Immediate stabilization and safety
›First minutes priorities
›Team safety and room preparation
›Remove potential weapons from environment
›Limit stimulation
›Clear exit path for staff
›Monitoring setup
›Cardiac monitor when moderate to severe agitation
›Pulse oximetry
›Capnography after parenteral sedation
›Airway readiness
›Suction and oxygen available
›Bag valve mask available
Nonpharmacologic de escalation
›De escalation approach
›One calm speaker
›Simple choices and boundaries
›Space and nonthreatening posture
›Offer oral medication first when safe
Pharmacologic sedation options
›Medication selection by phenotype
›Predominant psychosis or mania
›Haloperidol IM 5 mg
›Repeat dosing 2.5 mg to 5 mg every 15 minutes to 30 minutes as needed
›Maximum cumulative dose local protocol dependent
›Olanzapine IM 10 mg
›Repeat dosing 5 mg to 10 mg after 2 hours if needed
›Avoid IM olanzapine with parenteral benzodiazepine within 1 hour
›Droperidol IM 5 mg to 10 mg
›Repeat dosing 5 mg after 15 minutes to 30 minutes if needed
›Predominant stimulant intoxication or severe anxiety
›Midazolam IM 5 mg
›Repeat dosing 2.5 mg to 5 mg every 10 minutes to 15 minutes as needed
›Lorazepam IM 2 mg
›Repeat dosing 1 mg to 2 mg every 20 minutes to 30 minutes as needed
›Extreme agitation with immediate violence risk
›Ketamine IM 4 mg per kg
›Maximum single dose local protocol dependent
›Airway escalation readiness due to hypersalivation and laryngospasm risk
Medication safety and adverse effect mitigation
›Medication safety
›Avoid benzodiazepines as sole agent in suspected delirium when possible
›Avoid excessive polypharmacy
›QT prolongation risk mitigation
›Correct potassium and magnesium when low
›Avoid additional QT prolonging agents when QTc prolonged
›Dystonia treatment
›Diphenhydramine IV 25 mg to 50 mg
›Benztropine IV or IM 1 mg to 2 mg
›Restraint use principles
›Indication
›Immediate danger to patient or staff
›Failure of de escalation and medication
›Technique safety
›Avoid prone positioning
›Frequent reassessment with documented times
›Circulation and skin checks
›Removal criteria
›Calm behavior sustained
›Patient able to follow commands
Etiology directed management
›Cause specific treatment
›Hypoglycemia
›Dextrose dosing per local protocol
›Repeat glucose checks
›Alcohol withdrawal
›Benzodiazepine symptom triggered protocol
›Thiamine before glucose when feasible
›Opioid withdrawal
›Symptomatic management
›Buprenorphine initiation pathway local protocol dependent
›Hyperthermia or suspected hypermetabolic toxidrome
›Active cooling measures
›IV fluids
›CK monitoring and rhabdomyolysis prevention
›Reassessment schedule
›Vital signs every 5 minutes to 15 minutes during escalation
›Sedation scale every 15 minutes until stable
›Airway and ventilation checks after each parenteral dose
›Repeat neurologic assessment after calming