Acute agitation

Presentation and initial formulation #

Agitation is increased motor or verbal activity with distress and impaired behavioural control. The immediate formulation should identify the likely medical, substance-related, psychiatric and environmental contributors. A historical psychiatric diagnosis does not explain new abnormal vital signs or altered attention. Separate an emergency calming intervention from treatment of the underlying disorder.

Two-stage assessment #

Initially obtain the information needed for urgent decisions: observed behaviour, consciousness, vital signs, bedside glucose, trauma and exposure history. Complete the mental-state and psychiatric assessment once engagement permits. Compare the person’s account with collateral and records; document contradictions rather than suppressing one version. Ask about earlier helpful interventions, adverse medication experiences and communication needs.

Clinical pattern and implication #

Investigate the suspected cause #

New-onset or atypical agitation warrants particular concern for medical illness. Testing should follow the differential rather than a routine “psychiatric clearance” panel. ECG is relevant before QT-active treatment; electrolytes, toxicology, imaging and other investigations depend on the history and examination. Reassess as soon as a fuller examination becomes possible.

De-escalation and medication selection #

Reduce stimulation, maintain personal space, use a single calm communicator and offer practical choices. If urgent parenteral medication is necessary, NICE includes IM lorazepam alone or IM haloperidol with IM promethazine. It favours lorazepam when information is insufficient or no ECG is available for the haloperidol option. Consider intoxication, prior response and all doses already administered.

Doses & prescribing #

Each prescribing record identifies its population and source jurisdiction; international labeling does not establish Indian approval. The clinician selects treatment after assessment.

Before giving another dose #

Review whether enough time has elapsed, what was actually administered, respiratory status and the likely cause. Repeated dosing without a cumulative medication record risks stacking sedatives. Persistent agitation despite an appropriate intervention requires senior review and possibly a more closely monitored medical setting, rather than an unbounded sequence of injections.

After calming #

Once the person can participate, complete diagnostic assessment and agree definitive treatment. Record the trigger, intervention, response and adverse effects. Review ongoing PRN orders so an acute episode does not create an indefinite sedative regimen. Debrief with the patient and team and revise the prevention plan.

Adapt the setting and regimen #

Frailty, pregnancy, respiratory disease, intoxication and neurodevelopmental or communication differences materially change the plan. The adult IM regimen shown is not a paediatric or frail-older-adult schedule. Protect airway, breathing and circulation during any restraint and use the least restrictive feasible intervention.

Post-intervention observation #

Monitor respiratory rate, oxygen saturation, blood pressure, pulse, temperature and consciousness. NICE requires at least hourly observations until concern resolves, with 15-minute checks in specified higher-concern situations such as sedation or alcohol/drug exposure. Local protocols may be more intensive. Deteriorating observations require immediate medical escalation; sleep is not an adequate outcome measure.

Errors that change outcome #

Do not label a patient “cleared” on the basis of a screening score. Do not give another dose solely because behaviour remains inconvenient. Where observations cannot be obtained, document the limitation and arrange appropriate assessment rather than interpreting missing values as normal.

Assessment tools #

Open assessment flowchart ↗

Choose the instrument for its intended purpose; interpretation accompanies the linked tool.

Patient discussion #