Acute Agitation Identified
Patient presenting with agitation, aggression, or behavioral emergency
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PsychiatryEmergency
Acute Agitation Management (AAEP Project BETA)
Acute Agitation Management (AAEP Project BETA): Acute Agitation Identified → ⚠️ Staff Safety First → Verbal De-escalation (FIRST LINE) → De-escalation S...
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Warning ⚠️ Staff Safety First
Ensure adequate staff, clear exit routes, remove dangerous objects
- Never approach alone
- Maintain safe distance
- Remove ties, lanyards, stethoscopes
- Have security present
03Action Verbal De-escalation (FIRST LINE)
Always attempt verbal de-escalation before medications
- Speak calmly and slowly
- Identify yourself and role
- Offer choices when possible
- Acknowledge patient's feelings
- Avoid threatening body language
- Maintain comfortable distance
04Decision De-escalation Successful?
Assess if patient is responding to verbal intervention
05Outcome Agitation Controlled
Continue monitoring, address underlying cause
06Decision Identify Likely Etiology
Determine most likely cause of agitation
- Psychiatric: psychosis, mania, personality disorder
- Intoxication: alcohol, stimulants, PCP, anticholinergics
- Withdrawal: alcohol, benzodiazepines, opioids
- Medical: delirium, hypoglycemia, hypoxia, infection
07Action Primary Psychiatric (Psychosis/Mania)
Antipsychotic-based regimen preferred
- First line: Olanzapine 10mg IM OR Ziprasidone 20mg IM
- Alternative: Haloperidol 5-10mg IM + Lorazepam 2mg IM
- Droperidol 5-10mg IM if available (fastest onset)
- Avoid benzodiazepine monotherapy
- May repeat in 20-30 min if needed
08Decision Response to Initial Medication?
Reassess 15-30 minutes after administration
09Action Post-Medication Monitoring
Essential safety monitoring after sedation
- Continuous pulse oximetry
- Q15min vitals initially
- Airway positioning (lateral if needed)
- ECG if high-dose antipsychotics (QTc)
- Have reversal agents available
10Outcome Patient Stabilized
Transition to ongoing psychiatric/medical care
11Action Escalate Treatment
If inadequate response after initial dose
- Repeat same medication at same/higher dose
- Add complementary agent (antipsychotic + benzodiazepine)
- Consider ketamine 4-5mg/kg IM for severe agitation
- Maximum haloperidol: 20mg/24hr recommended
- Monitor for respiratory depression with combinations
- Path rejoins step 08Shared downstream outcome
12Warning Consider ICU/Higher Level of Care
For refractory agitation or medical compromise
- Propofol/dexmedetomidine infusion
- Intubation if airway compromise
- Continuous sedation monitoring
13Action Intoxication/Unknown Etiology
Consider ketamine or combination therapy
- Alcohol/unknown: Haloperidol 5mg + Lorazepam 2mg IM (B52)
- Stimulants: Benzodiazepines preferred (Lorazepam 2-4mg IM)
- Severe: Ketamine 4-5mg/kg IM (rapid onset)
- PCP: Benzodiazepines, avoid antipsychotics if possible
- Anticholinergic: Physostigmine if identified
- Path rejoins step 08Shared downstream outcome
14Action Withdrawal States
Benzodiazepines are first-line
- Alcohol/benzo withdrawal: Lorazepam 2-4mg IM/IV
- May need high doses for severe withdrawal
- Avoid antipsychotics (lower seizure threshold)
- Monitor for seizures
- Consider phenobarbital for refractory cases
- Path rejoins step 08Shared downstream outcome
15Warning Medical Delirium
Treat underlying cause, use minimal sedation
- Identify and treat underlying cause FIRST
- Hypoglycemia: Dextrose
- Hypoxia: Oxygen, airway management
- Infection: Antibiotics, source control
- If sedation needed: Low-dose haloperidol 0.5-2mg
- Avoid benzodiazepines (may worsen delirium)
- Path rejoins step 08Shared downstream outcome
Guideline Source
The Psychopharmacology of Agitation: Consensus Statement of the AAEP Project BETA Psychopharmacology Workgroup
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Verbal de-escalation should ALWAYS be attempted first
- Does not replace clinical judgment in specific contexts
- Drug dosing may need adjustment for elderly or medically compromised
- Specific antidotes/reversal agents not detailed
- Pediatric dosing not included - requires specialist input
Contraindicated Populations
pediatric
Applicable Regions
USEUGlobal
EU: Haloperidol IV restricted in some countries due to QT risk
US: Droperidol availability varies by institution
Version 1Next review: 2028-01-01
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Frequently Asked Questions
What is the Acute Agitation Management (AAEP Project BETA)?
The Acute Agitation Management (AAEP Project BETA) is a emergency clinical algorithm for Psychiatry. It provides a structured decision tree to guide clinical decision-making, based on The Psychopharmacology of Agitation: Consensus Statement of the AAEP Project BETA Psychopharmacology Workgroup.
What guideline is the Acute Agitation Management (AAEP Project BETA) based on?
This algorithm is based on The Psychopharmacology of Agitation: Consensus Statement of the AAEP Project BETA Psychopharmacology Workgroup (DOI: 10.5811/westjem.2011.9.6867).
What are the limitations of the Acute Agitation Management (AAEP Project BETA)?
Known limitations include: Verbal de-escalation should ALWAYS be attempted first; Does not replace clinical judgment in specific contexts; Drug dosing may need adjustment for elderly or medically compromised; Specific antidotes/reversal agents not detailed; Pediatric dosing not included - requires specialist input. Individual patient factors may require deviation from these recommendations.
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