Browse categories and answer follow-up questions to refine your symptom profile.
Approach to the Critical Patient
Immediate safety and stabilization
Immediate priorities
Scene safety and staff safety
Security presence for violent behavior
Remove potential weapons and hazards
Medical instability screen
Airway compromise risk from sedation or restraints
Respiratory depression risk after benzodiazepines or opioids
Rapid vitals and monitoring
Heart rate
Blood pressure
Respiratory rate
Temperature
SpO2
Point of care glucose
Hypoglycaemia mimic of agitation or confusion
Hyperglycaemia with dehydration and delirium risk
If severe agitation with danger to self or others, immediate calming strategy
Verbal de escalation
Environmental control
If unsafe, medication for agitation
Calming environment
Low stimulation
Quiet room
Reduce crowding
Therapeutic stance
Non threatening posture
Simple choices and clear limits
Medication safety checkpoints
Sedation goals
Calm and cooperative
Awake or easily rousable
QT prolongation risk awareness
Prior long QT syndrome history
Antipsychotic dose stacking risk
Respiratory depression risk awareness
Co ingestion of alcohol or opioids
Obstructive sleep apnoea risk
Time critical red flags
Psychosis with fever and rigidity
Neuroleptic malignant syndrome
Serotonin toxicity
Psychosis with autonomic instability and agitation after stopping sedatives
Alcohol withdrawal
Benzodiazepine withdrawal
New focal neurologic deficit
Stroke
Intracranial haemorrhage
Head trauma
Intracranial injury
Severe headache with meningismus
Meningitis
Encephalitis
Key concepts
Core framing
Acute psychosis is a diagnosis of exclusion in the emergency setting
Primary psychotic disorder exacerbation
Substance induced psychosis
Medical or neurologic delirium
Stabilize then differentiate
Safety first
Then medical causes screen
Then psychiatric formulation
History
Presenting episode
Episode timeline
Onset pattern
Sudden onset hours to days
Subacute onset days to weeks
Course
Fluctuating symptoms
Progressive worsening
Precipitant context
Medication nonadherence
Sleep deprivation
Acute psychosocial stressor
Psychotic symptom domains
Positive symptoms
Auditory hallucinations
Delusions
Disorganized speech
Disorganized behavior
Negative symptoms
Avolition
Alogia
Flat affect
Social withdrawal
Cognitive symptoms
Attention impairment
Working memory impairment
Agitation and risk
Violence risk signals
Command hallucinations to harm others
Persecutory delusions with fear
Self harm risk signals
Passive death wish
Thoughts of self harm
Access to weapons
Firearms access
Knives access
Medical symptom screen
Fever
Headache
Seizure
Chest pain
Dyspnoea
Dysuria
Psychiatric and treatment history
Diagnosis history
Schizophrenia history
ICD-10 F20.0 paranoid schizophrenia
ICD-10 F20.1 hebephrenic schizophrenia
ICD-10 F20.2 catatonic schizophrenia
ICD-10 F20.3 undifferentiated schizophrenia
ICD-10 F20.5 residual schizophrenia
ICD-10 F20.9 schizophrenia unspecified
Schizoaffective disorder history
ICD-10 F25.0 schizoaffective disorder bipolar type
ICD-10 F25.1 schizoaffective disorder depressive type
Brief psychotic disorder history
ICD-10 F23 acute and transient psychotic disorders
Prior episodes and response
Prior hospitalizations
Prior effective antipsychotic
Prior adverse reactions
Medication adherence context
Missed doses last week
Stopped medication last month
Long acting injectable timing
Side effects history
Extrapyramidal symptoms
Akathisia
Tardive dyskinesia
Hyperprolactinaemia symptoms
Metabolic syndrome history
Substance use history
Alcohol
Cannabis
Stimulants
Cocaine
Methamphetamine
Hallucinogens
Opioids
Prescription misuse
Stimulants
Anticholinergics
Collateral and functional baseline
Collateral sources
Family report
EMS report
Police report
Pharmacy fill history
Baseline function
Housing stability
Employment or school attendance
ADL independence
Capacity related history
Ability to understand and appreciate illness
Prior substitute decision maker
Physical Exam
General and safety focused exam
Initial observations
Level of arousal
Somnolent
Alert
Hypervigilant
Psychomotor activity
Agitation
Psychomotor retardation
Behavior
Threatening posture
Pacing
Responding to internal stimuli
Vital sign pattern
Fever
Infection concern
NMS concern with rigidity
Tachycardia
Stimulant intoxication
Withdrawal state
Hypertension
Stimulant intoxication
Pain or agitation
Focused cardiopulmonary
Work of breathing
Wheeze
Signs of aspiration after sedation
Neurologic screen
Orientation
Pupillary size and reactivity
Motor asymmetry
Gait if safe
Mental status exam
Appearance and behavior
Hygiene
Eye contact
Cooperation
Speech
Rate
Volume
Pressured speech
Poverty of speech
Thought process
Tangentiality
Loose associations
Thought blocking
Thought content
Persecutory delusions
Grandiosity
Somatic delusions
Ideas of reference
Perception
Auditory hallucinations
Visual hallucinations
Tactile hallucinations
Mood and affect
Affect congruence
Flat affect
Labile affect
Insight and judgment
Illness awareness
Treatment acceptance
Medication adverse effect exam
Extrapyramidal signs
Dystonia
Parkinsonism
Akathisia
Catatonia signs
Stupor
Mutism
Waxy flexibility
Posturing
Negativism
NMS screen
Rigidity
Hyperthermia
Autonomic instability
Altered mental status
Differential Diagnosis
Primary psychiatric causes
Primary psychosis differential
Schizophrenia acute exacerbation
ICD-10 F20.9 schizophrenia unspecified
SNOMED CT concept schizophrenia
Schizoaffective disorder
ICD-10 F25.9 schizoaffective disorder unspecified
SNOMED CT concept schizoaffective disorder
Bipolar disorder with psychotic features
ICD-10 F31.2 manic episode with psychotic symptoms
Major depressive disorder with psychotic features
ICD-10 F32.3 severe depressive episode with psychotic symptoms
Substance and medication related causes
Substance induced psychosis
Stimulant related
ICD-10 F15.5 psychotic disorder due to stimulants
Cannabis related
ICD-10 F12.5 psychotic disorder due to cannabinoids
Hallucinogen related
ICD-10 F16.5 psychotic disorder due to hallucinogens
Alcohol related
ICD-10 F10.5 psychotic disorder due to alcohol
Medication induced psychosis
Corticosteroids
Dopaminergic agents
Anticholinergics
Medical and neurologic causes
Delirium and encephalopathy
Infection
Sepsis
Meningitis
Encephalitis
Metabolic derangements
Hypoglycaemia
Hyponatraemia
Hypercalcaemia
Uraemia
Hepatic encephalopathy
Hypoxia
Hypercapnia
Neurologic disorders
Seizure and post ictal state
Stroke
Intracranial haemorrhage
Brain tumour
Autoimmune encephalitis
Toxic syndromes
Neuroleptic malignant syndrome
Serotonin toxicity
Anticholinergic toxicity
Psychiatric mimics with medical urgency
Thyroid storm
Pheochromocytoma crisis
Laboratory Tests
Core medical screen
Baseline labs
Complete blood count
Leukocytosis with infection concern
Anaemia with hypoxia contribution
Electrolytes and renal function
Sodium
Hyponatraemia delirium risk
Potassium
Hypokalaemia QT risk with antipsychotics
Creatinine
Renal impairment and medication dosing
Glucose
Hypoglycaemia delirium mimic
Hyperglycaemia dehydration risk
Liver enzymes
Hepatic impairment and medication dosing
Thyroid function
Hyperthyroidism mania or psychosis mimic
Pregnancy test when applicable
Urine or serum beta hCG
Medication safety planning
Imaging risk planning
Tox and infection evaluation
Toxicology
Urine drug screen
Stimulants
Cannabinoids
Opioids
Blood alcohol if indicated
Intoxication contribution
Withdrawal risk prediction
Infection workup if febrile or toxic
Blood cultures if sepsis concern
Draw before antibiotics when feasible
Urinalysis
UTI delirium trigger
C reactive protein or procalcitonin
Support infection probability
Antipsychotic and complication labs
NMS and rhabdomyolysis evaluation
Creatine kinase
Marked elevation supports NMS or rhabdomyolysis
Serum creatinine
Acute kidney injury from rhabdomyolysis
Urinalysis for myoglobin
Heme positive with few RBC
Medication safety
Magnesium
Low magnesium increases torsades risk
Lipids and HbA1c when initiating long term antipsychotic plan
Metabolic baseline for atypical agents
Diagnostic Tests
Scoring Systems
Rating and decision supports
Agitation severity scales
Behavioral Activity Rating Scale
Useful for tracking response to calming measures
Richmond Agitation Sedation Scale
Target light sedation if medication used
Psychosis severity scales
Brief Psychiatric Rating Scale
Tracks positive and negative symptom burden
Positive and Negative Syndrome Scale
Tracks symptom domains over time
Catatonia scale
Bush Francis Catatonia Rating Scale
Supports diagnosis and monitoring
MRI
MRI brain indications
New focal neurologic deficits
Concern for mass or demyelination
First episode psychosis with atypical features
New onset after age 40
Seizures
Suspected autoimmune encephalitis
Limbic changes consideration
MRI limitations
Limited availability in acute agitation
Motion artifact risk
Need for sedation risk tradeoff
CT
CT head indications
Head trauma
Anticoagulation use
Persistent vomiting
New severe headache
Subarachnoid haemorrhage concern
New focal neurologic deficit
Stroke or haemorrhage concern
New onset psychosis with delirium features
Fluctuating attention
Disorientation
CT pearls and pitfalls
Normal CT does not exclude encephalitis
Consider lumbar puncture pathway if infectious concern
Radiation exposure consideration
Pregnancy planning
Ultrasound
Point of care ultrasound use
Dehydration assessment
IVC size and collapsibility as supportive data
Urinary retention assessment
Bladder volume support for agitation from discomfort
Soft tissue infection assessment
Abscess identification if agitation with pain
Ultrasound limitations
Not a primary test for psychosis etiology
Adjunct for medical contributors
Disposition
Level of care and legal status
Disposition decision structure
Medical admission triggers
Unstable vitals
Delirium or suspected medical cause
NMS concern
Severe dehydration or electrolyte derangement
Psychiatric admission triggers
Persistent psychosis with impaired self care
High risk violence
Active self harm thoughts
Grave disability
Observation unit considerations
Medication titration and reassessment
Substance washout and re evaluation
Involuntary hold considerations
Danger to self or others
Imminent risk behaviors
Credible threats
Inability to care for basic needs
No shelter plan
No food or hydration plan
Safe discharge criteria
Discharge readiness
Calm baseline behavior
No need for repeated PRN sedation
No acute medical cause identified
Stable vitals
Normal or acceptable labs
Low acute risk assessment
No current self harm intent
No current violence intent
Support and follow up in place
Family or support contact
Outpatient psychiatry plan
Medication access confirmed
Treatment
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
Special Populations
Pregnancy
Pregnancy considerations
Risk benefit framing
Untreated psychosis risk to patient and fetus
Medication exposure risk tradeoff
Medication selection tendencies
Haloperidol has long historical use in pregnancy
Avoid polypharmacy when possible
Workup modifications
Minimize ionizing radiation when feasible
Prefer MRI when neuroimaging required and stable
Geriatric
Older adult considerations
Delirium probability higher than primary psychosis
Prioritize medical cause evaluation
Medication dosing principles
Start low and go slow
Higher sensitivity to anticholinergic and sedative burden
Antipsychotic black box awareness
Increased mortality risk in dementia related psychosis
Pediatrics
Youth and adolescent considerations
First episode psychosis probability higher than chronic schizophrenia exacerbation
Broader medical and substance differential
Weight based dosing need
Use local pediatric dosing references
Monitor for oversedation
Family involvement and safeguarding
Guardian presence when appropriate
School and community supports linkage
Background
Epidemiology
Epidemiologic anchors
Typical onset
Late adolescence to early adulthood
Earlier onset in males on average
Chronic course features
Relapsing and remitting exacerbations
Functional decline risk without sustained treatment
Pathophysiology
Mechanistic framing
Dopamine dysregulation model
Mesolimbic hyperdopaminergia linked to positive symptoms
Mesocortical hypodopaminergia linked to negative symptoms
Glutamate and neurodevelopment models
NMDA hypofunction hypothesis relevance
Neurodevelopmental vulnerability
Therapeutic Considerations
Treatment principles
Antipsychotics reduce relapse risk
Maintenance therapy reduces recurrence frequency
Adherence is a dominant determinant of relapse
Long acting injectable reduces missed dose risk
Psychosocial supports improve outcomes
Family psychoeducation
Supported employment
Metabolic risk management is integral
Lifestyle counseling
Diabetes screening plan
Patient Discharge Instructions
copy discharge instructions
Discharge instructions
Medication plan
Take medications exactly as prescribed
Do not stop antipsychotic suddenly without clinician guidance
Safety plan
Avoid alcohol and recreational drugs
Avoid driving if sedated or dizzy
Follow up
Psychiatry or family doctor appointment within 7 days
Pharmacy refill plan confirmed
Return to emergency care now if any of the following occur
Worsening hallucinations or delusions with unsafe behavior
Thoughts of self harm or harm to others
Fever with muscle stiffness or confusion
Chest pain or trouble breathing
New severe headache or new weakness or numbness
Support resources
Contact local crisis line if symptoms escalate
Contact trusted family or support person
References
Clinical guidelines and consensus
Guideline sources
American Psychiatric Association practice guideline for schizophrenia
Antipsychotic maintenance and monitoring principles
NICE guideline psychosis and schizophrenia in adults
Antipsychotic and psychosocial interventions
Project BETA consensus statement for agitation
De escalation and medication calming options
Evidence based sources
Evidence anchors
Antipsychotics for acute agitation systematic reviews
Comparative efficacy and adverse effects
Long acting injectable antipsychotics outcomes literature
Relapse and rehospitalization reduction evidence
Catatonia recognition and benzodiazepine response literature
Lorazepam challenge concept support
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.