This handout is for acute agitation / behavioral emergency (ed) — de-escalation-first + chemical restraint (po if cooperative / im if not / ketamine rescue) + parallel underlying-cause workup (poc glucose always) + post-sedation monitoring (project beta aaep 2012; acep 2024 clinical policy; adept wilson 2017 pmid 28856060). Your care team identified this based on: escalating motor activity / pacing / restlessness / threatening posture in the ed — rass +2 to +4, bars 5-7, or abs rising (sessler ajrccm 2002 pmid 12421743; swift j psychopharmacol 2002 pmid 12377938; project beta nordstrom 2012 pmid 22461916).
Other reasons your team may use this plan: verbal threats, shouting, aggression toward self / staff / others — danger trigger requiring immediate verbal de-escalation ± containment (project beta richmond 2012 pmid 22461922); failure of verbal de-escalation and environmental modification with continued escalation — threshold to consider least-coercive chemical restraint (project beta richmond + wilson 2012 pmid 22461922 / 22461923); abnormal vitals (tachycardia / hyperthermia / hypoxia / hypertension) or abnormal poc glucose accompanying agitation — medical/toxic-cause flag; agitation is a symptom not a diagnosis (project beta nordstrom 2012 pmid 22461916).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| verbal de-escalation (Project BETA Richmond 10 domains) | Respect personal space; do not be provocative; establish verbal contact; be concise; identify wants/feelings; listen closely; agree or agree to disagree; lay down the law + set limits; offer choices + optimism; debrief patient + staff | NA | continuous until calmer or escalation requires restraint | Project BETA Richmond 2012 PMID 22461922 — verbal de-escalation is first-line for ALL agitation; reduces need for coercive intervention; one trained provider leads, single voice; goal is calming not control |
| environmental modification + reduced stimulation | Quiet low-stimulation space; remove dangerous objects; safe egress for staff; reduce crowding; meet basic needs (food/water/warmth/phone); orienting cues for delirium | NA | continuous | Project BETA — environmental de-escalation complements verbal; reduce triggers; for delirium add orientation, lighting, family presence (cross-ref psych.delirium.core.v1) |
| family / caregiver presence (pediatric + geriatric) | Calm familiar caregiver at bedside if safe; child-life specialist for pediatric; familiar object/voice | NA | continuous if de-escalating | Family presence is a core de-escalation lever in pediatric + geriatric agitation; reduces coercion + chemical restraint need (Project BETA; ACEP 2024) |
Plan: Verbal de-escalation + environmental modification — ALWAYS first-line before any chemical or physical restraint (Project BETA Richmond West J Emerg Med 2012 PMID 22461922 — 10-domain framework)
Call 911 or go to the nearest emergency room right away if you have:
Cause-directed — psychiatric follow-up / disease-specific engine; addiction services if substance-driven; delirium-prevention bundle if delirium (cross-ref psych.delirium.core.v1); restraint debrief + documentation + trauma-informed review with patient when calm; least-restrictive lesson for future episodes (Project BETA Knox/Holloman 2012 PMID 22461917; ACEP 2024)
Guideline: Project BETA — Best practices in Evaluation and Treatment of Agitation, AAEP 2012 consensus suite (West J Emerg Med 2012: Holloman & Zeller overview PMID 22461917; Wilson psychopharmacology PMID 22461923; Richmond verbal de-escalation PMID 22461922; Nordstrom medical evaluation/triage PMID 22461916 — still the operational standard) + ACEP 2024 Clinical Policy on the agitated/restrained ED patient + ADEPT tool (Wilson West J Emerg Med 2017 PMID 28856060) + ketamine-for-agitation evidence (Cole Ann Emerg Med 2016 PMID 26920090; Barbic PLoS One 2021 PMID 33936339) + droperidol safety (Calver Ann Emerg Med 2015 DORM II PMID 25920334)