Approach to the Agitated ED Patient


**Remember - safety for both patients and staff in ED is important!**



  1. Nonpharmacological 

  1. Verbal de-escalation 

  1. Redirection (TV, food, magazines/toys) 

  1. Changing environment (turning off lights, blankets, quiet area) 

  1. Be understanding of what is frustrating them / what they want - maybe there is a compromise? 

  1. Be concise in your goals of treatment and speak without provocation! 


  1. Pharmacological  

  1. Antipsychotic 

  1. Side effects: extrapyramidal, dystonia, akathisia, prolonged QT 

  1. First generation 

  1. Haloperidol 5mg 

  1. Useful as it’s available PO/IM/IV  

  1. Fast acting 

  1. Second generation 

  1. Less side effects, not all available in IM so less useful in acute agitation setting without access 

  1. Olanzapine 5-10mg 

  1. PO/IM/IV 

  1. Ziprasadone 10-20mg IM 

  1. Risperadone 2mg PO


  1. Benzodiazepine 

  1. Side effects: sedation, respiratory depression 

  1. Lorazepam 2mg 

  1. Longer acting 

  1. PO/IV/IM 

  1. Midazolam 5mg 

  1. Quicker on, quicker off 

  1. PO/IV/IM


  1. Other 

  1. Ketamine 

  1. Side effects: increased agitation, apnea, seizures 

  1. IM: 4-6 mg / kg 

  1. IV: 1-2 mg / kg 


  • Physical restraints should be used as a last resort when a patient is a danger to him/herself or others and the above cannot be used/do not work. 

  • Restraints should be removed as soon as safe to do so!
  • Drugs are NOT benign, use with caution in already intoxicated, pregnant, elderly, young, those with comorbidities 


Take into Consideration 

  • Do a comprehensive exam, psychiatric disease is NOT the only cause for agitation 

  • Infectious (check for fever, abnormal vitals, s/s of infection) 

  • Toxicologic (strong HPI/history, other s/s of toxidromes?) 

  • Metabolic (use history or exam to guide your work up) 

  • Neurologic (thorough neuro exam!, imaging if needed) 

  • Structural/Trauma (thorough physical exam, EMS/bystander reports?) 

  • Vital signs are vital - don’t forget that POC glucose! 





Richmond JS, Berlin JS, Fishkind AB, et al. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012 Feb;13(1):17-25. 

Emdocs cases: Ed approach to agitation. - Emergency Medicine Education. Published February 5, 2018. Accessed August 6, 2021.  

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