Approach to the Agitated Patient

Agitation in the emergency department is a safety problem first and a diagnostic problem second. The key bedside split is agitation with versus without CNS dysfunction, because delirium, toxidromes, withdrawal, and primary psychiatric illness do not get managed the same way.

ED Agitation Assessment and De-escalation

• Initial safety framing: Provider, staff, and patient safety come first, with the first clinical question being whether agitation reflects acute CNS dysfunction that demands rapid control for evaluation.
• Broad dangerous differential: Agitation can signal delirium, sympathomimetic or anticholinergic toxicity, serotonin syndrome, neuroleptic malignant syndrome, withdrawal, infection, or structural CNS disease.
• Bias-aware bedside mindset: Implicit bias can distort threat assessment, especially around the poorly defined label of excited delirium, which is not recognized in DSM-5 or ICD-10.
• Project BETA approach: Verbal de-escalation is the preferred first step, emphasizing personal space, concise communication, limit-setting, and offering choices before coercive measures. We walk through the bedside tone in the episode.

Chemical Sedation and Restraint Pearls

• No proven best regimen: Current literature is low quality and does not support one universally superior chemical sedation strategy, so agent choice should follow likely etiology rather than habit.
• Benzodiazepine niche: Benzodiazepines fit withdrawal states and many toxidromes, with midazolam acting faster than lorazepam for acute agitation when speed matters.
• Antipsychotic options: Droperidol and olanzapine have strong practical roles in acute agitation, with olanzapine showing faster early sedation in some studies and droperidol comparing well throughout.
• Avoid the B-52: Diphenhydramine-haloperidol-lorazepam is not evidence-backed for routine agitation care, and diphenhydramine's anticholinergic effects can worsen confusion and agitation.
• Ketamine tradeoffs: Ketamine has a very fast onset, including IM use, but lower-than-dissociative dosing can worsen agitation and serious airway complications remain a real concern.
• Restraint as bridge only: Physical restraint should be a temporary bridge to medication, using a five-person team, avoiding neck or chest compression, and reassessing frequently. The practical setup is worth hearing in the chapter.

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