Level 2 of 6Must-remember

The agitated patient: acute agitation and psychosis

Assess, manage and stay safe — enough on its own

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The card — assess, manage, caution

Assessment— look, ask, measure

Treat agitation as an organic emergency until an organic cause has been excluded: it is a syndrome of arousal, not a diagnosis, and the presentation is behavioural but the diagnostic information is physiological.
Capillary glucose is the first test in every agitated patient without exception: below 4 mmol/L requires immediate treatment (below 3 mmol/L in a child, below 2.6 mmol/L in a neonate); recheck at 10 minutes and re-examine.
Oxygen saturation and respiratory effort: SpO₂ below 94% or any respiratory distress — hypoxaemia and hypercapnia both produce a restless, combative patient, and a rising PaCO₂ explains the agitation and contraindicates sedation without ventilatory support.
Blood pressure, pulse, perfusion: hypotension, tachycardia, cold peripheries or prolonged capillary refill — agitation is a classical early sign of shock, and the restless injured patient is bleeding until proved otherwise.
Temperature: above 39 °C, particularly with rigidity (neuroleptic malignant syndrome), clonus (serotonin syndrome) or a stimulant history — that is a hyperthermic emergency, not a behavioural one.
Neurological red flags: focal signs, unequal pupils, new seizure, neck stiffness, a fluctuating conscious level, head injury, anticoagulation or a fall.
Age red flags: over 65 with new confusion, or under 3 months — agitation in an infant under three months is never behavioural; it is sepsis, hypoglycaemia or raised intracranial pressure.
Onset: onset over hours in a person previously well is organic; months of decline with stable personality suggests dementia or chronic psychiatric illness.
Watch for the quiet, guarded, paranoid patient who will not let anyone near — calm concealment is more dangerous than noise.
Read the prodrome of violence: increasing restlessness and pacing, rising volume and rate of speech, refusal to sit, intrusion into personal space, clenched fists and jaw, prolonged staring or complete avoidance of eye contact, striking objects, and finally assault.
Separate delirium from psychosis: delirium has onset over hours to days, a course fluctuating markedly and worse at dusk and overnight, clouded and variable consciousness, grossly impaired attention (the patient cannot sustain the months of the year backwards), disorientation in time and place, and fleeting, poorly formed visual hallucinations.
Primary psychosis has a clear sensorium with preserved orientation and attention, auditory hallucinations often second- or third-person and consistent over time, systematised persecutory delusions, previous similar episodes, a steady course, and commonly recent cessation of medication; mania adds pressured speech, flight of ideas, grandiosity, reduced need for sleep and disinhibition.
Timing discriminates withdrawal: alcohol withdrawal begins 6–24 hours after the last drink with tremor, sweating, tachycardia, hypertension, anxiety and nausea; withdrawal seizures cluster at 12–48 hours; withdrawal delirium (delirium tremens) typically appears at 48–96 hours with tactile and visual hallucinations classically of insects or threads.
Recognise toxicity by the pupils and the skin: stimulants give dilated pupils, tachycardia, hypertension and sweating; the anticholinergic patient is dry, flushed, hyperthermic and mydriatic with absent bowel sounds; serotonin syndrome adds diaphoresis, tremor, hyperreflexia, clonus and fever with the neuromuscular signs greatest in the legs; neuroleptic malignant syndrome shows lead-pipe rigidity, autonomic instability, markedly raised creatine kinase and onset over days.
In older people agitation is nearly always delirium, and the delirium is nearly always saying something specific — pain, urinary retention, faecal impaction, infection, a new drug, dehydration or a blocked catheter; agitation in an older patient who is anticoagulated, or whose conscious level fluctuates, is a subdural haematoma until imaging says otherwise.
In children agitation is organic until proved otherwise: hypoglycaemia, hypoxaemia, raised intracranial pressure, post-ictal states, pain from an unrecognised source, poisoning (including a parent's alcohol, where severe hypoglycaemia may accompany intoxication because ethanol inhibits gluconeogenesis), febrile delirium and unmet need in neurodevelopmental disorder.

Management— do this, in order

Exclude reversible physiological causes before sedating: hypoglycaemia and hypoxaemia are excluded first, and only then are benzodiazepines administered — a drug given before a glucose measurement is a drug given blind.
Hypoglycaemia: 50 mL of 25% glucose intravenously in an adult (or an equivalent 25 g) with a repeat capillary glucose at 10 minutes; in children 2 mL/kg of 10% glucose intravenously, then recheck and start a glucose-containing maintenance infusion.Doctor / Nurse
Thiamine 100 mg intravenously or intramuscularly before or with the glucose in anyone malnourished, alcohol-dependent or with poor intake, and higher-dose parenteral B vitamins where Wernicke's encephalopathy is suspected.Doctor / Nurse
Hypoxaemia: oxygen titrated to target saturation and a blood gas — do not sedate a hypercapnic patient without ventilatory support. Hypoperfusion is resuscitated as shock, with a search for the bleeding source.Not available at your setup — Arterial blood gas. Where a blood gas is unavailable, respiratory rate and clinical work of breathing decide whether it is safe to sedate.
Temperature above 39 °C: strip the patient, cool actively externally, give cooled intravenous fluids and a benzodiazepine to abolish muscular hyperactivity; antipyretics are ineffective in toxic and exertional hyperthermia.Doctor / Nurse
The drug is the last rung of a ladder: environment, then verbal de-escalation, then oral medication offered as a choice, then intramuscular medication, with physical restraint used only to maintain safety and to permit an injection.
De-escalate — it works more often than expected and costs 90 seconds: reduce stimulation and remove the audience, ensure both clinician and patient have an unobstructed route out, keep two arms' lengths of distance, stand at an angle with hands visible, remove anything worn round the neck, and speak slowly with one voice only.
Address the emotion rather than the behaviour, and neither argue with nor endorse a delusion; offer something acceptable — a chair, water, the toilet, dimmed light, the return of a relative, analgesia. Unmet basic needs cause a large share of agitation and none of them respond to haloperidol.
Match the drug class to the cause — the single most consequential prescribing decision: benzodiazepine for alcohol or sedative withdrawal and for stimulant toxicity; antipsychotic for primary psychosis, mania and established psychotic aggressive states; benzodiazepine plus withdrawal of the offending agent for serotonin syndrome, neuroleptic malignant syndrome and anticholinergic delirium; and for delirium in the older person or in dementia, find and fix the cause with drugs used last, lowest and singly.Doctor / Nurse
Where the cause is unknown in an adult with no head injury or respiratory compromise, start with a benzodiazepine — it is the safer choice if the cause turns out to be withdrawal or stimulant toxicity, and it does not prolong the QT.Doctor / Nurse
Give medications sequentially rather than together, allowing 30 minutes to 1 hour for each to take effect; stacking agents within minutes is the mechanism of iatrogenic respiratory arrest. Record pulse, blood pressure, respiratory rate and oxygen saturation before and after every dose.Doctor / Nurse
Adult benzodiazepines: lorazepam 0.5–1 mg orally or IM, repeated after 30–60 min if needed, up to 1–2 mg every 2 hours as required; diazepam 5 mg for mild to moderate agitation, or 10 mg IV then 5–10 mg IV every 3–5 hours until controlled, or 10–20 mg IV repeated as required in stimulant, organophosphate or cannabinoid toxicity; midazolam 5–10 mg IM, lower in the elderly and frail.Doctor / Nurse
Adult antipsychotics: haloperidol 2.5–5 mg orally or 5–10 mg IM, and in a seriously violent or psychotic aggressive state antipsychotics may be repeated intramuscularly every 1–2 hours until symptoms are alleviated; olanzapine 10 mg IM (2.5–5 mg in the frail elderly); aripiprazole 9.75 mg (1.3 mL) or ziprasidone 10 mg (0.5 mL) IM; promethazine 50 mg IM as an adjunct.Doctor / Nurse
Children: diazepam 0.1–0.2 mg/kg IV, maximum single dose 10 mg, given slowly; lorazepam 0.05–0.1 mg/kg orally or IM, maximum 2 mg; where no weight is available, weight (kg) is approximately (age in years + 4) × 2 for ages 1–10 years.Doctor / Nurse
Acute dystonic reaction or oculogyric crisis: procyclidine 5–10 mg IV or IM — relief is dramatic and diagnostic.Doctor / Nurse
Iatrogenic benzodiazepine-induced respiratory depression: airway support first, antidote second — flumazenil is titrated in small increments and is relatively contraindicated in mixed poisoning with proconvulsants such as tricyclics, and in epilepsy or benzodiazepine dependence, because it may cause convulsions.Doctor / Nurse
If restraint is unavoidable: never prone, never with weight, a knee or a body across the chest, abdomen or neck; a minimum of five people, one to each limb and one whose sole responsibility is the head and airway — that person is never given a limb to hold; time-limited to the injection, with limbs released as sedation takes effect.
Monitor after sedation: continuous oximetry and direct observation, a full set of observations every 15 minutes to 1 hour, and a complete set reviewed before every repeat dose, with oxygen, suction and a bag-valve-mask immediately available. The therapeutic target is a calm, rousable patient (RASS 0 to −1), not an unconscious one.Doctor / Nurse

Caution— what harms

Never give an antipsychotic first in alcohol or sedative withdrawal: only a GABA-ergic drug corrects the deficit, and antipsychotics lower the seizure threshold in a patient already at risk.
Never sedate a hypercapnic patient without ventilatory support, and never sedate before the glucose is measured.
Never stack drugs within minutes — give them sequentially 30 minutes to 1 hour apart; stacking is how patients stop breathing, particularly where a benzodiazepine follows alcohol or an opioid.
Never give intramuscular olanzapine with a parenteral benzodiazepine without close respiratory and haemodynamic monitoring — excessive sedation and cardiorespiratory depression are described.
Never restrain prone or with weight across the chest, abdomen or neck: positional asphyxia is the mechanism of most restraint deaths, and deaths have occurred as a direct consequence of restraint, particularly when combined with psychotropic medication.
A struggling patient who suddenly goes quiet has either settled or stopped breathing — never assume the first.
Never give more of a drug that has made the patient worse: akathisia from the antipsychotic already given, acute dystonia, and paradoxical benzodiazepine disinhibition all look like worsening agitation — switch class rather than repeating.
Never use an antipsychotic without an ECG where one is possible: a QTc above 500 ms, or a rise of more than 60 ms from baseline, marks substantial torsades risk and should redirect the choice of drug.
Avoid haloperidol in withdrawal states, Parkinson's disease and dementia; no antipsychotic has been shown to be reliably effective for agitation in dementia, and antipsychotics may increase the risk of early mortality in this group.
Benzodiazepines can worsen confusion and agitation in the elderly and delirious, and diazepam has a long half-life to be avoided in the elderly and in liver disease; midazolam is the benzodiazepine most likely to depress respiration.
Promethazine is contraindicated under 2 years because of the risk of fatal respiratory depression, and should be avoided in young children generally; haloperidol is not recommended under 12 years without specialist paediatric agreement.
Do not assume a positive urine dipstick explains delirium — asymptomatic bacteriuria is common; and urine drug screens are of limited acute value, detecting metabolites for days after the effect has passed.
Do not treat cocaine-related agitation with a beta-blocker — its use in cocaine poisoning is controversial; and never miss hyperthermia in stimulant toxicity.
Do not let sedation mask a deteriorating conscious level from an intracranial cause; ask what would be investigated if this patient were not agitated.

Refer / escalate

Call for help or transfer urgently for any agitated patient with a red flag you cannot resolve — hypoxaemia or a rising PaCO₂, temperature above 39 °C, focal neurological signs, head injury or anticoagulation needing CT, suspected meningoencephalitis or non-convulsive status, an infant under 3 months, refractory withdrawal needing dexmedetomidine or airway capability, or any patient requiring intramuscular ketamine or restraint beyond your monitoring capacity.

The card — assess, manage, caution

The agitated patient: acute agitation and psychosis — Level 1: CorePrevious The agitated patient: acute agitation and psychosis — Level 3: Core practiceNext

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