emergency Cardiovascular Care: Adult Basic and Advanced Life Support. Circulation. 2020. https://www.heart.org
3. National Association of EMS Physicians (NAEMSP). Patient Restraint and Sedation in the Prehospital Environment: Position Statements and Clinical Considerations. https://www.naemsp.org
4. Tintinalli JE, Ma OJ, Yealy DM, et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 10th Edition. McGraw Hill; 2024.
5. Goldfrank LR, Hoffman RS, Howland MA, Lewin NA, Nelson LS, Smith SW. Goldfrank’s Toxicologic Emergencies. 12th Edition. McGraw Hill; 2024.
6. Marx JA, Hockberger RS, Walls RM. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 10th Edition. Elsevier; 2022.
7. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS): Student Course Manual. 11th Edition. American College of Surgeons; 2023.
8. Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Intensive Care Medicine. 2021;47:1181–1247. https://www.survivingsepsis.org