Nonpharmacologic first line
›De escalation and setting
›Verbal de escalation elements
›Calm tone
›One speaker approach
›Simple choices
›Environmental controls
›Remove triggers
›Reduce stimulation
›Restraints and seclusion
›Indications
›Imminent danger to staff or patient
›Failure of less restrictive measures
›Safety requirements
›Continuous observation
›Neurovascular checks
›Early transition to medication based calming
Pharmacologic calming for agitation
›Medication selection framework
›Suspected primary psychosis
›Antipsychotic first line
›Consensus and common emergency practice
›ACEP Level C support for medication calming when de escalation fails
›Suspected stimulant intoxication
›Benzodiazepine first line
›Lower dystonia risk than antipsychotic monotherapy
›ACEP Level C support for benzodiazepines in tox agitation
›Suspected alcohol withdrawal
›Benzodiazepine first line
›Prevents withdrawal seizures
›Oral options for cooperative patient
›Risperidone PO 1 mg
›Repeat 1 mg after 1 to 2 hours if needed
›Typical total 2 to 4 mg in 24 hours for acute symptom control
›Olanzapine ODT PO 5 mg
›Repeat 5 mg after 2 hours if needed
›Typical maximum 20 mg in 24 hours
›Lorazepam PO 1 mg
›Repeat 1 mg after 1 to 2 hours if needed
›Respiratory depression risk with other sedatives
›Intramuscular options for severe agitation
›Haloperidol IM 5 mg
›Repeat 2.5 to 5 mg after 30 to 60 minutes if needed
›Typical maximum 20 mg in 24 hours
›Extrapyramidal symptoms risk
›Higher risk with high dose or repeated dosing
›Olanzapine IM 10 mg
›Repeat 5 to 10 mg after 2 hours if needed
›Typical maximum 30 mg in 24 hours
›If benzodiazepine also used, separate by at least 1 hour due to respiratory depression risk
›Ziprasidone IM 10 mg
›Repeat 10 mg after 2 hours if needed
›Typical maximum 40 mg in 24 hours
›QT prolongation risk
›Lorazepam IM 2 mg
›Repeat 1 to 2 mg after 30 to 60 minutes if needed
›Monitor for respiratory depression
›Combination strategies
›Haloperidol IM 5 mg plus lorazepam IM 2 mg
›Reduced dystonia risk compared with haloperidol alone
›Increased sedation monitoring needs
›Avoid olanzapine IM plus benzodiazepine IM close together
›Respiratory depression risk
Antipsychotic optimization for schizophrenia exacerbation
›Restart or resume maintenance antipsychotic
›Prior effective agent continuation preference
›Improves adherence and response probability
›If nonadherence is key driver
›Long acting injectable discussion when stable
›Oral scheduled antipsychotic examples
›Risperidone PO 1 mg twice daily
›Titrate by 1 mg per day
›Typical target 2 to 4 mg per day
›Olanzapine PO 5 mg nightly
›Titrate by 5 mg every 2 to 3 days
›Typical target 10 to 20 mg per day
›Quetiapine PO 50 mg nightly
›Titrate 50 to 100 mg per day
›Typical target 300 to 600 mg per day
›Monitoring while titrating
›Orthostatic hypotension
›Higher risk with quetiapine
›Sedation
›Driving and safety counseling at discharge
›Metabolic monitoring baseline planning
›Weight and BMI
›HbA1c
›Lipids
Management of complications and adverse effects
›Acute dystonia treatment
›Benztropine IM 1 mg
›Repeat 1 mg after 15 to 30 minutes if needed
›Diphenhydramine IV 25 mg
›Repeat 25 mg after 15 to 30 minutes if needed
›Akathisia treatment
›Propranolol PO 10 mg
›Titrate to 20 mg twice daily if needed
›Avoid in severe asthma or bradycardia
›Lorazepam PO 0.5 mg
›Short term bridge when severe
›QT prolongation response
›Electrolyte targets
›Potassium above 4.0 mmol per L
›Magnesium above 1.0 mmol per L
›Avoid additional QT prolonging agents
›Macrolides
›Fluoroquinolones
›Suspected neuroleptic malignant syndrome pathway
›Stop antipsychotics immediately
›Remove dopamine blockade trigger
›Supportive care
›IV fluids
›Active cooling for hyperthermia
›ICU level monitoring triggers
›Hyperthermia
›Autonomic instability
›Rising creatine kinase
›Specific therapies consideration
›Dantrolene specialist guided use
›Bromocriptine specialist guided use
Evidence levels and guideline anchors
›Evidence and consensus statements
›De escalation and least restrictive approach
›Widely endorsed consensus standard
›ACEP Level C framing for initial nonpharmacologic calming
›Antipsychotic or benzodiazepine for severe agitation when unsafe
›ACEP Level C support for medication calming as needed for safety
›ECG monitoring when using QT prolonging antipsychotics in high risk patients
›Class IIa style recommendation in many institutional protocols
›Higher weight with known cardiac disease or electrolyte derangement