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Acute Agitation Management in Adults (Safer Care Victoria 2024, ACEP 2024, Project BETA)

Acute Agitation Management in Adults (Safer Care Victoria 2024, ACEP 2024, Project BETA): Acute agitation in an adult → Staff and patient safety first →...

Pathway Overview

17 steps

Algorithm Steps

17 total

  1. 01Start

    Acute agitation in an adult

    Agitation, aggression or behavioural disturbance in the ED or ward. Doses in this pathway are for adults aged 16 to 65 years.

  2. 02Warning

    Staff and patient safety first

    Enough trained staff, clear exits, remove dangerous objects. Never use prone restraint.

    • Never approach alone; security present
    • Keep a safe distance; remove ties, lanyards, stethoscopes
    • Prone restraint has caused deaths: avoid it; if used, keep it as short as possible
  3. 03Action

    Verbal de-escalation first

    Try verbal de-escalation and a low-stimulus space before medication.

    • Speak calmly and slowly; say who you are and your role
    • Acknowledge feelings; offer choices
    • Offer oral medication if accepted (adult 16-65 years): oral olanzapine 5-10 mg (not in Parkinson's or Lewy body dementia) or oral diazepam 5-20 mg (not if alcohol-intoxicated)
    • Look for a medical cause: glucose, oxygen saturation, temperature, head injury
  4. 04Decision

    Calm after de-escalation or oral medication?

  5. If Yes
    1. 05Outcome

      Calm without IM sedation: treat the cause

      Continue observation. Assess and treat the underlying cause.

    If No
    1. 06Warning

      Before IM sedation: check exclusions and risks

      Not calm: IM sedation may be needed. Doses are for adults 16-65 years. Under 16 years: use a paediatric guideline. Hyperthermia, rigidity or clonus (possible NMS, serotonin, anticholinergic or stimulant toxicity): avoid antipsychotics; benzodiazepine; treat as a medical emergency. Pregnancy, obesity, poor health, drug overdose, opioids or other sedatives, COPD or sleep apnoea: higher risk from any sedation; senior advice.

      • Parkinson's disease, Lewy body dementia or past NMS: avoid all antipsychotics; if sedation is essential, benzodiazepine with senior advice
      • Long QT, QT-prolonging drugs, low K or Mg, bradycardia or significant heart disease: no droperidol or haloperidol
      • Age 65 years or older or dementia: lower doses, senior advice
    2. 07Decision

      Most likely cause of the agitation?

      Choose the medication by the most likely cause. Cause unclear: use the Psychiatric step (droperidol) and keep looking for a medical cause.

    3. Psychiatric
    4. 08Action

      Psychiatric (psychosis or mania): antipsychotic

      Antipsychotic preferred over benzodiazepine alone. After IM olanzapine, do not give a parenteral benzodiazepine at the same time (PI: cardiorespiratory depression, deaths).

      • Droperidol 5-10 mg IM (adult 16-65 years); repeat after 15 minutes; max total 20 mg
      • Or olanzapine 10 mg IM (5 mg if 65 years or older); 2nd dose (up to 10 mg) no sooner than 2 hours; 3rd no sooner than 4 hours after the 2nd; max 30 mg in 24 hours
      • Or haloperidol 5 mg IM (PI range 0.5-10 mg); max 20 mg in 24 hours
      • Reassess 15 minutes after each dose
    5. 09Decision

      Settled 15 minutes after the dose?

      Aim: drowsy but rousable (SAT score -1 or 0).

    6. If Yes
      1. 10Action

        Settled: post-sedation monitoring

        After any IM sedation: clinical check at least every 15 minutes for the first hour.

        • SAT score, BP, HR, RR and SpO2; continuous observation if SAT -3
        • Lateral position if drowsy; no prone position
        • ECG after droperidol or high-dose antipsychotic, when safe
        • Resuscitation equipment and airway-skilled staff at hand
      2. 11Outcome

        Settled: ongoing medical or psychiatric care

        Reassess the cause. Change to oral medication when possible.

      If No
      1. 12Action

        Not settled: escalate

        Not settled 15 minutes after the first dose. After IM olanzapine, no parenteral benzodiazepine at the same time. Alcohol intoxication: no benzodiazepine unless withdrawal. Opioids or other sedatives taken, COPD or sleep apnoea: lower midazolam dose; watch breathing.

        • After droperidol: repeat 5-10 mg IM (max total 20 mg), or add midazolam 5-10 mg IM (max total 20 mg)
        • After haloperidol: add midazolam 5-10 mg IM (max total 20 mg); calms faster with fewer EPS than haloperidol alone. After IM olanzapine: senior advice; no benzodiazepine at the same time
        • Extreme and immediate risk: ketamine IM, one dose, airway skills (adult 16-65 years). Dose: see Safer Care Victoria ABD 2024, Table 6
        • Still not settled after maximum doses: senior or specialist advice
      2. Settled
      3. Path rejoins step 10Shared downstream outcome
      4. Refractory
      5. 13End

        Refractory or red-flag vital signs: senior help and ICU

        Not settled after maximum doses, or airway, breathing or circulation compromised. Senior clinician for IV sedation or intubation.

    7. Intoxication
    8. 14Warning

      Intoxication: cautions before sedation

      Medicate alcohol intoxication sparingly, if at all. Opioids or other sedatives taken, COPD or sleep apnoea: lower benzodiazepine dose; watch breathing.

      • Alcohol intoxication: avoid benzodiazepines (breathing) unless withdrawal; no antipsychotic if drowsy
      • Physostigmine only on toxicologist advice (Poisons 13 11 26); not if wide QRS, bradycardia or tricyclic possible
      • Ketamine only with airway skills and monitoring
    9. 15Action

      Intoxication: choose by substance

      Stimulant or unknown drug: benzodiazepine first. Alcohol: antipsychotic if medication is needed. Hyperthermia, rigidity or clonus: medical emergency; cool actively; benzodiazepine; no antipsychotic; toxicology advice.

      • Stimulants: midazolam 5-10 mg IM; repeat after 15 minutes; max total 20 mg; may add droperidol 5-10 mg IM
      • Alcohol: droperidol 5-10 mg IM if needed (max total 20 mg); not if drowsy
      • Anticholinergic: benzodiazepine and supportive care; toxicology advice
      • Extreme and immediate risk: ketamine IM, one dose, only with airway skills (adult 16-65 years). Dose: see Safer Care Victoria ABD 2024, Table 6
    10. Path rejoins step 09Shared downstream outcome
    11. Withdrawal
    12. 16Action

      Withdrawal (alcohol or benzodiazepine): benzodiazepine first

      Benzodiazepines are preferred over antipsychotics in alcohol or benzodiazepine withdrawal. Opioids or other sedatives taken, COPD or sleep apnoea: lower midazolam dose; watch breathing.

      • Needs IM sedation (adult 16-65 years): midazolam 5-10 mg IM; repeat after 15 minutes; max total 20 mg
      • Can take oral medication: diazepam; dose per local alcohol withdrawal protocol
      • Alcohol-dependent or malnourished: give thiamine; never delay glucose for hypoglycaemia
      • Antipsychotics are second line (lower seizure threshold)
      • Opioid withdrawal: treat symptoms; addiction medicine advice
    13. Path rejoins step 09Shared downstream outcome
    14. Medical
    15. 17Action

      Medical cause or delirium: treat the cause first

      Find and treat the cause. Sedate only if needed for safety. Avoid benzodiazepines unless alcohol or benzodiazepine withdrawal.

      • Hypoglycaemia: give glucose now; add thiamine if alcohol-dependent or malnourished (do not delay glucose)
      • Hypoxia: oxygen and airway support; infection: treat
      • If sedation needed: low-dose antipsychotic, e.g. haloperidol 0.5 mg IM; titrate slowly
      • Hyperthermia, very abnormal vital signs or head injury: treat as a medical emergency
    16. Path rejoins step 09Shared downstream outcome

Guideline Source

Safer Care Victoria: Caring for people displaying acute behavioural disturbance (ABD), updated June 2024 (supporting: Project BETA psychopharmacology consensus 2012; ACEP severe agitation clinical policy 2024)

View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Doses are for adults 16 to 65 years. Not for children. Age 65 or older and dementia need lower doses; pregnancy needs senior advice.
  • Ketamine dose, oral alcohol withdrawal dosing and ICU sedation are not given in detail; follow Safer Care Victoria ABD 2024 and local protocols.
  • Severe hyperthermic or hyperactive delirium needs the behavioural emergency pathway.
  • Try verbal de-escalation and oral medication first. IM sedation needs trained staff, monitoring and resuscitation equipment.
  • Does not replace clinical judgement.

Contraindicated Populations

pediatric (under 16 years)Parkinson's disease or Lewy body dementia (all antipsychotics)past neuroleptic malignant syndrome (antipsychotics; senior advice)older adults 65 years or older or dementia (lower doses; senior advice)pregnancy (senior advice)

Applicable Regions

AUUSEUGlobal

AU: Doses follow Safer Care Victoria ABD guidance (June 2024) and TGA product information. Droperidol and olanzapine IM are ARTG-registered. Physostigmine is not on the ARTG. Poisons Information Centre 13 11 26.

EU: Haloperidol injection is for IM use; IV use needs continuous ECG monitoring.

US: Droperidol availability varies by institution.

Version 2Next review: 2027-09-30

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Frequently Asked Questions

What is the Acute Agitation Management in Adults (Safer Care Victoria 2024, ACEP 2024, Project BETA)?

The Acute Agitation Management in Adults (Safer Care Victoria 2024, ACEP 2024, Project BETA) is a emergency clinical algorithm for Psychiatry. It provides a structured decision tree to guide clinical decision-making, based on Safer Care Victoria: Caring for people displaying acute behavioural disturbance (ABD), updated June 2024 (supporting: Project BETA psychopharmacology consensus 2012; ACEP severe agitation clinical policy 2024).

What guideline is the Acute Agitation Management in Adults (Safer Care Victoria 2024, ACEP 2024, Project BETA) based on?

This algorithm is based on Safer Care Victoria: Caring for people displaying acute behavioural disturbance (ABD), updated June 2024 (supporting: Project BETA psychopharmacology consensus 2012; ACEP severe agitation clinical policy 2024).

What are the limitations of the Acute Agitation Management in Adults (Safer Care Victoria 2024, ACEP 2024, Project BETA)?

Known limitations include: Doses are for adults 16 to 65 years. Not for children. Age 65 or older and dementia need lower doses; pregnancy needs senior advice.; Ketamine dose, oral alcohol withdrawal dosing and ICU sedation are not given in detail; follow Safer Care Victoria ABD 2024 and local protocols.; Severe hyperthermic or hyperactive delirium needs the behavioural emergency pathway.; Try verbal de-escalation and oral medication first. IM sedation needs trained staff, monitoring and resuscitation equipment.; Does not replace clinical judgement.. Individual patient factors may require deviation from these recommendations.

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