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psych.agitation-ed.v1PRODUCTION
psych.agitation-ed.v1

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)

psychiatryacutesubacuteadultpediatricgeriatricpregnancy
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Agitation is a SYMPTOM not a diagnosis (Project BETA Domain 1; Holloman PMID 22461917) — set frame: medical/toxic-metabolic vs primary-psychiatric vs undifferentiated × mild/moderate/severe × pediatric/adult/geriatric/pregnant; medical workup runs in PARALLEL with behavioral containment, never deferred behind it

Inputs
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Advance rule
Set
Advance when

Cause-frame hypothesis + population + severity band assigned; parallel medical-workup track opened

Patient inputs (13)

Pediatric (weight-based dosing — ketamine 4-5 mg/kg IM, olanzapine/haloperidol weight-tiered; family-present de-escalation; AVOID IM olanzapine + IM benzo combination); geriatric (agitation = delirium until proven otherwise; lower antipsychotic doses; anticholinergic burden — AVOID diphenhydramine/benzodiazepine where possible; AGS Beers 2023); adult standard (Project BETA Wilson 2012 PMID 22461923)

Pregnancy — haloperidol + benzodiazepine preferred for chemical restraint; AVOID prolonged droperidol exposure (QT + limited pregnancy data); avoid hypotension/hypoxia harming uteroplacental perfusion; left-lateral positioning if restrained late pregnancy (Project BETA Wilson 2012 PMID 22461923)

Alcohol / stimulant / sedative-hypnotic / opioid use + timing — intoxication vs withdrawal drives chemical-restraint choice (benzodiazepine for withdrawal; avoid antipsychotic-only in stimulant toxicity hyperthermia) and tox cross-routing (Project BETA Wilson 2012 PMID 22461923)

Known psychosis / mania / agitated depression / personality disorder + prior agitation pattern + prior effective agents — biases agent selection and disposition; suicidality must be re-screened after stabilization (Project BETA Wilson 2012 PMID 22461923; cross-ref psych.suicidality.ed.core.v1)

Antipsychotic exposure (NMS risk after additional chemical restraint — cross-ref psych.neuroleptic-malignant-syndrome.v1); serotonergic load (serotonin syndrome — cross-ref psych.serotonin-syndrome.v1); anticholinergic burden; QTc-prolonging combinations gating droperidol/haloperidol choice (Project BETA Wilson 2012 PMID 22461923)

Acute onset + fluctuating course + inattention + abnormal vitals + age ≥65 → medical/toxic (delirium) LR+ ≈ 9; chronic stable psych history + normal vitals + normal glucose + familiar pattern → primary-psychiatric; the pivot determining workup depth + cross-routing (Project BETA Nordstrom 2012 PMID 22461916; cross-ref psych.delirium.core.v1)

Point-of-care glucose ALWAYS — hypoglycemia is a rapidly reversible cause of agitation; the single mandatory test in every agitated patient (Project BETA Nordstrom 2012 PMID 22461916)

HR / BP / RR / SpO2 / temperature — abnormal vitals are the primary medical-cause flag; hypoxia + hyperthermia are immediately life-threatening reversible causes (Project BETA Nordstrom 2012 PMID 22461916)

RASS (+4 combative … 0 calm … −5 unarousable; Sessler AJRCCM 2002 PMID 12421743) OR BARS (1-7; Swift 2002 PMID 12377938) OR ABS — severity band drives de-escalation-only vs oral chemical vs IM/IV chemical ± physical restraint (Project BETA Wilson 2012 PMID 22461923; ADEPT Wilson 2017 PMID 28856060)

Anticholinergic (mydriasis + dry flushed skin + urinary retention + hyperthermia; LR+ ≈ 10) vs sympathomimetic (diaphoresis + mydriasis + HTN + tachycardia + recent stimulant; LR+ ≈ 8) vs sedative-hypnotic withdrawal — toxidrome gestalt routes to tox engines (Project BETA Stowell/Nordstrom 2012 PMID 22461916)

ECG for QTc BEFORE droperidol / haloperidol where feasible (or as soon as safe) — QTc > 500 ms shifts agent away from butyrophenones toward benzodiazepine / ketamine; droperidol QT concern overstated at sedation doses but ECG advisable (Calver Ann Emerg Med 2015 DORM II PMID 25920334; Project BETA Wilson 2012 PMID 22461923)

Urine drug screen + ethanol level — targeted when toxic-metabolic flag present; results refine cause + tox routing; do NOT delay containment for results (Project BETA Stowell/Nordstrom 2012 PMID 22461916)

CBC + renal panel + targeted infection workup when medical-cause flag present — sepsis / metabolic derangement / occult infection as agitation drivers, especially geriatric (Project BETA Nordstrom 2012 PMID 22461916; cross-ref psych.delirium.core.v1)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningsevere_undifferentiated_excited_delirium_ketamine_rescue (Cole Ann Emerg Med 2016 PMID 26920090; Barbic PLoS One 2021 PMID 33936339; ACEP 2024)
    Severe undifferentiated agitation / excited-delirium hyperdynamic phenotype (extreme agitation + hyperthermia + autonomic hyperactivity + diaphoresis) failing first-line chemical restraint
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningreversible_medical_cause_flag (Project BETA Nordstrom 2012 PMID 22461916)
    Agitation with hypoglycemia OR hypoxia OR hyperthermia OR other abnormal vitals — immediately reversible / life-threatening medical cause
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpost_chemical_restraint_NMS_or_serotonin_syndrome (Strawn AJP 2007 PMID 17541055; Boyer NEJM 2005 PMID 15784664)
    Rigidity + hyperthermia + autonomic instability + ↑CK after antipsychotic chemical restraint (NMS) OR clonus + hyperreflexia + hyperthermia on serotonergic agents (serotonin syndrome)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningagitation_with_concurrent_suicidality (VA/DoD 2022; Posner AJP 2011 PMID 22193671)
    Agitation with concurrent suicidal ideation / self-harm intent surfacing during or after stabilization
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_agitation_imminent_danger_IM_chemical_restraint (Project BETA Wilson 2012 PMID 22461923; ACEP 2024; RASS +4 / BARS 7)
    Severe agitation with imminent danger to self / staff / others — RASS +4 / BARS 7, uncooperative — IM chemical restraint ± physical restraint required
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatemoderate_agitation_oral_chemical_restraint (Project BETA Wilson 2012 PMID 22461923; RASS +3 / BARS 6)
    Moderate agitation — RASS +3 / BARS 6 — de-escalation insufficient but patient can cooperate; oral chemical restraint (least coercive) appropriate
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildmild_agitation_verbal_responsive (Project BETA Richmond 2012 PMID 22461922; RASS +1-+2 / BARS 5)
    Mild agitation — restlessness, raised voice, RASS +1 to +2 / BARS 5 — responsive to verbal de-escalation; no chemical restraint indicated
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

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)
axis: de_escalation_first
Selected axis "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)" by default fallback (first axis)
  • verbal de-escalation (Project BETA Richmond 10 domains)
    first line
    behavioral_intervention
    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
    triggers: any_agitation_first_line, mild_agitation_RASS_1_2_BARS_5, before_any_chemical_or_physical_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
    first line
    environmental_intervention
    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
    triggers: any_agitation_first_line, sensory_overload_contributing, delirium_suspected_orienting_environment
    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)
    add on
    behavioral_intervention
    Calm familiar caregiver at bedside if safe; child-life specialist for pediatric; familiar object/voice • NA • continuous if de-escalating
    triggers: pediatric_agitation, geriatric_delirium_agitation, familiar_presence_calming
    Family presence is a core de-escalation lever in pediatric + geriatric agitation; reduces coercion + chemical restraint need (Project BETA; ACEP 2024)

ed playbook — drug actions (6)

  1. 1. verbal de-escalation + environmental modification (ALWAYS first)
    Project BETA Richmond 10-domain framework; quiet space; remove dangers; family presence (peds/geriatric) • NA • continuous
    trigger: Any agitation, before any chemical/physical restraint unless imminent danger (Project BETA Richmond 2012 PMID 22461922)
    De-escalation is first-line for ALL agitation and reduces coercive intervention (Project BETA Richmond 2012 PMID 22461922)
  2. 2. POC glucose + vitals + SpO2 in parallel (do not defer)
    POC glucose ALWAYS; treat hypoglycemia/hypoxia/hyperthermia immediately • NA • at presentation
    trigger: Every agitated patient — medical workup runs in parallel with containment (Project BETA Nordstrom 2012 PMID 22461916)
    Agitation is a symptom not a diagnosis; reversible medical causes excluded/treated first (Project BETA Domain 1; Holloman PMID 22461917)
  3. 3. oral chemical restraint if cooperative
    Risperidone 2 mg PO/ODT OR olanzapine 10 mg ODT OR lorazepam 2 mg PO (geriatric dose-reduced) • PO/ODT • once; repeat per response
    trigger: Moderate agitation, patient can cooperate — least coercive (Project BETA Wilson 2012 PMID 22461923)
    Oral preferred when feasible — least coercive, effective (Project BETA Wilson 2012 PMID 22461923)
  4. 4. IM chemical restraint if refusing/uncooperative
    Olanzapine 10 mg IM (NOT with IM benzo) OR haloperidol 5 mg + lorazepam 2 mg ± diphenhydramine 25-50 mg IM OR droperidol 5-10 mg IM (QTc caution) • IM • once; repeat q15-60 min titrated
    trigger: Severe agitation, uncooperative, danger — RASS +4 / BARS 7 (Project BETA Wilson 2012 PMID 22461923; Calver DORM II 2015 PMID 25920334)
    IM agent selection per Project BETA; benzo first-line for withdrawal/stimulant toxicity; haloperidol preferred parenteral in pregnancy
  5. 5. IM/IV ketamine RESCUE for severe undifferentiated / excited-delirium phenotype
    Ketamine 4-5 mg/kg IM (or 1-2 mg/kg IV) with airway-capable continuous monitoring • IM/IV • single dissociative dose
    trigger: Severe undifferentiated / excited-delirium hyperdynamic phenotype failing other agents (Cole 2016 PMID 26920090; Barbic 2021 PMID 33936339; ACEP 2024)
    Fastest sedation (5 min) but higher intubation rate — rescue only with airway-capable monitoring (Cole 2016 PMID 26920090; ACEP 2024)
  6. 6. treat the underlying cause concurrently
    Glucose / O2 / benzo for withdrawal / toxidrome antidote / cause-directed therapy • as indicated • concurrent
    trigger: Reversible / toxic-metabolic cause identified (Project BETA Nordstrom 2012 PMID 22461916)
    Sedation contains the behavior; treating the cause resolves it (Project BETA Domain 1; Holloman PMID 22461917)

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: 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); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**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)** (psych.agitation-ed.v1).
Phenotype framing: Medical/toxic-metabolic (delirium, hypoglycemia, hypoxia, intoxication/withdrawal, anticholinergic / sympathomimetic toxidrome, structural/infectious CNS — pre-test ~0.40-0.50) vs primary-psychiatric (psychosis, mania, agitated depression — pre-test ~0.40) vs undifferentiated (default until medical cause excluded); can co-exist (intoxicated psychiatric patient); delirium-vs-psychosis pivot = acute onset + fluctuating course + inattention + abnormal vitals (LR+ ≈ 9 for delirium) (Project BETA Nordstrom 2012 PMID 22461916; cross-ref psych.delirium.core.v1 + psych.first-episode-psychosis.core.v1)
Scope: Agitation is a SYMPTOM not a diagnosis (Project BETA Domain 1; Holloman PMID 22461917) — set frame: medical/toxic-metabolic vs primary-psychiatric vs undifferentiated × mild/moderate/severe × pediatric/adult/geriatric/pregnant; medical workup runs in PARALLEL with behavioral containment, never deferred behind it

No severity triggers fired against current inputs.

Plan

Regimen axis: **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)**.
1. 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 (behavioral_intervention, first line) — 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
2. 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 (environmental_intervention, first line) — Project BETA — environmental de-escalation complements verbal; reduce triggers; for delirium add orientation, lighting, family presence (cross-ref psych.delirium.core.v1)
3. 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 (behavioral_intervention, add on) — Family presence is a core de-escalation lever in pediatric + geriatric agitation; reduces coercion + chemical restraint need (Project BETA; ACEP 2024)

Setting playbook (ed) — Rapidly contain the behavioral emergency with the least coercive effective means while running the medical/toxic-metabolic workup in parallel — de-escalation first, POC glucose ALWAYS, chemical restraint escalated only by failure + danger, safe monitored sedation, cause-directed disposition (Project BETA AAEP 2012; ACEP 2024; ADEPT Wilson 2017 PMID 28856060)
4. verbal de-escalation + environmental modification (ALWAYS first) Project BETA Richmond 10-domain framework; quiet space; remove dangers; family presence (peds/geriatric) NA continuous — Any agitation, before any chemical/physical restraint unless imminent danger (Project BETA Richmond 2012 PMID 22461922) (De-escalation is first-line for ALL agitation and reduces coercive intervention (Project BETA Richmond 2012 PMID 22461922))
5. POC glucose + vitals + SpO2 in parallel (do not defer) POC glucose ALWAYS; treat hypoglycemia/hypoxia/hyperthermia immediately NA at presentation — Every agitated patient — medical workup runs in parallel with containment (Project BETA Nordstrom 2012 PMID 22461916) (Agitation is a symptom not a diagnosis; reversible medical causes excluded/treated first (Project BETA Domain 1; Holloman PMID 22461917))
6. oral chemical restraint if cooperative Risperidone 2 mg PO/ODT OR olanzapine 10 mg ODT OR lorazepam 2 mg PO (geriatric dose-reduced) PO/ODT once; repeat per response — Moderate agitation, patient can cooperate — least coercive (Project BETA Wilson 2012 PMID 22461923) (Oral preferred when feasible — least coercive, effective (Project BETA Wilson 2012 PMID 22461923))
7. IM chemical restraint if refusing/uncooperative Olanzapine 10 mg IM (NOT with IM benzo) OR haloperidol 5 mg + lorazepam 2 mg ± diphenhydramine 25-50 mg IM OR droperidol 5-10 mg IM (QTc caution) IM once; repeat q15-60 min titrated — Severe agitation, uncooperative, danger — RASS +4 / BARS 7 (Project BETA Wilson 2012 PMID 22461923; Calver DORM II 2015 PMID 25920334) (IM agent selection per Project BETA; benzo first-line for withdrawal/stimulant toxicity; haloperidol preferred parenteral in pregnancy)
8. IM/IV ketamine RESCUE for severe undifferentiated / excited-delirium phenotype Ketamine 4-5 mg/kg IM (or 1-2 mg/kg IV) with airway-capable continuous monitoring IM/IV single dissociative dose — Severe undifferentiated / excited-delirium hyperdynamic phenotype failing other agents (Cole 2016 PMID 26920090; Barbic 2021 PMID 33936339; ACEP 2024) (Fastest sedation (5 min) but higher intubation rate — rescue only with airway-capable monitoring (Cole 2016 PMID 26920090; ACEP 2024))
9. treat the underlying cause concurrently Glucose / O2 / benzo for withdrawal / toxidrome antidote / cause-directed therapy as indicated concurrent — Reversible / toxic-metabolic cause identified (Project BETA Nordstrom 2012 PMID 22461916) (Sedation contains the behavior; treating the cause resolves it (Project BETA Domain 1; Holloman PMID 22461917))

Non-pharmacologic actions:
- Single provider leads de-escalation, one voice (Project BETA Richmond 2012 PMID 22461922)
- Security activation + danger containment if armed/barricaded/imminent threat (ACEP 2024)
- Physical restraint only as last resort, minimised, time-limited, never prone (positional asphyxia) (ACEP 2024)
- Continuous pulse-ox + cardiac monitoring after any parenteral sedation (ACEP 2024)
- Physical-restraint reassessment — visual q15 min + face-to-face q1-2h adult / q1h peds & geriatric (CMS / Joint Commission)
- Family / caregiver / child-life presence for pediatric + geriatric de-escalation (Project BETA; ACEP 2024)
- Restraint debrief + documentation + trauma-informed review after each episode (Project BETA Knox/Holloman 2012 PMID 22461917)
- Cross-route to psych.delirium.core.v1 / tox engines / psych.suicidality.ed.core.v1 per cause

AVOID / contraindication checks:
- De_escalation_attempt_required_before_chemical_or_physical_restraint_unless_imminent_danger (Project BETA Richmond 2012 PMID 22461922)
- Single_provider_leads_de_escalation_one_voice (Project BETA Richmond 2012)
- Never_corner_patient_maintain_staff_egress (Project BETA Richmond 2012)
- Do_not_delay_POC_glucose_or_medical_workup_during_de_escalation (Project BETA Nordstrom 2012 PMID 22461916)

Monitoring

Regimen monitoring:
- Continuous observation of agitation trajectory RASS or BARS (Sessler 2002 PMID 12421743; Swift 2002 PMID 12377938)
- Reassess response to verbal de escalation q few minutes (Project BETA Richmond 2012)
- Escalate to chemical restraint only on de escalation failure plus danger (Project BETA Wilson 2012 PMID 22461923)
- Staff safety and egress maintained throughout (Project BETA Richmond 2012)

Setting (ed) monitoring:
- Serial RASS / BARS until calm and stable (Sessler 2002 PMID 12421743; Swift 2002 PMID 12377938)
- Continuous SpO2 + cardiac after parenteral sedation (ACEP 2024)
- Airway / oversedation watch — especially ketamine + benzo + olanzapine combinations (Cole 2016 PMID 26920090)
- ECG QTc when droperidol / haloperidol used (Calver DORM II 2015 PMID 25920334)
- Repeat POC glucose + vitals as cause workup proceeds (Project BETA Nordstrom 2012 PMID 22461916)

Follow-up plan: 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)
- Close-out criterion: Cause-directed follow-up arranged + restraint debrief documented + cross-route dossiers engaged

Monitoring phase: Continuous pulse-ox + cardiac monitoring if parenteral sedation given; oversedation / airway / hypoventilation watch (ketamine — laryngospasm/emesis/emergence; benzodiazepine + olanzapine combination — cardiorespiratory depression); serial RASS; physical-restraint reassessment intervals — visual q15 min + face-to-face q1-2h adult / q1h pediatric & geriatric per CMS / Joint Commission; remove restraint at earliest safe point (ACEP 2024; Project BETA Wilson 2012 PMID 22461923)

Disposition

Current setting: ed — Rapidly contain the behavioral emergency with the least coercive effective means while running the medical/toxic-metabolic workup in parallel — de-escalation first, POC glucose ALWAYS, chemical restraint escalated only by failure + danger, safe monitored sedation, cause-directed disposition (Project BETA AAEP 2012; ACEP 2024; ADEPT Wilson 2017 PMID 28856060)

Disposition criteria:
- Medical / ICU admission if reversible or toxic-metabolic cause requiring ongoing treatment or monitoring (hypoglycemia, toxidrome, sepsis, structural) (Project BETA Nordstrom 2012 PMID 22461916)
- Psychiatric admission or transfer if primary-psychiatric with ongoing risk — route disease-specific engine (psychosis / mania / agitated depression / suicidality)
- ED observation until sedation cleared + cause addressed + safe for level of care; serial RASS to calm baseline (ACEP 2024)
- Discharge only when fully cleared of sedation, cause addressed, no ongoing danger, with cause-directed follow-up + addiction/psych referral as applicable (ACEP 2024)

Escalation triggers (move to higher acuity):
- Hypoglycemia / hypoxia / hyperthermia / abnormal vitals → treat reversible cause immediately + medical/ICU pathway (Project BETA Nordstrom 2012 PMID 22461916)
- Acute onset + fluctuation + inattention + abnormal vitals (esp. ≥65) → cross-route psych.delirium.core.v1 (Marcantonio NEJM 2017)
- Post-antipsychotic rigidity + hyperthermia + autonomic instability + ↑CK → cross-route psych.neuroleptic-malignant-syndrome.v1 (Strawn AJP 2007 PMID 17541055)
- Clonus + hyperreflexia + hyperthermia on serotonergic agents → cross-route psych.serotonin-syndrome.v1 (Boyer NEJM 2005 PMID 15784664)
- Toxidrome / intoxication / withdrawal-driven → cross-route tox.alcohol-intoxication.core.v1 / tox engines
- Suicidal ideation / self-harm intent surfaces once calm → cross-route psych.suicidality.ed.core.v1 (VA/DoD 2022)
- Oversedation / airway compromise / hypoventilation → airway management + reduce/hold further sedation (ACEP 2024)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Severe undifferentiated agitation / excited-delirium hyperdynamic phenotype (extreme agitation + hyperthermia + autonomic hyperactivity + diaphoresis) failing first-line chemical restraint
- [LIFE_THREATENING] Agitation with hypoglycemia OR hypoxia OR hyperthermia OR other abnormal vitals — immediately reversible / life-threatening medical cause
- [LIFE_THREATENING] Rigidity + hyperthermia + autonomic instability + ↑CK after antipsychotic chemical restraint (NMS) OR clonus + hyperreflexia + hyperthermia on serotonergic agents (serotonin syndrome)

Citations

- 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) [PMID:22461917](https://pubmed.ncbi.nlm.nih.gov/22461917/)
- Cited evidence (PMID 22461923) [PMID:22461923](https://pubmed.ncbi.nlm.nih.gov/22461923/)
- Cited evidence (PMID 22461922) [PMID:22461922](https://pubmed.ncbi.nlm.nih.gov/22461922/)
- Cited evidence (PMID 22461916) [PMID:22461916](https://pubmed.ncbi.nlm.nih.gov/22461916/)
- Cited evidence (PMID 26920090) [PMID:26920090](https://pubmed.ncbi.nlm.nih.gov/26920090/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 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) — PMID:22461917
  • Cited evidence (PMID 22461923) — PMID:22461923
  • Cited evidence (PMID 22461922) — PMID:22461922
  • Cited evidence (PMID 22461916) — PMID:22461916
  • Cited evidence (PMID 26920090) — PMID:26920090