How is agitation treated in patients with traumatic brain injury (TBI)?

Updated: Mar 02, 2020
  • Author: Percival H Pangilinan, Jr, MD; Chief Editor: Stephen Kishner, MD, MHA  more...
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Answer

Environmental modifications are usually the first treatment. Minimizing unnecessary stimuli and assisting with tools for orientation may help to reduce the onset of agitation. External stimuli, such as noisy rooms, bright lights, and frequent visitors, should be minimized. Use of centrally acting drugs that may exacerbate agitation should be minimized. Physical restraints often exacerbate posttraumatic agitation and should not be used routinely. Restraints should be used only as a last resort to secure patient, staff, and visitor safety. However, the use of less restrictive restraints, such as net-covered beds (eg, Vail beds), has become acceptable and popular in the treatment of the agitated patient with a brain injury.

In addition to environmental and behavioral modifications, various drugs, such as high-dose beta blockers, anticonvulsants, and antidepressants (particularly selective serotonin re-uptake inhibitors [SSRIs]), have had some success in the management of posttraumatic agitation. [52] Brooke and colleagues found that the intensity of agitation was significantly lower in patients with TBI who were treated with propranolol than in subjects who were treated with placebo. [53] In addition, amantadine has shown some usefulness in reducing posttraumatic agitation. [54, 55] Case studies support the use of lamotrigine [56] or divalproex [57] to manage posttraumatic agitation.

The use of antipsychotics to treat posttraumatic agitation is controversial. Their effects on cognition and recovery are poorly studied. Antipsychotics may cause excessive drowsiness, exacerbate cognitive deficits, and inhibit neuronal recovery. Stanislav suggested that select areas of cognition may improve after thioridazine and haloperidol are discontinued. [58]


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