Behavioral Escalation and Restraint ConsiderationsAPPROACH

TOXICOLOGY AND BEHAVIORAL · 19 SECTIONS

⚲

433 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Undifferentiated Overdose Opioid Toxicity Opioid Withdrawal Alcohol Intoxication Alcohol Withdrawal Stimulant Toxicity Pediatric Ingestion Carbon Monoxide Exposure Inhalational Or Chemical Exposure Suicidal Ideation And Self Harm Risk Assessment Acute Psychosis And Mania Symptoms Anxiety And Panic Symptoms Capacity Assessment And Safe Disposition Behavioral Escalation And Restraint Considerations

Pediatrics16▾

Environmental and Exposure4▾

01History/hx33

Presentation context

›Context and setting

›Location

›Arrival method

›Custody status

›Safety concerns at triage

Escalation timeline

›Timeline pattern

›Time course

›Sudden onset

›Gradual progression

›Fluctuating course

Precipitating factors

›Triggers

›Interpersonal conflict

›Environmental overstimulation

›Pain trigger

›Sleep deprivation

Psychiatric symptom features

›Behavioral and thought features

›Hallucinations

›Delusions

›Paranoia

›Disorganized behavior

›Manic symptoms

Substance and toxin exposure

›Recent exposures

›Alcohol

›Cannabis

›Stimulants

›Opioids

›Benzodiazepines

›Unknown ingestions

Prior episodes and baseline

›Baseline and prior history

›Prior agitation episodes

›Prior need for restraints

›Prior response to medications

›Baseline cognition and function

02Alarm Features/alarm23

Immediate danger

›Imminent harm indicators

›Weapon access

›Attempted assault in ED

›Inability to follow any safety direction

›Uncontrolled running or climbing

Physiologic instability

›High risk physiology

›Airway compromise

›Hypoxia

›Severe hyperthermia

›Hypoglycemia

›Persistent hypotension

High risk medical etiologies

›Organic cause flags

›New focal neurologic deficit

›New seizure activity

›Meningismus

›Suspected sepsis

›Head trauma concern

Sedation and restraint red flags

›High risk restraint scenarios

›Prone positioning risk

›Suspected excited delirium or acute behavioural disturbance

›Stimulant intoxication with hyperthermia

›Known QT prolongation

›Significant respiratory disease

03Medications/meds25

Current regimen and adherence

›Home medications

›Antipsychotics

›Mood stabilizers

›Antidepressants

›Stimulants

›Opioids

›Benzodiazepines

Recent changes

›Medication change window

›New start within days

›Dose increase within days

›Abrupt discontinuation

High risk interaction classes

›Interaction risks

›QT prolonging agents

›Serotonergic agents

›Anticholinergic agents

›Monoamine oxidase inhibitors

Allergies and adverse reactions

›Prior reactions

›Neuroleptic malignant syndrome history

›Dystonia history

›Paradoxical agitation with benzodiazepines

Contraindications to common ED agents

›Medication hazard flags

›Parkinson disease

›Lewy body dementia

›Prolonged QT history

›Severe COPD

04Diet/diet12

Recent intake and hydration

›Intake pattern

›Poor oral intake

›Dehydration risk

›Prolonged fasting

Caffeine and stimulants

›Stimulant dietary exposures

›High caffeine intake

›Energy drinks

›Pre workout products

Alcohol intake

›Alcohol pattern

›Heavy recent use

›Last drink timing

›Withdrawal risk window

05Review of Systems/ros25

Infection and inflammation

›Infectious symptoms

›Fever

›Rigors

›Cough

›Dysuria

Neurologic

›Neurologic symptoms

›Headache

›Seizure

›Focal weakness

›New confusion

Cardiopulmonary

›Cardiopulmonary symptoms

›Chest pain

›Dyspnea

›Palpitations

›Syncope

Endocrine and metabolic

›Metabolic symptoms

›Polyuria

›Polydipsia

›Weight loss

›Heat intolerance

Toxidrome compatible symptoms

›Exposure syndrome clues

›Diaphoresis

›Tremor

›Nausea

›Vomiting

06Collateral History and Family History/chafh14

Collateral sources

›Source and reliability

›Family

›Police

›EMS

›Facility staff

Baseline function

›Baseline comparison

›Baseline cognition

›Baseline behavior

›Baseline substance use

Family history

›Relevant family history

›Bipolar disorder

›Schizophrenia spectrum

›Sudden cardiac death

›Substance use disorder

07Risk Factors/rf20

Violence and escalation risk

›Escalation risks

›Prior violence

›Access to weapons

›Acute intoxication

›Command hallucinations

Delirium risk

›Delirium risks

›Older age

›Dementia

›Infection

›Polypharmacy

Withdrawal risk

›Withdrawal risks

›Alcohol withdrawal risk

›Benzodiazepine withdrawal risk

›Opioid withdrawal risk

Sedation complication risk

›Sedation hazards

›Obstructive sleep apnea

›COPD

›Pregnancy

›Extreme obesity

›QT prolongation risk

08Differential Diagnosis/ddx30

Life threatening

›Cannot miss etiologies

›Hypoxia

›Hypoglycemia

›Sepsis

›Intracranial hemorrhage

›Acute stroke

›Meningitis or encephalitis

›Drug intoxication

›Drug withdrawal

›Thyroid storm

›Diabetic ketoacidosis

Common

›Common etiologies

›Alcohol intoxication

›Stimulant intoxication

›Primary psychotic disorder

›Bipolar disorder mania

›Major depressive disorder with agitation

›Anxiety or panic

›Personality disorder related dysregulation

Less common

›Less common etiologies

›Neuroleptic malignant syndrome

›Serotonin syndrome

›Anticholinergic toxicity

›Wernicke encephalopathy

›Autoimmune encephalitis

Mimics and distinguishing clues

›Key differentiators

›Delirium features

›Fluctuating attention

›Disorganized thinking

›New abnormal vitals

09Past Medical History/pmh18

Psychiatric history

›Psychiatric diagnoses

›Schizophrenia spectrum disorders (F20)

›Bipolar disorder (F31)

›Major depressive disorder (F32)

›Substance use disorders (F10 to F19)

Neurologic history

›Neurologic conditions

›Seizure disorder (G40)

›Traumatic brain injury (S06)

›Dementia (F03)

Medical comorbidities

›Medical conditions affecting sedation and restraint

›COPD (J44)

›Obstructive sleep apnea (G47.33)

›Chronic liver disease (K76.9)

›Chronic kidney disease (N18)

Prior procedures and devices

›Devices and procedures

›Pacemaker

›ICD

›Ventricular shunt

10Physical Exam/exam32

General and safety

›Immediate observations

›Level of arousal

›Speech pattern

›Motor activity

›Visible weapons

Vital signs pattern

›Vital sign interpretation

›Fever pattern

›Tachycardia pattern

›Hypertension pattern

›Hypoxia pattern

Mental status and agitation severity

›Behavioral assessment

›Orientation

›Attention

›Psychosis signs

›Suicidality cues

›Violence risk cues

Neurologic and toxidrome

›Focused neurologic and toxidrome exam

›Pupils

›Nystagmus

›Tremor

›Clonus

›Rigidity

Trauma survey

›Trauma and occult injury screen

›Head and face injury

›Cervical spine tenderness

›Chest wall injury

›Abdominal tenderness

Post restraint safety checks

›Restraint related exam

›Distal perfusion

›Skin integrity

›Respiratory effort

›Positioning safety

11Lab Studies/labs27

Core labs

›Initial labs for undifferentiated agitation

›Point of care glucose

›CBC

›Electrolytes

›Creatinine

›Liver enzymes

›Magnesium

Rhabdomyolysis and hyperthermia

›Exertional complication labs

›Creatine kinase

›Potassium

›Creatinine trend

Toxicology and ingestion

›Exposure evaluation

›Ethanol level

›Acetaminophen level

›Salicylate level

›Urine drug screen limitations

Infection and sepsis

›Infection evaluation

›Lactate

›Blood cultures when febrile and unstable

›Urinalysis

Endocrine and pregnancy

›Targeted tests

›Pregnancy test

›TSH when clinically indicated

Interpretation pitfalls

›Common limitations

›Urine drug screen false positives

›Urine drug screen false negatives

›Normal labs do not exclude delirium

12Imaging/img16

Scoring Systems

›Imaging decision supports

›Canadian CT Head Rule

›NEXUS C spine criteria

›PECARN pediatric head trauma rule

MRI

›MRI indications in agitation workup

›Suspected encephalitis with negative CT

›Suspected stroke with unclear onset

›Concern for spinal cord pathology

›CT indications in agitation workup

›Head CT for new focal deficit

›Head CT for significant head trauma concern

›CT C spine for high risk mechanism

Ultrasound

›POCUS uses in unstable agitation

›FAST for trauma

›Lung ultrasound for hypoxia

›Bladder ultrasound for urinary retention

13Special Tests/spec17

Bedside cognitive screening

›Delirium screening tools

›4AT

›CAM ICU

›Attention testing

Withdrawal assessment

›Withdrawal scales

›CIWA Ar for alcohol withdrawal

›COWS for opioid withdrawal

›Tremor and autonomic signs correlation

Agitation severity tracking

›Standardized agitation scales

›RASS

›BARS

›Documented response to intervention

Capacity and consent screening

›Capacity elements

›Understanding

›Appreciation

›Reasoning

›Communication of a choice

14ECG/ecg17

Indications

›When ECG changes management

›Before QT prolonging antipsychotics when feasible

›Suspected overdose

›Chest pain

›Syncope

High risk findings

›ECG red flags

›QTc prolongation

›Wide QRS

›Brugada pattern

›Ischemic changes

Toxidrome patterns

›Overdose associated patterns

›TCA pattern

›Sympathomimetic tachyarrhythmia

›Opioid hypoxia related changes

Serial ECG logic

›Repeat strategy

›After initial sedation if pre sedation unobtainable

›After QT prolonging medication dose escalation

15Assessment/ax18

Etiology classification

›Working category

›Medical delirium suspected

›Intoxication suspected

›Withdrawal suspected

›Primary psychiatric syndrome suspected

Severity stratification

›Agitation severity

›Mild and redirectable

›Moderate with impaired cooperation

›Severe with immediate danger

Risk stratification

›Harm risk synthesis

›Risk to staff

›Risk to patient

›Risk to bystanders

Complications to rule out

›High consequence complications

›Hypoxia

›Hyperthermia

›Rhabdomyolysis

›Occult trauma

16Plan/plan63

First 5 minutes

›Immediate stabilization

›Staff safety plan

›Security presence

›Remove hazards from room

›Continuous pulse oximetry when feasible

›Large bore IV when safe

Environment and de escalation

›Non pharmacologic measures

›Calm single lead communicator

›Reduce noise and crowding

›Offer food and water when safe

›Offer oral medication when feasible

Pharmacologic approach

›Medication strategy by phenotype

›Psychosis or mania predominance

›Olanzapine PO 5 mg to 10 mg

›Olanzapine IM 5 mg to 10 mg

›Haloperidol IM 2.5 mg to 5 mg

›Droperidol IM 2.5 mg to 5 mg

›Severe agitation with immediate danger

›Midazolam IM 5 mg

›Lorazepam IM 1 mg to 2 mg

›Ketamine IM 4 mg per kg

›Alcohol withdrawal phenotype

›Diazepam PO 10 mg to 20 mg

›Lorazepam IV 1 mg to 2 mg

›Thiamine IV local protocol dependent

›Opioid withdrawal phenotype

›Buprenorphine local protocol dependent

›Clonidine PO 0.1 mg

›Antiemetic local protocol dependent

Medication safety and contraindications

›Avoidance rules

›Avoid benzodiazepine plus olanzapine IM within 1 hour

›Avoid haloperidol in known Parkinson disease

›Avoid excessive physical struggle in hyperthermia

›Avoid prone restraint when possible

Physical restraint considerations

›Least restrictive safe option

›Indications

›Immediate danger despite de escalation

›Unsafe for medication administration without restraint

›Technique essentials

›Team based application

›Supine positioning when possible

›Head of bed elevation when possible

›Frequent neurovascular checks

Monitoring after sedation or restraint

›Monitoring bundle

›Continuous pulse oximetry

›Cardiac monitoring for QT prolonging agents

›Blood pressure cycle

›Temperature trending

›Capnography when available

Diagnostic sequencing

›Medical workup logic

›Glucose first

›Oxygenation assessment early

›Focused trauma evaluation

›Targeted labs based on phenotype

Reassessment loop

›Timed re evaluation

›Response check every 5 to 15 minutes in severe agitation

›Repeat vitals after medication doses

›Escalate level of care for persistent instability

Consultation plan

›Consult triggers

›Psychiatry for primary psychiatric syndrome

›Toxicology for suspected ingestion

›Medicine or ICU for delirium and instability

›Neurology for focal deficit

17Disposition/dispo24

ICU level care criteria

›ICU indications

›Persistent hypoxia

›Need for airway support

›Severe hyperthermia

›Refractory agitation requiring repeated parenteral sedation

Inpatient admission criteria

›Medical admission

›Delirium

›Rhabdomyolysis

›Sepsis

›Significant trauma

Observation criteria

›ED observation pathway

›Intoxication requiring monitoring until clinically sober

›Post sedation monitoring need

›Diagnostic uncertainty with stable vitals

Psychiatric disposition criteria

›Psychiatric admission or crisis pathway

›Persistent psychosis with impaired reality testing

›Inability to care for self

›Ongoing violence risk despite stabilization

Discharge criteria

›Safe discharge requirements

›Calm and cooperative

›Stable vital signs

›No medical red flags identified

›Reliable supervision plan when needed

›Follow up arranged

18Discharge Instructions/di12

Copy discharge instructions

›Discharge message

›Today you were treated for severe agitation and unsafe behavior

›Your vital signs and exam improved after treatment

›Return now for trouble breathing

›Return now for chest pain

›Return now for new confusion

›Return now for fever

›Return now for severe muscle pain or dark urine

›Avoid alcohol and drugs for the next 24 hours

›Do not drive for 24 hours after sedating medications

›Follow up with your doctor within 1 to 3 days

›Follow up with mental health services as arranged

19References/r7

Guidelines and consensus

›Core references

›ACEP The Agitated Patient in the Emergency Department 2021

›ACEP Clinical Policy Severe Agitation 2024

›American Association for Emergency Psychiatry Project BETA Psychopharmacology 2012

›NICE Violence and Aggression Short Term Management NG10 2015 last reviewed 2024

›RCEM Acute Behavioural Disturbance in Emergency Departments 2024

Source file

›Project instructions source

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Behavioral Escalation and Restraint ConsiderationsAPPROACH

TOXICOLOGY AND BEHAVIORAL · 19 SECTIONS

⚲

433 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx33

Presentation context

›Context and setting

›Location

›Arrival method

›Custody status

›Safety concerns at triage

Escalation timeline

›Timeline pattern

›Time course

›Sudden onset

›Gradual progression

›Fluctuating course

Precipitating factors

›Triggers

›Interpersonal conflict

›Environmental overstimulation

›Pain trigger

›Sleep deprivation

Psychiatric symptom features

›Behavioral and thought features

›Hallucinations

›Delusions

›Paranoia

›Disorganized behavior

›Manic symptoms

Substance and toxin exposure

›Recent exposures

›Alcohol

›Cannabis

›Stimulants

›Opioids

›Benzodiazepines

›Unknown ingestions

Prior episodes and baseline

›Baseline and prior history

›Prior agitation episodes

›Prior need for restraints

›Prior response to medications

›Baseline cognition and function

02Alarm Features/alarm23

Immediate danger

›Imminent harm indicators

›Weapon access

›Attempted assault in ED

›Inability to follow any safety direction

›Uncontrolled running or climbing

Physiologic instability

›High risk physiology

›Airway compromise

›Hypoxia

›Severe hyperthermia

›Hypoglycemia

›Persistent hypotension

High risk medical etiologies

›Organic cause flags

›New focal neurologic deficit

›New seizure activity

›Meningismus

›Suspected sepsis

›Head trauma concern

Sedation and restraint red flags

›High risk restraint scenarios

›Prone positioning risk

›Suspected excited delirium or acute behavioural disturbance

›Stimulant intoxication with hyperthermia

›Known QT prolongation

›Significant respiratory disease

03Medications/meds25

Current regimen and adherence

›Home medications

›Antipsychotics

›Mood stabilizers

›Antidepressants

›Stimulants

›Opioids

›Benzodiazepines

Recent changes

›Medication change window

›New start within days

›Dose increase within days

›Abrupt discontinuation

High risk interaction classes

›Interaction risks

›QT prolonging agents

›Serotonergic agents

›Anticholinergic agents

›Monoamine oxidase inhibitors

Allergies and adverse reactions

›Prior reactions

›Neuroleptic malignant syndrome history

›Dystonia history

›Paradoxical agitation with benzodiazepines

Contraindications to common ED agents

›Medication hazard flags

›Parkinson disease

›Lewy body dementia

›Prolonged QT history

›Severe COPD

04Diet/diet12

Recent intake and hydration

›Intake pattern

›Poor oral intake

›Dehydration risk

›Prolonged fasting

Caffeine and stimulants

›Stimulant dietary exposures

›High caffeine intake

›Energy drinks

›Pre workout products

Alcohol intake

›Alcohol pattern

›Heavy recent use

›Last drink timing

›Withdrawal risk window

05Review of Systems/ros25

Infection and inflammation

›Infectious symptoms

›Fever

›Rigors

›Cough

›Dysuria

Neurologic

›Neurologic symptoms

›Headache

›Seizure

›Focal weakness

›New confusion

Cardiopulmonary

›Cardiopulmonary symptoms

›Chest pain

›Dyspnea

›Palpitations

›Syncope

Endocrine and metabolic

›Metabolic symptoms

›Polyuria

›Polydipsia

›Weight loss

›Heat intolerance

Toxidrome compatible symptoms

›Exposure syndrome clues

›Diaphoresis

›Tremor

›Nausea

›Vomiting

06Collateral History and Family History/chafh14

Collateral sources

›Source and reliability

›Family

›Police

›EMS

›Facility staff

Baseline function

›Baseline comparison

›Baseline cognition

›Baseline behavior

›Baseline substance use

Family history

›Relevant family history

›Bipolar disorder

›Schizophrenia spectrum

›Sudden cardiac death

›Substance use disorder

07Risk Factors/rf20

Violence and escalation risk

›Escalation risks

›Prior violence

›Access to weapons

›Acute intoxication

›Command hallucinations

Delirium risk

›Delirium risks

›Older age

›Dementia

›Infection

›Polypharmacy

Withdrawal risk

›Withdrawal risks

›Alcohol withdrawal risk

›Benzodiazepine withdrawal risk

›Opioid withdrawal risk

Sedation complication risk

›Sedation hazards

›Obstructive sleep apnea

›COPD

›Pregnancy

›Extreme obesity

›QT prolongation risk

08Differential Diagnosis/ddx30

Life threatening

›Cannot miss etiologies

›Hypoxia

›Hypoglycemia

›Sepsis

›Intracranial hemorrhage

›Acute stroke

›Meningitis or encephalitis

›Drug intoxication

›Drug withdrawal

›Thyroid storm

›Diabetic ketoacidosis

Common

›Common etiologies

›Alcohol intoxication

›Stimulant intoxication

›Primary psychotic disorder

›Bipolar disorder mania

›Major depressive disorder with agitation

›Anxiety or panic

›Personality disorder related dysregulation

Less common

›Less common etiologies

›Neuroleptic malignant syndrome

›Serotonin syndrome

›Anticholinergic toxicity

›Wernicke encephalopathy

›Autoimmune encephalitis

Mimics and distinguishing clues

›Key differentiators

›Delirium features

›Fluctuating attention

›Disorganized thinking

›New abnormal vitals

09Past Medical History/pmh18

Psychiatric history

›Psychiatric diagnoses

›Schizophrenia spectrum disorders (F20)

›Bipolar disorder (F31)

›Major depressive disorder (F32)

›Substance use disorders (F10 to F19)

Neurologic history

›Neurologic conditions

›Seizure disorder (G40)

›Traumatic brain injury (S06)

›Dementia (F03)

Medical comorbidities

›Medical conditions affecting sedation and restraint

›COPD (J44)

›Obstructive sleep apnea (G47.33)

›Chronic liver disease (K76.9)

›Chronic kidney disease (N18)

Prior procedures and devices

›Devices and procedures

›Pacemaker

›ICD

›Ventricular shunt

10Physical Exam/exam32

General and safety

›Immediate observations

›Level of arousal

›Speech pattern

›Motor activity

›Visible weapons

Vital signs pattern

›Vital sign interpretation

›Fever pattern

›Tachycardia pattern

›Hypertension pattern

›Hypoxia pattern

Mental status and agitation severity

›Behavioral assessment

›Orientation

›Attention

›Psychosis signs

›Suicidality cues

›Violence risk cues

Neurologic and toxidrome

›Focused neurologic and toxidrome exam

›Pupils

›Nystagmus

›Tremor

›Clonus

›Rigidity

Trauma survey

›Trauma and occult injury screen

›Head and face injury

›Cervical spine tenderness

›Chest wall injury

›Abdominal tenderness

Post restraint safety checks

›Restraint related exam

›Distal perfusion

›Skin integrity

›Respiratory effort

›Positioning safety

11Lab Studies/labs27

Core labs

›Initial labs for undifferentiated agitation

›Point of care glucose

›CBC

›Electrolytes

›Creatinine

›Liver enzymes

›Magnesium

Rhabdomyolysis and hyperthermia

›Exertional complication labs

›Creatine kinase

›Potassium

›Creatinine trend

Toxicology and ingestion

›Exposure evaluation

›Ethanol level

›Acetaminophen level

›Salicylate level

›Urine drug screen limitations

Infection and sepsis

›Infection evaluation

›Lactate

›Blood cultures when febrile and unstable

›Urinalysis

Endocrine and pregnancy

›Targeted tests

›Pregnancy test

›TSH when clinically indicated

Interpretation pitfalls

›Common limitations

›Urine drug screen false positives

›Urine drug screen false negatives

›Normal labs do not exclude delirium

12Imaging/img16

Scoring Systems

›Imaging decision supports

›Canadian CT Head Rule

›NEXUS C spine criteria

›PECARN pediatric head trauma rule

MRI

›MRI indications in agitation workup

›Suspected encephalitis with negative CT

›Suspected stroke with unclear onset

›Concern for spinal cord pathology

›CT indications in agitation workup

›Head CT for new focal deficit

›Head CT for significant head trauma concern

›CT C spine for high risk mechanism

Ultrasound

›POCUS uses in unstable agitation

›FAST for trauma

›Lung ultrasound for hypoxia

›Bladder ultrasound for urinary retention

13Special Tests/spec17

Bedside cognitive screening

›Delirium screening tools

›4AT

›CAM ICU

›Attention testing

Withdrawal assessment

›Withdrawal scales

›CIWA Ar for alcohol withdrawal

›COWS for opioid withdrawal

›Tremor and autonomic signs correlation

Agitation severity tracking

›Standardized agitation scales

›RASS

›BARS

›Documented response to intervention

Capacity and consent screening

›Capacity elements

›Understanding

›Appreciation

›Reasoning

›Communication of a choice

14ECG/ecg17

Indications

›When ECG changes management

›Before QT prolonging antipsychotics when feasible

›Suspected overdose

›Chest pain

›Syncope

High risk findings

›ECG red flags

›QTc prolongation

›Wide QRS

›Brugada pattern

›Ischemic changes

Toxidrome patterns

›Overdose associated patterns

›TCA pattern

›Sympathomimetic tachyarrhythmia

›Opioid hypoxia related changes

Serial ECG logic

›Repeat strategy

›After initial sedation if pre sedation unobtainable

›After QT prolonging medication dose escalation

15Assessment/ax18

Etiology classification

›Working category

›Medical delirium suspected

›Intoxication suspected

›Withdrawal suspected

›Primary psychiatric syndrome suspected

Severity stratification

›Agitation severity

›Mild and redirectable

›Moderate with impaired cooperation

›Severe with immediate danger

Risk stratification

›Harm risk synthesis

›Risk to staff

›Risk to patient

›Risk to bystanders

Complications to rule out

›High consequence complications

›Hypoxia

›Hyperthermia

›Rhabdomyolysis

›Occult trauma

16Plan/plan63

First 5 minutes

›Immediate stabilization

›Staff safety plan

›Security presence

›Remove hazards from room

›Continuous pulse oximetry when feasible

›Large bore IV when safe

Environment and de escalation

›Non pharmacologic measures

›Calm single lead communicator

›Reduce noise and crowding

›Offer food and water when safe

›Offer oral medication when feasible

Pharmacologic approach

›Medication strategy by phenotype

›Psychosis or mania predominance

›Olanzapine PO 5 mg to 10 mg

›Olanzapine IM 5 mg to 10 mg

›Haloperidol IM 2.5 mg to 5 mg

›Droperidol IM 2.5 mg to 5 mg

›Severe agitation with immediate danger

›Midazolam IM 5 mg

›Lorazepam IM 1 mg to 2 mg

›Ketamine IM 4 mg per kg

›Alcohol withdrawal phenotype

›Diazepam PO 10 mg to 20 mg

›Lorazepam IV 1 mg to 2 mg

›Thiamine IV local protocol dependent

›Opioid withdrawal phenotype

›Buprenorphine local protocol dependent

›Clonidine PO 0.1 mg

›Antiemetic local protocol dependent

Medication safety and contraindications

›Avoidance rules

›Avoid benzodiazepine plus olanzapine IM within 1 hour

›Avoid haloperidol in known Parkinson disease

›Avoid excessive physical struggle in hyperthermia

›Avoid prone restraint when possible

Physical restraint considerations

›Least restrictive safe option

›Indications

›Immediate danger despite de escalation

›Unsafe for medication administration without restraint

›Technique essentials

›Team based application

›Supine positioning when possible

›Head of bed elevation when possible

›Frequent neurovascular checks

Monitoring after sedation or restraint

›Monitoring bundle

›Continuous pulse oximetry

›Cardiac monitoring for QT prolonging agents

›Blood pressure cycle

›Temperature trending

›Capnography when available

Diagnostic sequencing

›Medical workup logic

›Glucose first

›Oxygenation assessment early

›Focused trauma evaluation

›Targeted labs based on phenotype

Reassessment loop

›Timed re evaluation

›Response check every 5 to 15 minutes in severe agitation

›Repeat vitals after medication doses

›Escalate level of care for persistent instability

Consultation plan

›Consult triggers

›Psychiatry for primary psychiatric syndrome

›Toxicology for suspected ingestion

›Medicine or ICU for delirium and instability

›Neurology for focal deficit

17Disposition/dispo24

ICU level care criteria

›ICU indications

›Persistent hypoxia

›Need for airway support

›Severe hyperthermia

›Refractory agitation requiring repeated parenteral sedation

Inpatient admission criteria

›Medical admission

›Delirium

›Rhabdomyolysis

›Sepsis

›Significant trauma

Observation criteria

›ED observation pathway

›Intoxication requiring monitoring until clinically sober

›Post sedation monitoring need

›Diagnostic uncertainty with stable vitals

Psychiatric disposition criteria

›Psychiatric admission or crisis pathway

›Persistent psychosis with impaired reality testing

›Inability to care for self

›Ongoing violence risk despite stabilization

Discharge criteria

›Safe discharge requirements

›Calm and cooperative

›Stable vital signs

›No medical red flags identified

›Reliable supervision plan when needed

›Follow up arranged

18Discharge Instructions/di12

Copy discharge instructions

›Discharge message

›Today you were treated for severe agitation and unsafe behavior

›Your vital signs and exam improved after treatment

›Return now for trouble breathing

›Return now for chest pain

›Return now for new confusion

›Return now for fever

›Return now for severe muscle pain or dark urine

›Avoid alcohol and drugs for the next 24 hours

›Do not drive for 24 hours after sedating medications

›Follow up with your doctor within 1 to 3 days

›Follow up with mental health services as arranged

19References/r7

Guidelines and consensus

›Core references

›ACEP The Agitated Patient in the Emergency Department 2021

›ACEP Clinical Policy Severe Agitation 2024

›American Association for Emergency Psychiatry Project BETA Psychopharmacology 2012

›NICE Violence and Aggression Short Term Management NG10 2015 last reviewed 2024

›RCEM Acute Behavioural Disturbance in Emergency Departments 2024

Source file

›Project instructions source

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.