Identify the cause of agitation, choose proportionate calming treatment, monitor medication and restraint, and assess capacity and safe disposition.
A patient pacing beside the stretcher might be frightened, psychotic, hypoglycemic, withdrawing from alcohol, or developing delirium. The volume of the patient's voice does not identify the cause. Your first decision is whether conversation can proceed safely while you assess physiology, or whether immediate protective treatment is needed to make that assessment possible.
Assess the person and the physiology
Agitation describes behavior, not a diagnosis. Look for oxygenation or ventilation problems, abnormal temperature, glucose disturbance, injury, pain, intoxication, withdrawal, infection, and medication effects. Obtain vital signs and bedside glucose early when feasible. Ask staff or family what changed, review medications and exposures, and examine attention as well as orientation. Investigations follow the history and findings rather than an automatic laboratory bundle for every psychiatric presentation. [1]
Delirium is an acute, fluctuating disturbance of attention and awareness with additional cognitive change. A person can name the hospital yet be unable to sustain a brief conversation. New inattention in an older adult with fever needs medical evaluation even if dementia or schizophrenia is already documented. Quiet intervals do not establish recovery. Treat the underlying illness, support hearing and vision, provide orientation, and address hydration, toileting, and pain. [9]
Immediate danger
Protect the patient and others, call trained assistance, create space, and prepare monitoring and airway equipment. Severe ongoing assault or physiologic collapse may require urgent parenteral medication.
Medical cause
Assess breathing, circulation, temperature, glucose, trauma, attention, and exposures. Continue this work during and after calming treatment.
Reassessment
Check response, ventilation, vital signs, and adverse effects. Revisit the diagnosis when the patient can participate. Sleep alone is not the endpoint.
Severe agitation with hyperthermia, extreme exertion, and altered awareness is a medical emergency requiring rapid stabilization. Use descriptive clinical findings and a differential diagnosis. ACEP withdrew support for its older excited delirium report; that label must not substitute for identifying intoxication, delirium, metabolic illness, or trauma. [14]
For delirium with distress or danger to self or others, NICE advises considering short-term haloperidol, usually one week or less, only when verbal and nonverbal de-escalation is ineffective or inappropriate. Use the lowest appropriate dose and cautious titration. Review cardiac risk and neurological vulnerability, particularly Parkinson disease or dementia with Lewy bodies. This treats dangerous symptoms while the underlying cause is addressed. [9]
Try it here · Checkpoint 1 of 3
Make your prediction before reading the choices. A first attempt is just a starting point.
Case 2
Show answer and explanations for case 2
A. Wait for antipsychotic medication to restore attention before obtaining vital signs. (Why this does not fit)
Assessment of potentially serious illness should proceed alongside calming treatment.
B. Discharge if the patient correctly identifies the hospital. (Why this does not fit)
Naming a location does not exclude delirium or establish medical stability.
C. Investigate an acute medical cause of delirium while maintaining safety. (Best answer)
Fever and impaired attention are new findings that require medical evaluation despite a psychiatric history.
D. Treat this as an uncomplicated psychotic relapse. (Why this does not fit)
The abrupt cognitive change and abnormal physiology are not adequately explained by the historical diagnosis.
Takeaway: New inattention and abnormal vital signs require medical assessment.
When engagement is possible, use one calm speaker, introduce yourself, maintain personal space, and keep exits accessible. Ask what the patient needs and listen for a correctable trigger. Offer concrete choices, such as a quieter room or oral medication, without promising something unavailable. State limits respectfully and specifically. A crowd, unexpected touch, humiliation, or an argument about a delusion can intensify fear. [2]
Trauma-informed care is practical. Before an examination or procedure, explain what will happen, obtain agreement when possible, offer a support person, and establish a stop signal. A patient who becomes frightened when staff reach for clothing may respond to restored control. This does not mean postponing lifesaving care indefinitely when immediate danger prevents meaningful participation.
Medication aims for calm engagement while preserving breathing and the ability to reassess. A cooperative patient can often accept oral medication appropriate to the cause. An orally disintegrating tablet is still an oral formulation; it is not equivalent to an injection or a reliably rapid sublingual rescue. Conversely, inhaled loxapine is a pulmonary delivery system with bronchospasm risks, not a tablet option. [3][15]
Do not turn a least-restrictive principle into a compulsory sequence of failed attempts. An actively attacking patient may need a coordinated team response and immediate medication. Select the route, drug, and monitoring for the clinical situation. Document why less restrictive measures were ineffective or not feasible, and resume collaboration as soon as the person can participate. [4][8]
Match calming treatment to the cause
Similar behavior can require different medication
Pattern
Treatment direction
Why the distinction matters
PatternStimulant hyperadrenergic toxicity
Treatment directionBenzodiazepine, cooling and supportive care as indicated
Why the distinction mattersReduce excessive sympathetic activity and muscular exertion. Treat associated psychosis when present.
PatternAlcohol intoxication
Treatment directionSupportive care first; an antipsychotic may be appropriate if medication is essential
Why the distinction mattersAdditional respiratory depressants can compound alcohol's effects.
Why the distinction mattersPrevent seizures and treat the underlying withdrawal physiology.
PatternPsychosis or mania
Treatment directionAntipsychotic treatment with route matched to cooperation and urgency
Why the distinction mattersAddress the syndrome driving the behavior.
PatternNonwithdrawal delirium
Treatment directionCorrect causes and provide supportive care
Why the distinction mattersRoutine sedation does not cure delirium and can obscure deterioration.
Benzodiazepines are a first-line medication option for stimulant-related agitation. Antipsychotics are not categorically prohibited in stimulant intoxication; ASAM recommends an antipsychotic for stimulant-induced psychotic symptoms, while specifically advising against chlorpromazine and clozapine in that setting because of seizure risk. Hyperthermia requires active cooling and evaluation for organ injury in addition to calming treatment. Nystagmus with reduced pain perception can suggest PCP exposure, but neither finding independently proves it. [7][3][17]
For adults with undifferentiated severe agitation requiring immediate sedation in the ED, ACEP gives Level B support to droperidol plus midazolam or an atypical antipsychotic plus midazolam. If only one agent is used, droperidol or an atypical is supported; haloperidol alone or with lorazepam is another Level B option. This policy excludes pediatric, pregnant, out-of-hospital, and over-65 populations. These are not interchangeable prescriptions for every patient. The olanzapine label specifically advises against IM olanzapine with parenteral benzodiazepines because of excessive sedation and cardiorespiratory depression. A one-hour interval is not a universal FDA assurance of safety. [4][5]
For severe agitation in the ED, ACEP gives a Level C consensus recommendation to consider IV or IM ketamine when immediate safety is threatened and rapid control is necessary. It requires a setting prepared for airway complications and continued medical evaluation. A routine three-drug haloperidol, lorazepam, and diphenhydramine combination is not mandatory. Additional sedating or anticholinergic drugs can create new problems, especially in older adults. Consider recent doses, QT risk, hypotension, respiratory disease, and co-ingestants before adding medication. [4]
Check the calculation separately from the treatment decision. If an adult ED prescription specifies ketamine 4 mg/kg IM and the verified weight is 90 kg, the calculated dose is 360 mg. This IM regimen was studied in an adult ED trial; it is not a universal dose, and the number must not be transferred to IV administration. Confirm the patient, order, route, concentration and monitoring before administration. [20]
Alcohol withdrawal can occur while alcohol remains measurable. A withdrawal seizure is commonly seen within roughly 8 to 48 hours after reduction or cessation. Benzodiazepines address recurrent withdrawal seizures; phenytoin does not treat this mechanism unless another seizure disorder independently requires it. Give thiamine to at-risk patients, but never delay urgent glucose for hypoglycemia. Glucose and thiamine can be given concurrently or in either order. [6]
Reassess treatment and recognize new illness
After parenteral medication, reassess respiratory rate, oxygenation, level of consciousness, blood pressure, pulse, temperature when relevant, and the need for additional treatment. Use monitoring appropriate to acuity and local sedation practice, with airway support immediately available. Do not automatically redose a patient whose agitation has become hypoxia, hypotension, or an adverse drug reaction. [4][5]
Painful neck twisting, sustained jaw contraction, or upward eye deviation after a dopamine-blocking drug suggests acute dystonia. Anticholinergic treatment such as diphenhydramine or benztropine can reverse it; laryngeal involvement requires immediate airway attention. Fever, generalized rigidity, altered consciousness, and autonomic instability after an antipsychotic raise concern for neuroleptic malignant syndrome. Stop the implicated drug and arrange urgent supportive medical treatment. Specialist-directed therapies may be used in severe cases; dantrolene is not an obligatory first prescription for every presentation. [5][18]
A prolonged QTc should prompt review of medications, electrolytes, and cardiac risk. Avoid casually stacking QT-prolonging drugs. A comparatively smaller average QT effect does not make a drug risk-free. Similarly, delirium with dry skin, urinary retention, dilated pupils, and tachycardia suggests an anticholinergic toxidrome; adding diphenhydramine would aggravate that pattern. [19]
Withdrawal delirium needs monitored treatment and an assessment tool suitable for a patient who cannot reliably answer questions. CIWA-Ar depends substantially on patient report and should not be used to direct dosing in delirium. ASAM permits phenobarbital in experienced hands: inpatient monotherapy when benzodiazepines are contraindicated, or an adjunct for severe withdrawal with close monitoring. Parenteral use requires a highly supervised setting such as an ICU because of oversedation and respiratory risk. Selected extensively monitored ambulatory protocols also exist; it is not universally reserved for a final failed step. [6]
Agitation in dementia deserves a search for pain, urinary retention, constipation, environmental stress, or acute illness. If a medication is needed for severe distress or danger, discuss its specific risks and indication. Brexpiprazole has an FDA indication for agitation associated with Alzheimer dementia, but it is scheduled therapy rather than an emergency rescue and retains the antipsychotic mortality warning. Neither an SSRI nor trazodone is a universal substitute for this assessment. [9][16]
Try it here · Checkpoint 2 of 3
Make your prediction before reading the choices. A first attempt is just a starting point.
Case 14
Show answer and explanations for case 14
A. Begin a VMAT2 inhibitor as the immediate rescue. (Why this does not fit)
VMAT2 inhibitors address tardive dyskinesia rather than this acute dystonic reaction.
B. Diagnose NMS solely from the abnormal posture. (Why this does not fit)
NMS typically includes systemic findings such as fever and altered mental status that are absent here.
C. Treat acute dystonia with an appropriate anticholinergic and assess the airway. (Best answer)
The abrupt sustained contractions after dopamine blockade fit dystonia; airway involvement must be considered.
D. Give more haloperidol because the abnormal posture represents worsening psychosis rather than an acute medication reaction. (Why this does not fit)
Further dopamine blockade can worsen this medication adverse effect.
Takeaway: Acute sustained muscle contractions after dopamine blockade suggest dystonia.
Physical restraint and seclusion are last-resort safety interventions, not punishment, staff convenience, or compensation for inadequate observation. They require trained application, attention to positioning and breathing, and the least restrictive effective approach. Avoid pressure that compromises ventilation or circulation. Use a position that allows uninterrupted airway and respiratory assessment; avoid pressure on the neck, chest, or abdomen and positions that impair breathing. Reposition promptly if ventilation is compromised. [8]
Under the US hospital regulation, restraint or seclusion must stop at the earliest possible time, even if an order has time remaining. Orders cannot be standing or PRN. For violent or self-destructive behavior, renewal limits are up to four hours for adults, two hours for ages 9 through 17, and one hour below age 9, unless a more restrictive state rule applies. These limits are not reassessment intervals or permission to continue restraint for the full duration.
The required face-to-face evaluation occurs within one hour for violent or self-destructive restraint or seclusion. The regulation permits specified qualified clinicians, including a trained registered nurse or physician assistant under its conditions; it is not always restricted to a physician. Hospital policy determines monitoring intervals within regulatory requirements and clinical needs. Concurrent restraint and seclusion require continuous monitoring. A universal statement that every restrained patient only needs a check every 15 minutes or every two hours is unsafe.
Document the immediate behavior, alternatives considered, order and evaluation, ongoing respiratory and circulatory status, hydration and toileting needs, response to treatment, and criteria for discontinuation. As the patient regains control, reassess whether the restriction is still necessary. A calmer patient can still need close observation without needing continued restraint.
Separate capacity, legal authority, and discharge safety
Capacity concerns a particular decision at a particular time. Ask the patient to explain the condition and options in their own words, apply likely consequences to themselves, compare options using coherent reasoning, and communicate a choice. Orientation alone is insufficient. Neither a psychiatric diagnosis, an alcohol level, a religious belief, nor an unpopular decision automatically establishes incapacity. Treat reversible barriers and reassess. [10]
Understanding and appreciation can diverge. A patient may accurately repeat that untreated infection can be fatal yet deny that the infection could affect their own body because of a fixed delusion. Conversely, a patient who accepts the personal risk and refuses blood for longstanding religious reasons may retain capacity. Document the functional assessment rather than merely writing that the patient is intoxicated or uncooperative.
Emergency treatment for a patient lacking capacity and civil psychiatric detention are separate authorities. A person with intact decision-making abilities may nevertheless meet local criteria for emergency detention because of immediate suicide danger. A person lacking capacity from delirium may need medical treatment without meeting psychiatric commitment criteria. Serious inability to meet basic needs may qualify under some statutes even without violence. Duration, authorized decision-makers, and procedural rights vary; do not teach a universal 72-hour hold. [12]
A credible serious imminent threat against another person requires an immediate protective assessment, including intent, access to means, potential targets, and available interventions. HIPAA can permit appropriately limited disclosure to people able to lessen the threat. The existence and scope of a legal duty to warn or protect depend on jurisdiction and circumstances; consult applicable law and institutional support without delaying necessary safety measures. [11]
Before discharge, reassess medical stability, capacity for the proposed plan, suicidal or violent intent, supports, access to lethal means, and follow-up. Superficial self-injury without stated suicidal intent still warrants psychosocial assessment. A risk score, a promise, a quiet interval, or the mere passage of intoxication is not sufficient. Build a collaborative safety plan and address access to lethal means when relevant. [13]
Try it here · Checkpoint 3 of 3
Make your prediction before reading the choices. A first attempt is just a starting point.
Case 28
Show answer and explanations for case 28
A. Take immediate protective action and consider limited disclosure under applicable law to people able to lessen the threat. (Best answer)
HIPAA permits certain good-faith disclosures for serious imminent threats, while duties and required recipients vary by jurisdiction.
B. HIPAA prohibits disclosure until a shooting has occurred. (Why this does not fit)
The serious-imminent-threat permission is intended to enable preventive action.
C. Limit disclosure to the internal treatment team even when an identified outside person could avert the imminent threat, because confidentiality must otherwise remain absolute. (Why this does not fit)
HIPAA may permit limited disclosure to others able to reduce a serious imminent threat. Restricting action to the internal team can leave the identified danger unaddressed.
D. Apply a universal rule that every state requires exactly the same warning calls. (Why this does not fit)
Duty-to-protect law is not uniform; the local legal framework matters.
Takeaway: Protect against credible imminent threats using appropriately limited, lawful disclosure.
Each original educational case asks for one best decision. Read the whole presentation before choosing; the same behavior can arise from very different mechanisms.
Case 1
Show answer and explanations for case 1
A. Give IM ketamine immediately. (Why this does not fit)
Rapid dissociation is disproportionate when the patient is conversant and immediate safety is not threatened.
B. Apply four-point restraint before discussing care. (Why this does not fit)
Pacing alone does not establish the need for restraint, and coercion may worsen this encounter.
C. Have several staff members simultaneously explain hospital rules and insist on immediate compliance. (Why this does not fit)
Multiple competing voices can increase overload; one calm communicator is preferable here.
D. Use one speaker to acknowledge the concern, explain the plan, and offer a quieter space. (Best answer)
The patient can engage and has no immediate physiologic or assaultive emergency; a concrete response to the stated trigger can restore collaboration.
Takeaway: Match the intensity of intervention to the actual danger and ability to engage.
A. Titrate a benzodiazepine with respiratory and cardiovascular monitoring. (Best answer)
This addresses stimulant-related agitation and hyperadrenergic activity while monitoring for treatment complications.
B. Use haloperidol alone as the initial treatment for the autonomic syndrome. (Why this does not fit)
An antipsychotic can treat stimulant psychosis, but without persistent psychosis a benzodiazepine more directly addresses the agitation and hyperadrenergic state.
C. Use clonidine alone as the first treatment for severe agitation. (Why this does not fit)
An alpha-2 agonist may be an adjunct for persistent autonomic symptoms; it does not replace monitored GABAergic treatment of this severe syndrome.
D. Use chlorpromazine alone to obtain sedation. (Why this does not fit)
ASAM advises avoiding chlorpromazine in stimulant psychosis because of seizure risk; its hypotensive and anticholinergic effects also make it a poor fit here.
Takeaway: Stimulant hyperadrenergic agitation often responds to benzodiazepine treatment.
A. Treat antipsychotics as absolutely contraindicated whenever a stimulant was used, regardless of current symptoms. (Why this does not fit)
That blanket rule leaves the persistent psychotic driver untreated and conflicts with current guidance.
B. Benzodiazepines must be stopped because psychosis is now present. (Why this does not fit)
The patient may still need treatment for hyperadrenergic toxicity alongside treatment for psychosis.
C. Persistent hallucinations establish lifelong schizophrenia during this visit. (Why this does not fit)
An intoxication-associated episode cannot by itself establish the longitudinal diagnosis.
D. Use an antipsychotic for stimulant-induced psychosis after assessing patient-specific risks. (Best answer)
ASAM recommends treatment of stimulant psychosis; antipsychotics are not universally prohibited in this setting. Chlorpromazine and clozapine should be avoided in this setting because of seizure risk.
Takeaway: Treat stimulant psychosis as well as the associated physiologic toxicity.
A. Use CIWA-Ar to prove that the high ethanol level excludes withdrawal and removes the need for monitored withdrawal treatment. (Why this does not fit)
CIWA-Ar does not establish the cause of symptoms, and a measurable ethanol level does not exclude withdrawal.
B. Ignore the respiratory rate until the assaultive behavior ends. (Why this does not fit)
Safety treatment must include ventilation assessment, not merely behavioral control.
C. Prioritize airway support and avoid worsening alcohol-related respiratory depression; if medication is essential, choose it accordingly. (Best answer)
The slow breathing is an immediate concern, and alcohol intoxication changes the risk of adding a benzodiazepine.
D. Give escalating benzodiazepines solely because alcohol is involved. (Why this does not fit)
Benzodiazepines treat withdrawal, but may worsen respiratory depression in intoxication.
Takeaway: Alcohol intoxication and alcohol withdrawal have different medication priorities.
A. Administer medication and then stop medical assessment until full awakening. (Why this does not fit)
Treatment creates a need for ongoing respiratory, cardiovascular, and diagnostic reassessment.
B. Use restraint as punishment after the patient regains control. (Why this does not fit)
Restraint is justified only by a current safety need, not by prior behavior.
C. Use immediate parenteral treatment because of the immediate threat; ketamine is one option in this prepared setting. (Best answer)
A compulsory oral trial would delay control of an active life-threatening safety problem; rapid treatment still requires monitoring.
D. Complete a prolonged verbal de-escalation trial before any medication, even while the patient continues immediate dangerous assaults. (Why this does not fit)
Verbal approaches are valuable when feasible but are not a required delay during an active attack.
Takeaway: Immediate danger can justify rapid intervention without a rigid sequence.
A. Choose another appropriate calming treatment because asthma contraindicates inhaled loxapine. (Best answer)
The product has a bronchospasm contraindication in asthma; availability of albuterol does not cancel it.
B. Give inhaled loxapine if the patient is not wheezing at this moment, because absent wheeze removes the asthma contraindication. (Why this does not fit)
A history of asthma is a contraindication even without current wheeze.
C. Give prophylactic albuterol and then administer inhaled loxapine. (Why this does not fit)
Pretreatment with a bronchodilator does not erase the product contraindication.
D. Use a smaller inhaled loxapine dose to bypass the respiratory restriction. (Why this does not fit)
The label does not provide a reduced-dose workaround for asthma.
Takeaway: Inhaled loxapine has pulmonary restrictions that oral agents do not share.
A. Treat a one-hour delay as the FDA-labeled point at which concomitant parenteral benzodiazepines become safe without further precautions. (Why this does not fit)
The US label advises against IM olanzapine with parenteral benzodiazepines and does not supply a universal safe waiting interval.
B. Changing the benzodiazepine from IM to IV avoids the warning. (Why this does not fit)
The warning applies to parenteral benzodiazepines, including IV administration.
C. Adding routine pulse oximetry makes the combination recommended by the label. (Why this does not fit)
Monitoring is necessary for many sedation regimens but does not change the product recommendation against this combination.
D. The label advises against concomitant parenteral benzodiazepines; an hour is not a universal safety guarantee. (Best answer)
Excessive sedation and cardiorespiratory depression are the labeled concern, requiring a different individualized plan and monitoring.
Takeaway: Check the specific drug and route rather than applying a generic combination rule.
A. Provide immediate airway and ventilation assessment and support while evaluating medication effects. (Best answer)
The new respiratory abnormality is an emergency; quiet behavior cannot be counted as successful treatment.
B. Administer another sedative immediately to prevent recurrence of agitation before evaluating the new hypoxia and slow respirations. (Why this does not fit)
Additional sedation can worsen the current respiratory compromise.
C. Wait until the next routine restraint observation time. (Why this does not fit)
An acute deterioration requires immediate response regardless of the scheduled documentation interval.
D. Assume the pulse oximeter is wrong because the patient is asleep. (Why this does not fit)
Both slow breathing and low saturation support a clinically important problem.
Takeaway: The endpoint is safe calming, not unresponsiveness.
A. Stack additional QT-prolonging drugs because a baseline ECG has already been obtained, even though hypokalemia and a prolonged QTc remain present. (Why this does not fit)
Obtaining an ECG does not neutralize the risk it identifies.
B. Declare any alternative antipsychotic entirely free of arrhythmia risk. (Why this does not fit)
Relative differences do not establish absolute safety, especially with this electrolyte abnormality.
C. Delay all protective care until a cardiology clinic appointment. (Why this does not fit)
Immediate agitation and the abnormal physiology require a timely monitored plan.
D. Correct the electrolyte disturbance and select an individualized monitored calming plan that minimizes added QT risk. (Best answer)
Both the prolonged interval and hypokalemia increase concern; drug choice and cumulative exposure need reassessment.
Takeaway: QT findings should change medication selection and correction of reversible risks.
A. An adult's four-hour order limit is the required interval between observations. (Why this does not fit)
Order duration and observation frequency serve different purposes.
B. Use only intermittent checks for combined restraint and seclusion whenever the patient appears asleep, because sleep suspends the continuous-monitoring requirement. (Why this does not fit)
Simultaneous restraint and seclusion require continuous monitoring by appropriately trained staff; sleep does not remove that requirement.
C. Monitoring follows clinical needs and hospital policy; specified trained clinicians are permitted to perform the one-hour evaluation under its conditions. (Best answer)
The one-hour clinical evaluation and ongoing monitoring are separate requirements; observation frequency must meet policy and individualized clinical needs.
D. No face-to-face evaluation is required for violent restraint. (Why this does not fit)
The one-hour evaluation requirement does apply to violent or self-destructive restraint or seclusion.
Takeaway: Separate order limits, face-to-face evaluation, and ongoing monitoring requirements.
The patient can state the general risk but cannot apply it to their own illness because of the fixed belief.
B. Communication of a choice. (Why this does not fit)
The patient is communicating a refusal clearly; that ability alone does not establish capacity.
C. Understanding the general information. (Why this does not fit)
The patient can explain the general consequence, while the personal application is the central deficit.
D. Reasoning. (Why this does not fit)
Reasoning concerns comparing alternatives. The finding directly shown is failure to apply the stated medical risk personally; other abilities still need assessment.
Takeaway: Appreciation means recognizing how the information applies to oneself.
A. Treat the psychiatric diagnosis itself as automatic authority for indefinite detention without applying local statutory criteria. (Why this does not fit)
Diagnosis alone does not replace legal criteria, procedures, or periodic review.
B. Assess whether inability to meet essential needs satisfies the local emergency detention standard. (Best answer)
Some jurisdictions recognize serious disability or inability to meet basic needs even without violence.
C. Absence of an assault excludes every form of involuntary intervention. (Why this does not fit)
Violence is not the only possible statutory criterion.
D. Every clinician can impose a 72-hour hold in every state. (Why this does not fit)
Authority, duration, and criteria depend on the jurisdiction.
Takeaway: Essential-needs risk can matter, but legal criteria must be applied locally.
