Guides acute agitation management with de-escalation and emergency medication protocols. Use when managing psychiatric crises, treating acute agitation, or implementing emergency interventions.
Guides acute agitation management with de-escalation and emergency medication protocols. Use when managing psychiatric crises, treating acute agitation, or implementing emergency interventions.
Guides acute agitation management with de-escalation techniques, emergency medication protocols, seclusion/restraint documentation, and disposition planning in compliance with CMS Conditions of Participation and Joint Commission standards.
Why This Skill Exists
Acute psychiatric crises — severe agitation, psychotic decompensation, suicidal behavior in progress, catatonia, and behavioral emergencies — require rapid assessment and intervention to prevent harm to the patient and others. The AAEP/ACEP guidelines on the management of acute agitation establish a stepwise approach: verbal de-escalation first, followed by voluntary oral medication, then involuntary parenteral medication, and seclusion/restraint as last resort. CMS Conditions of Participation (42 CFR 482.13) and Joint Commission standards (PC.03.05) impose strict requirements on the use of restraint and seclusion including physician orders, time limits, face-to-face evaluations, and continuous monitoring.
Inadequate management of psychiatric crises leads to patient injury, staff injury, prolonged hospitalizations, litigation, and regulatory sanctions. The most common adverse outcomes in psychiatric emergencies are death or serious injury from restraint-related positional asphyxia, medication-related respiratory depression, and failure to identify and treat underlying medical emergencies (delirium, intoxication, metabolic crisis) presenting as behavioral disturbance.
Checkpoint A: Pre-Draft Intake (Mandatory)
What is the nature of the crisis? (acute agitation, psychotic decompensation, active suicidal behavior, homicidal threat, catatonia, severe self-harm, delirium, intoxication/withdrawal) — default: assess immediately
What is the setting? (emergency department, inpatient psychiatric unit, outpatient clinic, community, correctional) — default: identify
Is the patient medically cleared? — default: assess concurrently with behavioral management
Is the patient known to the treatment team or a new presentation? — default: obtain history rapidly
What is the patient's current medication regimen? — default: obtain immediately
Are there known allergies or adverse reactions to emergency medications? — default: verify before administering
Are there special populations considerations? (pregnancy, elderly, pediatric, intellectually disabled, known cardiac disease) — default: assess
What de-escalation resources are immediately available? (trained staff, safe environment, show of support team) — default: mobilize
Documents to Request
Most recent psychiatric evaluation and medication list
Prior crisis documentation and response to previous interventions
Allergy list and adverse medication reaction history
Advance directives or psychiatric advance directives (PADs)
Medical history relevant to emergency medication selection (QTc prolongation risk, respiratory disease, hepatic impairment)
Vital signs including temperature (rule out NMS, serotonin syndrome, infection)
Urine drug screen and blood alcohol level
Point-of-care glucose (hypoglycemia is a medical emergency that mimics psychiatric crisis)
Step 1: Rapid Safety Assessment and Triage
Immediate safety priorities (first 60 seconds):
Assess for weapons or objects that could be used as weapons
Ensure clear exit routes for staff and patient
Remove bystanders from the area
Call for additional staff support if needed (show of support)
Assess for medical emergency requiring immediate intervention (anaphylaxis, seizure, cardiac arrest, overdose)
Medical clearance priorities (concurrent with behavioral management):
Point-of-care glucose (rule out hypoglycemia — treat with glucose if <60 mg/dL)
Mental status: Is this delirium or psychiatric agitation? The distinction drives all subsequent management
Delirium indicators: Acute onset, fluctuating course, inattention, altered level of consciousness, visual hallucinations, disorientation. Treat the MEDICAL CAUSE, not just the agitation.
Psychiatric agitation indicators: Alert, oriented, coherent (even if psychotic), stable vitals, no evidence of medical illness
Agitation severity assessment (use BARS — Behavioral Activity Rating Scale or equivalent):
1 = Difficult or unable to rouse
2 = Asleep but responds to verbal/tactile stimulation
3 = Drowsy, appears sedated
4 = Quiet and awake
5 = Signs of overt activity, calms with verbal instructions
6 = Extremely or continuously active, not requiring restraint
7 = Violent, requires restraint
Verbal de-escalation should ALWAYS be attempted before medication or physical intervention unless there is imminent risk of harm that does not permit delay.
AAEP 10 Key Elements of De-Escalation:
Respect personal space (maintain arm's-length distance minimum)
Do not be provocative (avoid crossing arms, pointing, making demands)
Establish verbal contact (one person speaks, others remain quiet)
Be concise and use simple language
Identify wants and feelings ("I can see you're upset. What do you need right now?")
Listen closely and empathize ("That sounds really frustrating")
Agree or agree to disagree (find common ground)
Lay down the law and set clear limits ("I want to help you, but I can't do that if you're threatening the staff")
Offer choices and optimism ("Would you prefer to take a pill or have a drink of water and sit down?")
Debrief patient and staff after the event
Environmental modifications:
Reduce stimulation (dim lights, reduce noise, limit number of people)
Second-Line: Parenteral Medications (if oral refused or insufficient)
Olanzapine 10mg IM: Effective for psychotic agitation. Do NOT combine with IM benzodiazepines (respiratory depression risk). Onset: 15-30 minutes. May repeat x1 after 2 hours.
Ziprasidone 10-20mg IM: Alternative to olanzapine. Check QTc if possible (QTc prolongation risk). Onset: 15-30 minutes. May repeat 10mg after 2 hours.
Haloperidol 5mg IM + Lorazepam 2mg IM + Diphenhydramine 50mg IM ("B52"): Traditional combination, effective but more sedating. EPS risk with haloperidol.
Haloperidol 5-10mg IM: For severe psychotic agitation when antipsychotic monotherapy is preferred. Monitor for acute dystonia (treat with benztropine 1-2mg IM or diphenhydramine 50mg IM).
Lorazepam 2mg IM: For non-psychotic agitation, substance withdrawal, when antipsychotics are contraindicated. Onset: 15-30 minutes.
Droperidol 5-10mg IM: Rapid onset (3-10 minutes), very effective, but requires cardiac monitoring (FDA Black Box Warning for QTc prolongation).
Ketamine 4-5mg/kg IM: For extreme, refractory agitation when other agents have failed. Rapid onset (3-5 minutes). Requires advanced airway support.
Special Populations
Elderly: Reduce all doses by 50%. Avoid haloperidol if possible (EPS risk). Low-dose olanzapine 2.5mg or lorazepam 0.5-1mg.
Pregnancy: Haloperidol is relatively safest antipsychotic. Avoid benzodiazepines in first trimester. Diphenhydramine is generally safe.
Known cardiac disease / QTc prolongation: Avoid haloperidol IV, ziprasidone, droperidol. Prefer olanzapine or lorazepam.
Alcohol withdrawal: Benzodiazepines (lorazepam or chlordiazepoxide) per CIWA protocol.
Catatonia: Lorazepam 1-2mg IV challenge (not antipsychotics — antipsychotics can worsen catatonia and precipitate NMS).
Step 4: Seclusion and Restraint Documentation
Seclusion and restraint are last-resort interventions. CMS Conditions of Participation (42 CFR 482.13) require:
Order requirements:
Physician or LIP order required (standing orders prohibited)
Face-to-face evaluation within 1 hour of initiation
Time limits: 4 hours adults, 2 hours adolescents (9-17), 1 hour children (<9)
Orders must be renewed at time limit intervals; no PRN or standing orders
Order must document the clinical justification (behavioral description, not just "agitated")
Monitoring requirements:
Continuous observation (1:1) during restraint
Vital signs per institutional protocol (typically every 15 minutes)
Circulation, sensation, and movement checks of restrained extremities
Hydration, nutrition, toileting needs addressed at regular intervals
Range of motion offered every 2 hours
Ongoing assessment for readiness to discontinue restraint
Documentation:
Behavior that necessitated restraint (specific behavioral description)
Alternatives attempted before restraint (de-escalation, medication offered)
Type of restraint (4-point, 2-point, physical hold, seclusion room)
Time initiated and time discontinued
Patient's response during restraint
Face-to-face evaluation findings
Plan for de-escalation and restraint reduction
Post-restraint debriefing with patient and staff
Step 5: Disposition and Transition Planning
After acute crisis stabilization:
Reassess psychiatric diagnosis and risk level
Determine appropriate disposition: continue inpatient, transfer to higher level of care, step down to voluntary status, discharge with outpatient follow-up
Complete updated suicide risk assessment (C-SSRS) before disposition change
Update or create safety plan
Ensure follow-up appointment is scheduled (within 24-72 hours for high-risk patients)
Document the crisis event in the longitudinal treatment record
Seclusion/restraint order meets CMS requirements (physician order, time-limited, no PRN)
Face-to-face evaluation within 1 hour of restraint initiation documented
Continuous observation documented during restraint
Restraint discontinuation criteria and plan documented
Post-crisis debriefing completed with patient and staff
Incident report filed per institutional policy
Guidelines
Always rule out medical causes of agitation before treating as psychiatric — hypoglycemia, hypoxia, delirium, intoxication, sepsis, and head injury present as agitation and require medical, not psychiatric, intervention.
Never combine IM olanzapine with IM benzodiazepines — the combination carries significant risk of respiratory depression, hypotension, and death per FDA warning.
Verbal de-escalation is the first-line intervention for all acute agitation — document that it was attempted even when it is unsuccessful.
For suspected catatonia, administer lorazepam IV challenge before antipsychotics — antipsychotics can worsen catatonia and precipitate neuroleptic malignant syndrome.
Seclusion and restraint are interventions of last resort — document the alternatives attempted and the specific behavior that necessitated the intervention, per CMS requirements.
Monitor vital signs during and after chemical restraint — respiratory depression from medication combinations is the leading cause of death in behavioral emergencies.
Debrief all crisis events with both the patient and the treatment team — post-crisis debriefing improves therapeutic alliance, reduces future crises, and identifies system improvements.
Check QTc before administering IV haloperidol, ziprasidone, or droperidol when clinically feasible — QTc prolongation leading to Torsades de Pointes is a known cause of sudden cardiac death with these agents.
