Acute Agitation Management (AAEP Project BETA)

Algorithm Steps

1. ▶

   Start

   Acute Agitation Identified

   Patient presenting with agitation, aggression, or behavioral emergency

   1. ⚠

      Warning

      ⚠️ 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
      1. ●

         Action

         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
         1. ◆

            Decision

            De-escalation Successful?

            Assess if patient is responding to verbal intervention

            1. ✓

               Outcome

               Agitation Controlled

               Continue monitoring, address underlying cause

            2. ◆

               Decision

               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
               1. ●

                  Action

                  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
                  1. ◆

                     Decision

                     Response to Initial Medication?

                     Reassess 15-30 minutes after administration

                     1. ●

                        Action

                        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
                        1. ✓

                           Outcome

                           Patient Stabilized

                           Transition to ongoing psychiatric/medical care

                     2. ●

                        Action

                        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
                        1. ⚠

                           Warning

                           Consider ICU/Higher Level of Care

                           For refractory agitation or medical compromise

                           • Propofol/dexmedetomidine infusion
                           • Intubation if airway compromise
                           • Continuous sedation monitoring
               2. ●

                  Action

                  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
               3. ●

                  Action

                  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
               4. ⚠

                  Warning

                  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)