Severe Behavioral Emergency (Adult)
Extreme agitation with or without altered consciousness
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PsychiatryEmergency
Behavioral Emergency/Hyperactive Delirium with Severe Agitation (Adult)
Behavioral Emergency/Hyperactive Delirium with Severe Agitation (Adult): Severe Behavioral Emergency (Adult) → ⚠️ Medical Emergency: Look for Red Flags ...
Pathway Overview
18 steps
Algorithm Steps
18 total
01Start 02Warning ⚠️ Medical Emergency: Look for Red Flags
Hyperactive delirium with severe agitation can cause sudden death
- Red flags: abnormal vital signs, hyperthermia, confusion, head injury or focal neurological signs
- First episode at age 45 years or older: look hard for a medical cause
- Causes: stimulants, alcohol or sedative withdrawal, toxins, hypoglycaemia, hypoxia, infection
03Action Scene Safety & Team Approach
Protect patient and staff
- Clinical leader directs and watches head, airway and chest
- If restraint is needed: four staff, one per limb
- Clear exit routes; remove dangerous objects; security present
- Monitoring and resuscitation equipment ready before any sedation
04Decision Age under 16 or over 65, or frail?
The doses in this pathway are for adults aged 16–65 years
- If Yes
05End Under 16, over 65 or frail: use specific guidance
Child: paediatric acute behavioural disturbance guideline (e.g. RCH). Older or frail: find and treat the cause, use lower doses, follow delirium guidance. Safe restraint (never prone), temperature check and cooling, monitoring and medical workup still apply.
If No06Action Age 16–65, not frail: Verbal De-escalation
Brief attempt if safe
- Speak calmly; identify yourself; reduce stimuli
- Offer oral sedation if accepted: diazepam 5–20 mg PO or olanzapine 5–10 mg PO
- Alcohol or benzodiazepine withdrawal, suspected NMS, serotonin or anticholinergic toxicity, Parkinson's disease or Lewy body dementia: diazepam, not olanzapine
- Often not possible in hyperactive delirium; do not delay sedation if danger is imminent
07Decision Parenteral Sedation Needed?
Imminent danger, or oral sedation refused or unsafe
- If Yes
08Warning ⚠️ Sedation Needed: Restrain Safely and Briefly
Restraint is a last resort; use it only to give sedation safely
- Avoid prone restraint; if prone, 3 minutes maximum and one person times it
- Never compress the chest or abdomen, or block the nose or mouth
- Release as soon as safe; sedated patient supine or lateral, never prone
09Warning ⚠️ Before Sedation: Check Drug Cautions
Higher risk if pregnant, obese, alcohol-intoxicated, after overdose or in poor health: senior review and close monitoring. Breastfeeding: if droperidol is needed, withhold breastfeeding. Do not delay sedation to get an ECG.
- Hyperthermic, or suspected NMS, serotonin or anticholinergic toxicity: benzodiazepine; avoid antipsychotics
- Alcohol or benzodiazepine withdrawal: benzodiazepine; do not use an antipsychotic alone
- If known: long QT or QTc over 450 ms (female) or 440 ms (male), low K+ or Mg2+, bradycardia, QT-prolonging drugs, Parkinson's disease or Lewy body dementia: avoid droperidol and haloperidol. Phaeochromocytoma: avoid droperidol
10Action Adults 16–65, not frail: IM Sedation
Aim: drowsy but rousable. Do not place an IV line just to sedate.
- Droperidol 5–10 mg IM; repeat in 15 min if needed; max total 20 mg
- Midazolam 5–10 mg IM; repeat in 15 min; max total 20 mg. Add it for stimulant toxicity or alcohol withdrawal. Use it alone if hyperthermic, or if droperidol is not available or must be avoided
- Extreme, immediate danger or rescue: ketamine IM, only with airway skills present. Dose: see Safer Care Victoria ABD guidance, Table 6
- After IM sedation: assess at least every 15 min for the first hour; watch airway and breathing
- Already has IV access: senior advice first. IV doses: droperidol 5–10 mg (max total 30 mg); midazolam 2.5–5 mg (max total 20 mg)
- Not settled at maximum doses, or red flags persist: senior or specialist advice
11Warning ⚠️ Check Temperature: Treat Hyperthermia Now
Life-threatening in severe agitation; antipyretics do not work
- Hyperthermic: cool now (undress; fans with water spray; ice packs to neck, axillae, groin; cold IV fluids, smaller volumes in heart or kidney failure). Stop cooling at 38 °C
- Sedate to stop muscle activity, which makes heat (benzodiazepine preferred)
- Over 39 °C with ongoing agitation, rigidity, altered consciousness or no response to cooling, or rising despite sedation and cooling: early intubation and paralysis (avoid suxamethonium if K+ high or rhabdomyolysis); ICU
12Action Calm or Sedated: Assess and Resuscitate
When safe to approach. Temperature 38.5 °C or higher: cool actively. IV fluids: smaller boluses and reassess in heart or kidney failure.
- Capillary glucose as soon as safe; treat hypoglycaemia
- Temperature, SpO2, BP; continuous cardiac monitoring
- ECG: QTc, QRS width, arrhythmia
- Bloods: electrolytes incl. K+, creatinine, CK, VBG with lactate
- IV fluids for dehydration or rhabdomyolysis
13Action Monitor for Complications
Life-threatening; highest risk soon after struggle or restraint
- Sudden cardiac arrest: continuous monitoring; resuscitation ready
- Airway obstruction, hypoventilation or aspiration after sedation
- Rhabdomyolysis, hyperkalaemia, acute kidney injury
- Metabolic acidosis, arrhythmias, DIC
14Action Delirium Workup
After stabilization, identify cause
- History from others: drugs, alcohol, medicines, psychiatric history
- Toxicology advice: Poisons Information Centre 13 11 26 (Australia)
- Alcohol or drug withdrawal assessment
- Infection screen (LP if indicated)
- CT head if trauma, focal signs or no clear cause
- Metabolic workup
15Decision Medically Unstable?
Based on cause and stability
- If Yes
16Action Unstable: ICU or HDU Admission
Any of these
- Ongoing hyperthermia
- Rhabdomyolysis needing large-volume fluids
- Arrhythmias
- Respiratory compromise or intubated
- Kidney failure or severe hyperkalaemia
17Outcome ICU Care: Treat Cause, Support Organs
If No18Outcome Stable: Treat Cause, Then Mental Health Review
Medical cause: admit under the treating team. Psychiatric cause: mental health assessment after medical clearance. Risk assessment before transfer or discharge.
- Medical cause: admit under the treating team
- Psychiatric cause: mental health assessment
- Substance use: brief intervention and referral
- Risk assessment before transfer or discharge
If No- Path rejoins step 12Shared downstream outcome
Guideline Source
Safer Care Victoria: Caring for people displaying acute behavioural disturbance (June 2024 update)
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 16–65 years; not for children, older or frail people
- Always search for a medical cause; hyperthermia needs active cooling
- Delirium with a clear medical cause (e.g. sepsis, head injury, older inpatient) is outside the Safer Care Victoria scope: treat the cause; use the lowest effective dose
- Avoid prone restraint (asphyxia risk)
- Ketamine IM dose is not shown; see Safer Care Victoria ABD guidance, Table 6
- Historical term 'excited delirium' deprecated per ACMT/APA
Contraindicated Populations
children and adolescents under 16adults over 65 or frailolder inpatients with delirium
Applicable Regions
AUUSEUGlobal
AU: Doses follow Safer Care Victoria ABD guidance (June 2024). Poisons Information Centre 13 11 26.
US: ACEP 2024 clinical policy (severe agitation, including hyperactive delirium): droperidol or an atypical antipsychotic with midazolam; consider ketamine when safety is at risk.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Behavioral Emergency/Hyperactive Delirium with Severe Agitation (Adult)?
The Behavioral Emergency/Hyperactive Delirium with Severe Agitation (Adult) 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 (June 2024 update).
What guideline is the Behavioral Emergency/Hyperactive Delirium with Severe Agitation (Adult) based on?
This algorithm is based on Safer Care Victoria: Caring for people displaying acute behavioural disturbance (June 2024 update).
What are the limitations of the Behavioral Emergency/Hyperactive Delirium with Severe Agitation (Adult)?
Known limitations include: Doses are for adults 16–65 years; not for children, older or frail people; Always search for a medical cause; hyperthermia needs active cooling; Delirium with a clear medical cause (e.g. sepsis, head injury, older inpatient) is outside the Safer Care Victoria scope: treat the cause; use the lowest effective dose; Avoid prone restraint (asphyxia risk); Ketamine IM dose is not shown; see Safer Care Victoria ABD guidance, Table 6; Historical term 'excited delirium' deprecated per ACMT/APA. Individual patient factors may require deviation from these recommendations.
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