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
Laboratory Tests
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
Diagnostic Tests
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
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
Disposition
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
Treatment
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
Special Populations
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
Background
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
Patient Discharge Instructions
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
References
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
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.