Upset, Angry, Agitated, Confused– Pulling Every Tube and Line: Calming the Storm


It happens in the ICU and in the ED.  The upset, angry, agitated, confused patient who manages to pull on every tube and line in an effort to gain freedom or control over their situation. It’s a terrible thing to witness.  An elderly patient fighting so hard to free themselves from our hard work and interventions.

While restraints are one way to combat part of the physical issues it also complicates care and can essentially cause the patient more trauma,  increased confusion and increased chances of developing PTSD.

Treating these patients, especially the geriatric population, is a bit like baking a cake, you need the right recipe.

A elderly woman in her 90’s was admitted to a tele floor for chest pain, ARF and UTI.  While on the floor she had a witnessed cardiac arrest. ROSC was achieved  within 15 minutes after 1 epi and CPR .  The patient became alert before transfer to the ICU.  She was agitated to say the least.  She following some commands.  She attempted to pull out her ETT several times, even when family attempted to redirect her.  The patient turned out to be ureoseptic was put on a pressor, pain meds were given, but the agitation didn’t  improve. Prior to admission to the hospital the patient had told her family she did not want to be on life support, but the patient’s medical proxy at the time of the incident could not make that decision.  The patient was not on a sedation drip because the plan was to extubate in the morning.  Push doses of fentanyl were given with little decrease in agitation.

As the night went on the daughter in law of the patient continued to try to calm the patient.  She reviled that the patient was very hard of hearing and didn’t have her hearing aids in.  The patient was able to write.  She wrote clearly that she wanted the tube out of her mouth, “I want this out now”.

The patient was more calm when her care was explained to her via writing.  She still required push doses of fentanyl for the rib pain she had as a result of the chest compressions as well as the pain from the ETT itself.  She also received push doses of versed which reduced her anxiety and allowed her to rest.

What’s Causing the Behavior?  PAD Check

Assess the patient, identify the cause of the behavior is essential. Look for simple fixes  and causes, such as not having hearing aids in or not understanding the language spoken, and let us not forget about the intubated patient who is alert and did not want to be intubated because it was against this health care wishes!

Pain– Is the patient having pain? Are they intubated and sedated- what sedative is being utilized?  Do they have adequate analgesia?

Agitation– How agitated are they?  What’s their RASS score?  What illness/injury are you treating? Was a medication started or removed around the time the agitation began? What is the environment like- noise and lighting levels?

Delirium– Assess level of delirium  CAM-ICU score.  Are they able to sleep, do they have hearing aids in or their glasses?  Reorientate- Reorientate- Reorientate! Assess for early mobility. Are there family or loved ones visiting?– Educate them.

(CAM-ICU Assessment Link) 

Adopting the ABCDEF Bundle Approach in ICU PatientsThe goal of this bundle is to improve patient outcomes through an approach that includes early mobilization and a decrease in ventilator days.

Assess Treat & Manage Pain

Breathing Trial SAT (spontaneous awake trial) & SBT             (spontaneous breathing trial)

Choice of Sedatives

Delirium Reduction

Early Mobility & Exercise

Family Involvement & Communication

For more information and valuable resources on ICU delirium as well and ED and non ICU settings check out


Bring On the Meds! 

Traditionally Haloperidol (Haldol) was the go to drug, but it’s not always effective and it can have negative effects on the heart.  An alternative therapy that might beneficial is Olanzapine (Zyprexa).  Head over to PulmCrit for an great read on the topic.