Agitation:behavioral emergencyMANAGEMENT

PSYCHIATRIC PRESENTATIONS · 12 SECTIONS

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562 items

☷ Legend

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Cardiovascular Presentations66▾

Respiratory Presentations47▾

Neurological Presentations77▾

Gastrointestinal Presentations63▾

Genitourinary and Reproductive Presentations44▾

Infectious Disease Presentations146▾

Trauma Presentations88▾

Toxicologic Presentations67▾

Psychiatric Presentations25▾

Acute anxiety Acute psychosis Agitation:behavioral emergency Anorexia Nervosa (Medical Complications)Bipolar disorder Bipolar Disorder (Depressive Episode)Bipolar Disorder (Manic Episode)Bulimia Nervosa (Medical Complications)Catatonia Conversion disorder Factitious Disorder Failure to Cope (Social)Failure to Thrive Generalized Anxiety Disorder Homicidal Ideation Major Depressive Disorder Major depressive episode Malingering Neuroleptic malignant syndrome Panic Attack Post-Traumatic Stress Disorder (Acute)Schizophrenia Exacerbation Suicidal Ideation Suicidal ideation and attempt Suicide Attempt

Musculoskeletal and Rheumatologic Presentations89▾

Dermatology Presentations21▾

Environmental and Exposure Presentations26▾

Hematologic and Oncologic Presentations30▾

Pediatric-Specific Presentations13▾

Endocrine and Metabolic Presentations42▾

ENT and Maxillofacial Presentations21▾

Ophthalmologic Presentations15▾

Obstetric Presentations17▾

Systemic and Miscellaneous Presentations15▾

01Approach to the Critical Patient/attcp57

Immediate safety and stabilization

›Safety priorities

›Personal safety and scene control

›Staff safety positioning and exit access

›Remove potential weapons and hazards

›Patient safety

›Continuous visual observation for severe agitation

›Fall risk and aspiration risk mitigation

›Early team activation

›Security support for unsafe behavior

›Senior clinician presence for high-risk sedation

Rapid physiologic threats

›Time-critical threats

›Airway and ventilation risk

›Hypoventilation after sedatives

›Aspiration risk with vomiting or reduced consciousness

›Circulation and perfusion risk

›Shock states including hemorrhage and sepsis

›Hypertensive emergency with end-organ signs

›Temperature and metabolic risk

›Hyperthermia with stimulant toxidrome

›Hypoglycemia as reversible cause

›Neurologic catastrophe risk

›Intracranial hemorrhage after head trauma

›Status epilepticus and postictal agitation

Rapid reversible causes

›Immediate bedside checks

›Point-of-care glucose

›If glucose low, immediate dextrose per protocol

›If recurrent low glucose, consider long-acting hypoglycemic exposure

›Pulse oximetry and end-tidal CO2 when sedated

›If hypoventilation, airway repositioning and assisted ventilation

›If apnea, immediate airway management escalation

›Temperature

›If hyperthermia, active cooling and sedation escalation pathway

›If hypothermia, warming and metabolic evaluation

Nonpharmacologic de-escalation

›Environmental control

›Low stimulation setting

›Quiet room and reduced crowding

›Limit personnel to essential staff

›Basic needs

›Pain control pathway when pain suspected

›Hunger thirst toileting addressed when safe

›Verbal de-escalation

›Communication stance

›Calm tone and simple choices

›Clear limits and safety expectations

›Behavioral techniques

›Validate distress without agreeing to unsafe demands

›Offer oral medication as first option when feasible

Medical vs primary psychiatric pathway

›Initial decision points

›High suspicion medical delirium

›Acute onset and fluctuating course

›Inattention or disorganized thinking

›High suspicion intoxication or withdrawal

›Autonomic hyperactivity

›Mydriasis diaphoresis tremor

›High suspicion primary psychiatric

›Known psychiatric history with stable vitals

›Organized delusions without delirium features

02History/hx59

Immediate contextual history

›Presentation context

›Onset and course

›Sudden onset minutes to hours

›Progressive days to weeks

›Triggering events

›Trauma

›Pain

›Environmental stressor

›Baseline function

›Usual cognition and behavior

›Recent decline in activities of daily living

›Safety risk history

›Violence risk indicators

›Weapon access

›Threats toward specific people

›Self-harm risk indicators

›Passive death wish

›Recent attempt or escalating intent

Medical and substance history

›Medical history

›Neurologic conditions

›Seizure disorder

›Traumatic brain injury history

›Metabolic or endocrine conditions

›Diabetes and hypoglycemia risk

›Thyroid disease

›Infection risk

›Recent fever or systemic symptoms

›Immunosuppression

›Substance exposure

›Recent use

›Alcohol

›Stimulants and opioids

›Cannabis and hallucinogens

›Withdrawal risk

›Alcohol withdrawal timeline

›Benzodiazepine withdrawal timeline

›Medication review

›Deliriogenic agents

›Anticholinergics

›Sedative hypnotics

›Serotonergic agents

›SSRI SNRI MAOI and interacting drugs

›Neuroleptics

›Recent antipsychotic changes

›Recent dopamine blocker exposure

Psychiatric and social history

›Psychiatric history

›Prior psychosis or mania

›Prior hospitalizations

›Prior response to antipsychotics

›Trauma history

›Triggers for restraint related distress

›Prior adverse reactions to sedation

›Social determinants

›Housing insecurity

›Exposure to cold and dehydration

›Limited follow-up access

›Support system

›Family or caregiver availability

›Reliable transport and supervision

03Physical Exam/exam59

Vital signs and general appearance

›Physiologic severity

›Vital sign abnormalities

›Fever or hypothermia

›Hypoxia or tachypnea

›Hypotension or severe hypertension

›Level of consciousness pattern

›Somnolence alternating with agitation

›Nonresponsive episodes suggesting seizure activity

›Toxidrome cues

›Sympathomimetic pattern

›Mydriasis and diaphoresis

›Tachycardia and hypertension

›Anticholinergic pattern

›Dry skin and mydriasis

›Urinary retention and ileus

›Serotonin toxicity pattern

›Hyperreflexia and clonus

›Hyperthermia and agitation

Neurologic and mental status

›Neurologic screen

›Pupillary size and reactivity

›Pinpoint pupils suggesting opioid effect

›Asymmetry suggesting intracranial pathology

›Motor tone and reflexes

›Rigidity suggesting neuroleptic malignant syndrome

›Clonus suggesting serotonin toxicity

›Focal deficits

›Unilateral weakness or gaze deviation

›Aphasia or neglect

›Mental status domains

›Attention and orientation

›Inattention suggesting delirium

›Disorientation to time and place

›Thought content

›Hallucinations

›Paranoia and delusions

›Affect and psychomotor activity

›Pressured speech and grandiosity

›Severe psychomotor agitation

Trauma and medical exam

›Head and neck

›Signs of head injury

›Scalp hematoma or laceration

›Basilar skull fracture stigmata

›Neck stiffness

›Meningismus concern

›Odontoid injury concern after trauma

›Cardiopulmonary

›Breath sounds and work of breathing

›Wheeze and bronchospasm

›Pulmonary edema signs

›Perfusion

›Capillary refill and skin temperature

›Chest pain or ischemia signs

›Abdomen and genitourinary

›Abdominal tenderness

›Peritonitis concern

›Urinary retention concern

›Pregnancy possibility when relevant

›Missed menses history

›Recent delivery and postpartum status

04Differential Diagnosis/ddx43

Life-threatening and high-risk causes

›Dangerous causes

›Delirium due to medical illness

›Sepsis and CNS infection

›Hypoxia and hypercapnia

›Toxicologic emergencies

›Sympathomimetic intoxication

›Anticholinergic toxicity

›Withdrawal syndromes

›Alcohol withdrawal and delirium tremens

›Benzodiazepine withdrawal

›Neurologic emergencies

›Intracranial hemorrhage

›Nonconvulsive status epilepticus

›Hyperthermic syndromes

›Serotonin syndrome

›Neuroleptic malignant syndrome

Primary psychiatric and common mimics

›Psychiatric causes

›Acute psychosis

›ICD-10 F23 brief psychotic disorder

›ICD-10 F29 unspecified psychosis

›Mania

›ICD-10 F30 manic episode

›Decreased need for sleep and grandiosity

›Severe anxiety and panic

›ICD-10 F41.0 panic disorder

›Hyperventilation and paresthesias

›Common mimics

›Pain related agitation

›Renal colic

›Acute abdominal pain

›Hypoglycemia and metabolic derangements

›Hypoglycemia

›Hyponatremia and hypercalcemia

›Medication adverse effects

›Akathisia from dopamine blockers

›Steroid induced psychosis

Coding and terminology anchors

›Standardized terms

›ICD-10 R45.1 restlessness and agitation

›Use when symptom code needed without definitive cause

›SNOMED CT agitation finding

›Use for problem list standardization

›SNOMED CT delirium

›Use when delirium diagnosed clinically

05Laboratory Tests/lt44

Core labs for undifferentiated agitation

›Baseline testing set

›Glucose for altered behavior

›Fingerstick glucose for immediate rule-out

›Serum glucose confirmation when needed

›Electrolytes and renal function

›Sodium for delirium risk

›Creatinine for medication clearance and dehydration

›Liver enzymes when hepatic encephalopathy risk

›AST and ALT for hepatic injury context

›Ammonia only with compatible syndrome and caution in interpretation

›Complete blood count for infection or anemia concern

›Leukocytosis context with fever

›Severe anemia and hypoxia mimic

Targeted labs by syndrome

›Toxicology and medication related testing

›Acetaminophen and salicylate level when overdose possible

›Low threshold with unclear ingestion history

›Co-ingestion risk in intentional self-poisoning

›Serum ethanol when intoxication unclear

›Severe intoxication as cause of agitation or delirium

›Withdrawal risk when level falling

›Urine drug screen for supportive context only

›Poor sensitivity for many synthetics

›Do not delay care for results

›Infection and inflammatory testing

›Lactate when sepsis or shock concern

›Elevated lactate as marker of hypoperfusion

›Confounded by seizures and beta agonists

›Blood cultures when septic shock concern

›Timing before antibiotics when feasible

›Do not delay antibiotics in unstable patient

›Hyperthermia and rigidity syndromes

›Creatine kinase for rhabdomyolysis risk

›Risk increased with prolonged struggle and hyperthermia

›Serial trending when severe agitation persists

›Venous blood gas for acidosis and hypercapnia

›Hypercapnia in hypoventilation after sedation

›Metabolic acidosis in severe exertion and seizure

Endocrine and pregnancy testing

›Special labs when indicated

›Thyroid studies when thyrotoxicosis concern

›TSH and free T4

›Fever tachycardia and tremor cluster

›Pregnancy test when applicable

›Medication safety implications

›Ectopic pregnancy mimic with agitation and pain

06Diagnostic Tests/dt48

Scoring Systems

›Agitation and sedation scales

›Richmond Agitation-Sedation Scale

›+4 combative

›+3 very agitated

›+2 agitated

›+1 restless

›0 alert and calm

›-1 to -5 increasing sedation to unarousable

›Behavioral Activity Rating Scale

›1 difficult or unable to rouse

›2 asleep but responds normally to verbal or physical contact

›3 drowsy but awakens easily

›4 quiet and awake

›5 signs of overt activity and calms down with instruction

›6 extremely active and not requiring restraint

›7 violent and requires restraint

›Confusion Assessment Method for delirium

›Acute onset and fluctuating course

›Inattention

›Disorganized thinking

›Altered level of consciousness

MRI

›MRI indications

›Subacute neurologic concern with stable patient

›Suspected encephalitis when CT nondiagnostic

›Suspected stroke with atypical presentation

›MRI limitations

›Limited feasibility in severe agitation

›Sedation risk and airway monitoring requirements

›CT indications

›CT head without contrast

›Head trauma with altered behavior

›New focal neurologic deficit

›CT chest abdomen pelvis when medical cause suspected

›Suspected occult infection source

›Suspected toxic ingestion with body packing concern

›CT limitations

›Motion artifact in agitation

›Radiation risk and need for clear indication

Ultrasound

›Point-of-care ultrasound uses

›Cardiac POCUS

›Shock evaluation and tamponade

›Gross ventricular function assessment

›Lung POCUS

›Pulmonary edema patterns

›Pneumothorax exclusion when trauma suspected

›Bladder ultrasound

›Urinary retention contributing to agitation

›Post-void residual in delirium pathway

07Disposition/dispo34

Level of care selection

›Medical admission indications

›Delirium suspected or confirmed

›Acute fluctuating cognition

›Underlying medical trigger identified or suspected

›Unstable physiology

›Persistent abnormal vitals

›Ongoing hypoxia or hypercapnia risk

›Complications of agitation

›Rhabdomyolysis or acute kidney injury

›Hyperthermia requiring monitoring

›Psychiatric admission indications

›Primary psychiatric syndrome with danger or grave disability

›Inability to care for self

›High risk behavior toward others

›Need for inpatient stabilization

›Severe psychosis or mania

›Failed outpatient supports

Observation and discharge criteria

›ED observation pathway

›Transient intoxication with expected improvement

›Reassess when clinically sober

›Repeat mental status and safety evaluation

›Medication related akathisia resolved after treatment

›Symptom improvement after propranolol or benztropine

›No persistent delirium features

›Discharge prerequisites

›Calm and cooperative baseline restored

›Normal attention and orientation for baseline

›Safe ambulation and airway protective reflexes

›Stable vitals and no evolving medical concern

›Afebrile or explained fever

›No hypoxia and no persistent tachycardia

›Follow-up plan and supervision

›Reliable support person when needed

›Clear return precautions and crisis resources

08Treatment/t128

Nonpharmacologic and supportive care

›Supportive measures

›Environment

›Low stimulation room

›Remove restraints as soon as safe

›Analgesia when pain suspected

›Nonopioid analgesics when appropriate

›Opioids with close monitoring when indicated

›Hydration and cooling

›IV fluids for dehydration and rhabdomyolysis risk

›Active cooling for hyperthermia syndromes

Physical restraint and monitoring

›Restraint principles

›Indications

›Immediate danger to staff or patient

›Failed de-escalation and unsafe to delay sedation

›Technique

›Least restrictive effective method

›Supine positioning with head elevation when feasible

›Monitoring

›Continuous pulse oximetry

›End-tidal CO2 when deep sedation risk

›Medical risks

›Positional asphyxia risk

›Rhabdomyolysis risk with prolonged struggling

Pharmacologic strategy selection

›Medication approach

›Primary psychiatric agitation without delirium

›Antipsychotic first-line consideration

›Add benzodiazepine for severe agitation or stimulant co-use

›Delirium or medical agitation

›Antipsychotic preferred over benzodiazepine in most cases

›Benzodiazepine reserved for withdrawal and selected toxidromes

›Withdrawal states

›Benzodiazepine first-line for alcohol withdrawal

›Phenobarbital protocols per local practice when appropriate

›Excited delirium like severe hyperadrenergic state

›Rapid dissociative sedation pathway when immediate control required

›Aggressive cooling and complication prevention

Oral options when cooperative

›Oral medications

›Antipsychotics

›Olanzapine PO 5 to 10 mg

›Avoid combined IM olanzapine and parenteral benzodiazepine within short interval

›Sedation monitoring for respiratory depression risk

›Risperidone PO 1 to 2 mg

›Useful for psychosis with cooperation

›Add lorazepam PO for anxiety component when appropriate

›Benzodiazepines

›Lorazepam PO 1 to 2 mg

›Higher risk of delirium worsening in older adults

›Add monitoring when combined with other sedatives

Intramuscular and intravenous options

›Antipsychotics

›Haloperidol IM 5 mg

›Repeat dosing 5 mg every 15 to 30 minutes as needed

›Typical max total dose 20 to 30 mg in ED with monitoring

›EPS risk higher than atypicals

›Droperidol IM 5 mg

›Repeat dosing 2.5 to 5 mg every 10 to 15 minutes as needed

›QT prolongation risk and ECG consideration in high-risk patients

›Rapid onset for severe agitation

›Olanzapine IM 10 mg

›Repeat dosing 5 to 10 mg after 2 hours as needed

›Avoid concomitant parenteral benzodiazepine near in time

›Lower EPS risk than haloperidol

›Benzodiazepines

›Midazolam IM 5 mg

›Repeat dosing 2.5 to 5 mg every 5 to 10 minutes as needed

›Faster onset than lorazepam

›Higher respiratory depression risk when combined with opioids or alcohol

›Lorazepam IM 2 mg

›Repeat dosing 1 to 2 mg every 15 to 30 minutes as needed

›Longer duration and slower onset than midazolam

›Combination therapy

›Haloperidol plus benzodiazepine

›Haloperidol IM 5 mg plus lorazepam IM 2 mg

›Useful for severe psychosis with agitation

›Increased sedation risk requiring monitoring

Dissociative sedation for uncontrolled violence

›Ketamine pathway

›Ketamine IM 4 mg/kg

›Typical range 3 to 5 mg/kg

›Onset often within minutes

›Airway readiness and monitoring required

›Ketamine IV 1 to 2 mg/kg

›Titrate in small boluses when IV access secure

›Higher apnea risk with rapid IV push

›Post-ketamine care

›Treat hypersalivation with suction and anticholinergic if needed

›Emergence reaction management with benzodiazepine when clinically appropriate

Syndrome-specific treatments

›Alcohol withdrawal agitation

›Benzodiazepines

›Diazepam IV 10 mg

›Repeat dosing every 5 to 10 minutes to symptom control

›Longer half-life and active metabolites

›Lorazepam IV 2 mg

›Repeat dosing every 10 to 20 minutes to symptom control

›Preferred in liver dysfunction

›Thiamine

›Thiamine IV 100 mg before glucose when malnutrition risk

›Higher dose protocols per local practice for Wernicke concern

›Stimulant intoxication agitation

›Benzodiazepines first-line

›Midazolam IM 5 mg or IV 2.5 mg

›Titrate to calm without apnea

›Hyperthermia management

›Active cooling and IV fluids

›Avoid physical struggle and prolonged restraint

›Neuroleptic malignant syndrome concern

›Supportive care and stop dopamine blockers

›Cooling and IV fluids

›ICU consultation for severe rigidity and hyperthermia

›Serotonin toxicity concern

›Benzodiazepines and supportive care

›Cyproheptadine PO when moderate symptoms and able to take oral

›ICU consultation for severe hyperthermia or rigidity

Medication safety and monitoring

›Monitoring bundle after parenteral sedation

›Continuous pulse oximetry

›Early detection of hypoxia

›Escalation trigger with persistent desaturation

›End-tidal CO2 when deep sedation risk

›Early detection of hypoventilation

›Assisted ventilation escalation trigger

›ECG considerations

›QT risk factors review before QT-prolonging antipsychotics when feasible

›Electrolyte correction for hypokalemia and hypomagnesemia when present

›Evidence grading anchors

›ACEP Level B style recommendation for benzodiazepines in stimulant intoxication

›Strong clinical consensus and supportive evidence base

›Primary goal rapid sedation and complication prevention

›Class IIa style recommendation for antipsychotic use in primary psychosis agitation

›Benefit outweighs risk with monitoring

›Choice individualized to QT and EPS risk profile

09Special Populations/sp31

Pregnancy

›Pregnancy considerations

›Diagnostic approach

›Consider eclampsia and severe preeclampsia with hypertension and headache

›Consider postpartum psychosis in early postpartum period

›Medication selection

›Haloperidol generally preferred when antipsychotic needed

›Benzodiazepines limited use when benefits outweigh risks

›Obstetric coordination

›Fetal monitoring when viable gestation and maternal stabilization achieved

›Obstetrics consult for hypertensive emergency or obstetric complication

Geriatric

›Older adult considerations

›Delirium probability high

›Infection and medication effects common triggers

›Sensory impairment and dehydration contributors

›Medication dosing

›Start low and go slow sedation dosing

›Avoid high-dose benzodiazepines due to paradoxical agitation and delirium worsening

›Adverse effect risk

›Orthostatic hypotension and falls

›QT prolongation and polypharmacy interactions

Pediatrics

›Pediatric considerations

›Developmental approach

›Caregiver presence when calming and safe

›Sensory and communication adjustments

›Weight-based dosing

›Midazolam IM 0.1 to 0.2 mg/kg

›Lorazepam IV 0.05 mg/kg

›Haloperidol IM 0.05 to 0.1 mg/kg

›Etiology priorities

›Hypoglycemia and ingestion evaluation

›CNS infection and trauma evaluation based on presentation

10Background/b33

Epidemiology

›Epidemiologic notes

›ED agitation frequency

›Common presenting problem across medical and psychiatric emergencies

›High association with substance use and delirium

›Risk factors for violence

›Intoxication and withdrawal

›Prior violent behavior and acute psychosis

›High-risk syndromes

›Hyperthermia with stimulant intoxication

›Delirium in older adults

Pathophysiology

›Mechanisms

›Delirium mechanism

›Global cerebral dysfunction from systemic illness

›Neurotransmitter imbalance and inflammation

›Stimulant intoxication mechanism

›Excess catecholamine activity

›Hyperthermia and metabolic acidosis risk

›Withdrawal mechanism

›GABA downregulation and glutamate upregulation

›Autonomic hyperactivity and seizure risk

Therapeutic Considerations

›Treatment rationale

›Nonpharmacologic first when safe

›Reduces need for restraints and medication adverse events

›Preserves therapeutic alliance

›Antipsychotics role

›Target psychosis and severe agitation

›QT and EPS risk management required

›Benzodiazepines role

›First-line for withdrawal and selected toxidromes

›Delirium worsening risk in older adults

›Ketamine role

›Rapid control for extreme agitation with immediate danger

›Airway risk requires readiness and monitoring

11Patient Discharge Instructions/pdi19

Copy discharge instructions

›Discharge instructions

›Condition summary

›Agitation episode improved in ED

›Possible contributing factors reviewed

›Medication guidance

›Take prescribed medications only as directed

›Avoid alcohol and non-prescribed drugs

›Safety planning

›Stay with a trusted person for the next 24 hours if possible

›Remove access to weapons and dangerous items

›Return to ED immediately

›New confusion or severe drowsiness

›Trouble breathing or persistent vomiting

›Fever or severe headache

›Chest pain or fainting

›Feeling out of control or unsafe around others

›Follow-up

›Primary care or psychiatry follow-up within 1 week

›Substance use support referral if relevant

12References/r7

Clinical guidelines and key sources

›Reference list

›Project BETA consensus statement on agitation management in emergency settings

›ACEP policy statements and clinical resources on behavioral emergencies and chemical restraint

›Evidence base for droperidol use in acute agitation and safety monitoring

›Evidence base for ketamine use in severe agitation and prehospital or ED settings

›Delirium assessment standards including CAM and ED delirium management resources

›Clinical management system generator instructions

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 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.