Acute Agitation, Excited Delirium & Psych Emergencies

Resuscitation Quick Ribbon (First 2 Minutes)

Severe Agitation (Chemical Restraint):Droperidol 5–10 mg IM/IV OR Midazolam 5–10 mg IM OR 'B52' (Haldol 5mg + Ativan 2mg + Benadryl 50mg)

Violent / Excited Delirium:Ketamine 4–5 mg/kg IM (dissociation in 2–4 min) | Maintain airway & monitor ETCO2

Acute Dystonic Reaction:Diphenhydramine 50 mg IV/IM OR Benztropine 1–2 mg IV/IM (instant relief in 5–15 min)

NMS (Lead-Pipe Rigidity):Stop neuroleptics | Aggressive cooling | Dantrolene 1–2.5 mg/kg IV + Bromocriptine 2.5–5 mg

Serotonin Syndrome (Clonus):Benzodiazepines IV + Cyproheptadine 12 mg PO | Neuromuscular paralysis if temp > 41°C

Bottom-Line Clinical Pearl

In violent, uncooperative agitation with excited delirium, Ketamine (4–5 mg/kg IM) provides rapid dissociation within 2–4 minutes; monitor capnography and airway closely. Neuroleptic Malignant Syndrome (lead-pipe rigidity, hyperthermia, CK elevation) requires Dantrolene and Bromocriptine. Serotonin syndrome (clonus, hyperreflexia, tremor) requires Benzodiazepines and Cyproheptadine.

1. Rapid Triage & Richmond Agitation-Sedation Scale (RASS)

The agitated patient poses an immediate physical risk to themselves and ED staff. Assessment begins with the Richmond Agitation-Sedation Scale (RASS) to grade severity: +1 (Anxious/Restless), +2 (Frequent non-purposeful movement), +3 (Pulls at tubes/combative), +4 (Overtly combative, violent, immediate staff danger).

Severity / RASS	Patient Presentation	De-escalation & Pharmacotherapy Pathway
Mild (+1)	Anxious, restless, verbal pacing	Verbal de-escalation: offer food/drink, quiet room, open door, unhurried posture. Oral Lorazepam 1–2 mg or Olanzapine 5–10 mg ODT.
Moderate (+2 to +3)	Combative, uncooperative with oral meds	Intramuscular chemical restraint: Droperidol 5 mg IM OR Haloperidol 5 mg + Lorazepam 2 mg + Diphenhydramine 50 mg ('B52').
Severe / Violent (+4)	Immediate danger to self/staff, physical violence, excited delirium	Rapid dissociation: Ketamine 4–5 mg/kg IM (onset 2–4 min) OR Midazolam 10 mg IM. Place on continuous pulse oximetry, cardiac monitor, and capnography.

2. Rapid Chemical Restraint Formulations

Medication	Dose & Route	Onset of Sedation	Clinical Pearls & Safety
Droperidol	5–10 mg IM (or 2.5–5 mg IV)	5–10 minutes	First-line agent in many EDs; faster onset and less redosing than haloperidol. Black box QT warning exists, but evidence shows extremely low torsades risk in acute ED sedation.
B52 Cocktail	Haloperidol 5 mg + Lorazepam 2 mg + Diphenhydramine 50 mg IM	15–30 minutes	Classic gold-standard combination. Haloperidol provides dopamine blockade, Lorazepam provides GABA-mediated sedation, Diphenhydramine prevents acute dystonic reactions.
Ketamine	4–5 mg/kg IM (or 1–2 mg/kg IV)	2–4 minutes	Ideal for hyperactive delirium with severe agitation. Rapid dissociation preserving airway reflexes. Post-dissociation laryngospasm and emergence agitation treated with low-dose midazolam.
Midazolam	5–10 mg IM	5–10 minutes	Fast-acting benzodiazepine; risk of respiratory depression, especially if combined with alcohol or opioids. Have bag-valve-mask ready.
Olanzapine (Zyprexa)	5–10 mg IM (or 10 mg ODT)	15 minutes	Effective atypical antipsychotic with low EPS risk. DO NOT co-administer parenteral olanzapine with parenteral benzodiazepines (black box fatal cardiorespiratory collapse).

3. Neuroleptic Malignant Syndrome (NMS) vs. Serotonin Syndrome

Both conditions present with fever, autonomic instability, and altered mental status, but their neuromuscular examinations and management differ dramatically.

Diagnostic Feature	Neuroleptic Malignant Syndrome (NMS)	Serotonin Syndrome (SS)
Offending Agents	Dopamine D2 receptor antagonists (Haloperidol, Fluphenazine, Metoclopramide) OR sudden withdrawal of L-dopa	Serotonergic agents (SSRIs, SNRIs, MAOIs, TCAs, Tramadol, Fentanyl, MDMA, Linezolid, St. John's Wort)
Onset & Timeline	Gradual over 1 to 3 days (or weeks)	RAPID: Onset within 6 to 24 hours of drug initiation or dose increase
Neuromuscular Findings	SEVERE 'LEAD-PIPE' RIGIDITY; hyporeflexia, bradykinesia, cogwheeling	HYPERREFLEXIA & CLONUS (spontaneous, inducible, or ocular clonus); tremor; myoclonus
Pupils & Bowel Sounds	Normal pupils, normal/decreased bowel sounds	MYDRIASIS (dilated pupils), HYPERACTIVE bowel sounds, diarrhea
Laboratory Hallmarks	Marked Creatine Kinase elevation (> 1,000–50,000 U/L), leukocytosis (10,000–40,000), metabolic acidosis	Mild CK elevation (from seizure/hyperactivity); otherwise unrevealing
Specific Antidotes	1. Dantrolene 1–2.5 mg/kg IV (ryanodine antagonist) 2. Bromocriptine 2.5–5 mg PO/NG q8h (dopamine agonist)	1. Cyproheptadine 12 mg PO initial dose, then 2 mg q2h 2. IV Benzodiazepines (titrated aggressively)

Hyperthermia Alert: If core temperature exceeds 41.1°C (106°F) in either NMS or Serotonin Syndrome, end-organ brain damage and disseminated intravascular coagulation (DIC) ensue rapidly. Immediately paralyze with Rocuronium (1.2 mg/kg), perform endotracheal intubation to halt skeletal muscle heat production, and initiate aggressive evaporative and ice-water cooling. NEVER use Succinylcholine (causes fatal hyperkalemic cardiac arrest in muscle rigidity states).

4. Acute Dystonic Reactions

Sudden, involuntary, painful sustained contractions of muscle groups occurring hours to days following exposure to dopamine-blocking agents (typical antipsychotics, Metoclopramide, Compazine, Promethazine).

Common Manifestations: Torticollis (neck twisting), Oculogyric crisis (fixed upward eye deviation), Trismus (jaw clenching), Opisthotonus (severe back arching), Laryngeal dystonia (stridor and acute airway obstruction — true emergency).
Immediate Treatment: Diphenhydramine 50 mg IV/IM OR Benztropine (Cogentin) 1–2 mg IV/IM. Symptoms typically resolve within 5–15 minutes.
Discharge Prescription: Prescribe oral Benztropine 1–2 mg PO BID (or oral Diphenhydramine 25–50 mg TID) for 48–72 hours to prevent delayed recurrence as the offending neuroleptic clears.

5. Emergency Medical Clearance & Organic Exclusion

Before accepting a diagnosis of psychiatric decompensation, the emergency physician must systematically exclude medical and toxicologic etiologies ('medical clearance').

Medical Etiology Clue	Differential Diagnosis to Rule Out	Required ED Workup
Age > 40 with first psychiatric break	Intracranial mass, stroke, early dementia, autoimmune encephalitis	Non-contrast CT head, comprehensive metabolic panel, thyroid panel (TSH)
Abnormal Vital Signs (Fever, Tachycardia, Hypoxia)	Sepsis, meningitis, encephalitis, thyroid storm, pheochromocytoma, hypoxia	Pulse oximetry, CBC, blood cultures, urinalysis, lumbar puncture if meningismus
Fluctuating level of consciousness	Delirium (metabolic, toxic, infectious)	Fingerstick glucose (FIRST TEST), electrolyte panel, ammonia, ABG
Visual or Tactile Hallucinations	Substance intoxication (cocaine, methamphetamine, PCP), alcohol withdrawal (DTs)	Urine drug screen, serum alcohol level, CIWA scoring, ECG for QTc prolongation
Focal Neurologic Deficit	Acute ischemic stroke, intracranial hemorrhage, subdural hematoma	Stat non-contrast head CT, code stroke evaluation