Severe Behavioral Emergency
Patient with extreme agitation +/- altered consciousness
All Pathways
PsychiatryEmergency
Behavioral Emergency/Hyperactive Delirium Management
Behavioral Emergency/Hyperactive Delirium Management: Severe Behavioral Emergency → ⚠️ Recognize Warning Signs → Scene Safety & Team Approach → Attempt ...
Pathway Overview
14 steps
Algorithm Steps
14 total
01Start 02Warning ⚠️ Recognize Warning Signs
Hyperactive delirium with agitation - medical emergency
- Extreme agitation/combativeness
- Hyperthermia (may exceed 40°C)
- Diaphoresis
- Altered consciousness
- Tachycardia, hypertension
- Unusual strength/endurance
- May be associated with: stimulants, PCP, alcohol withdrawal, anticholinergics
03Action Scene Safety & Team Approach
Protect patient and staff
- Multiple trained personnel (5+ recommended)
- Clear exit routes
- Remove weapons/dangerous objects
- Security presence
- Prepare for chemical restraint
04Action Attempt Verbal De-escalation
Brief attempt if safe
- May not be possible in true hyperactive delirium
- Speak calmly, identify yourself
- Offer water, remove stimuli
- If no response within 1-2 minutes, proceed to sedation
05Decision Chemical Sedation Needed?
If de-escalation fails or patient danger imminent
06Action Rapid Tranquilization
For severe cases
- KETAMINE 4-5mg/kg IM (fastest onset, 2-5 min)
- - Preferred for severe agitation
- - Requires airway monitoring post-sedation
- OR DROPERIDOL 5-10mg IM (if available)
- OR MIDAZOLAM 5-10mg IM + HALOPERIDOL 5-10mg IM
- May need multiple doses
07Warning ⚠️ Physical Restraint Considerations
If needed, minimize duration
- NEVER leave in PRONE position
- Supine or lateral recovery position
- Continuous monitoring of airway
- Release as soon as sedation effective
- Document restraint every 15 min
08Warning ⚠️ Manage Hyperthermia Urgently
Life-threatening if untreated
- Remove clothing
- Ice packs to axillae, groin, neck
- Cooling blankets
- Cold IV fluids
- Target temperature <38.5°C
- Antipyretics NOT effective (drug-induced hyperthermia)
09Action IV Access & Resuscitation
After sedation achieved
- Aggressive IV fluid resuscitation
- Point-of-care glucose
- Labs: BMP, CK, lactate, VBG, toxicology
- ECG (stimulants cause arrhythmias)
- Continuous cardiac monitoring
10Action Monitor for Complications
Life-threatening sequelae
- Rhabdomyolysis (CK often >10,000)
- Acute kidney injury
- Metabolic acidosis
- DIC
- Cardiac arrhythmias
- Aspiration
- Sudden cardiac arrest (risk in first hour)
11Action Delirium Workup
After stabilization, identify cause
- Comprehensive toxicology
- Stimulant screen (amphetamines, cocaine, cathinones)
- Alcohol/drug withdrawal assessment
- Infection screen (LP if indicated)
- CT head if trauma or focal neuro signs
- Metabolic workup
12Decision Disposition
Based on etiology and stability
13Action ICU Admission
For unstable patients
- Ongoing hyperthermia
- Rhabdomyolysis requiring aggressive fluids
- Cardiac arrhythmias
- Respiratory compromise
- Renal failure
14Outcome Medical Clearance → Psychiatry
If medically stable and psychiatric etiology
- Complete medical clearance
- Psychiatric evaluation
- Substance use treatment if applicable
- Safety assessment before transfer
- Path rejoins step 09Shared downstream outcome
Guideline Source
RCEM Guidelines for Acute Behavioural Disturbance + ACMT/APA Recommendations
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Multiple etiologies possible - always search for medical cause
- Avoid prolonged prone positioning (asphyxiation risk)
- Hyperthermia is a medical emergency requiring active cooling
- Delirium workup needed after stabilization
- Historical term 'excited delirium' deprecated per ACMT/APA
Applicable Regions
USEUGlobal
Version 1Next review: 2027-01-11
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Frequently Asked Questions
What is the Behavioral Emergency/Hyperactive Delirium Management?
The Behavioral Emergency/Hyperactive Delirium Management is a emergency clinical algorithm for Psychiatry. It provides a structured decision tree to guide clinical decision-making, based on RCEM Guidelines for Acute Behavioural Disturbance + ACMT/APA Recommendations.
What guideline is the Behavioral Emergency/Hyperactive Delirium Management based on?
This algorithm is based on RCEM Guidelines for Acute Behavioural Disturbance + ACMT/APA Recommendations (DOI: 10.1111/acem.14853).
What are the limitations of the Behavioral Emergency/Hyperactive Delirium Management?
Known limitations include: Multiple etiologies possible - always search for medical cause; Avoid prolonged prone positioning (asphyxiation risk); Hyperthermia is a medical emergency requiring active cooling; Delirium workup needed after stabilization; Historical term 'excited delirium' deprecated per ACMT/APA. Individual patient factors may require deviation from these recommendations.
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