Nonpharmacologic and de-escalation
›Behavioral management
›Verbal de-escalation elements
›Calm tone and short sentences
›Offer choices and clear limits
›Environment modifications
›Reduce stimulation
›Limit number of staff
›Restraint principles
›Least restrictive
›Continuous observation after restraint
Antipsychotics for agitation with psychosis
›Antipsychotic options
›Haloperidol IM or IV
›2.5 mg to 5 mg initial
›Repeat 2.5 mg to 5 mg every 15 min to 30 min if needed
›Typical total 10 mg to 20 mg in first hours based on response
›EPS risk mitigation
›Benztropine 1 mg IM or IV for dystonia
›Diphenhydramine 25 mg to 50 mg IM or IV for dystonia
›QT prolongation precautions
›ECG if risk factors or high cumulative dosing
›Avoid with known long QT or torsades history
›Droperidol IM or IV
›2.5 mg to 5 mg initial
›Repeat 2.5 mg to 5 mg every 10 min to 20 min if needed
›Maximum institutional protocol dependent
›QT precautions
›ECG if risk factors
›Avoid with significant QT prolongation
›Olanzapine IM
›5 mg to 10 mg initial
›Repeat 5 mg to 10 mg after 2 hours if needed
›Maximum 30 mg in 24 hours
›Benzodiazepine separation
›Avoid parenteral benzodiazepine coadministration in close temporal proximity
›Monitor for respiratory depression if both used
›Ziprasidone IM
›10 mg to 20 mg initial
›Repeat 10 mg after 2 hours if needed
›Maximum 40 mg in 24 hours
›QT precautions
›Avoid with significant QT prolongation
›ECG if risk factors
Benzodiazepines and ketamine for severe agitation
›Sedation escalation
›Lorazepam IM or IV
›1 mg to 2 mg initial
›Repeat 1 mg to 2 mg every 15 min to 30 min if needed
›Increased monitoring for hypoventilation
›Best fit scenarios
›Alcohol withdrawal
›Stimulant intoxication
›Midazolam IM or IV
›2 mg to 5 mg initial
›Repeat 2 mg to 5 mg every 10 min to 15 min if needed
›Shorter onset and duration
›Monitoring requirements
›Continuous pulse oximetry
›Airway readiness
›Ketamine IM or IV for extreme agitation with immediate danger
›IM 4 mg/kg to 5 mg/kg
›Onset minutes
›Airway and emergence monitoring
›IV 1 mg/kg to 2 mg/kg
›Slow push per protocol
›Blood pressure and airway monitoring
Syndrome-specific management
›Catatonia pathway
›Lorazepam challenge
›1 mg to 2 mg IV or IM
›Repeat based on response and monitoring
›Avoid antipsychotic escalation if malignant catatonia concern
›Fever and autonomic instability
›Rigidity and elevated CK
›Neuroleptic malignant syndrome support
›Immediate antipsychotic discontinuation
›Rigidity and hyperthermia pattern
›Autonomic instability
›Supportive care priorities
›Aggressive cooling
›IV fluids and rhabdomyolysis management
›Serotonin syndrome support
›Offending agent discontinuation
›Clonus and hyperreflexia pattern
›Autonomic instability
›Benzodiazepines for agitation
›Lorazepam dosing per sedation pathway
›Avoid antipsychotic as primary agent
Evidence levels and recommendations
›Guideline alignment
›ACEP agitation management support for benzodiazepines and antipsychotics for acute agitation
›Level B for typical ED sedation strategies based on evidence and consensus
›Level C for agent selection tailored to toxidrome and comorbidities
›Class recommendations for monitoring after parenteral sedation
›Class I continuous pulse oximetry after sedatives
›Class IIa ECG monitoring when QT risk present