Step 1 · Scene safety + rapid triage
- Security at door · remove ligatures, weapons, sharps · open exit behind clinician
- Vitals + finger-stick glucose + SpO₂ + temp before sedation if safe
- Score severity — BARS (Behavioural Activity Rating Scale) or RASS
- Always rule out organic cause: hypoxia, hypoglycemia, sepsis, ICH, AMS, withdrawal, hypoxia, tox
Step 2 · Verbal de-escalation (≤ 5 min)
- One clinician speaks · low voice · respect 2-arm-length space · no sustained eye contact
- Offer choice: food/water, blanket, oral medication, family at bedside
- Offer PO first if cooperative: Olanzapine ODT 10 mg OR Risperidone 2 mg + Lorazepam 2 mg PO
Step 3 · IM sedation if refusing / dangerous
- Droperidol 5–10 mg IM (preferred — fast, safe, reliable)
- Midazolam 5 mg IM (good for EtOH/sedative withdrawal, pregnancy)
- Olanzapine 10 mg IM (avoid combining IM with parenteral benzo or EtOH — hypotension/respiratory depression)
- Haloperidol 5–10 mg IM + Lorazepam 2 mg IM ± Diphenhydramine 50 mg IM ("B52")
- Ketamine 4–5 mg/kg IM for severe / excited delirium / refractory — prepare airway
- Reassess q10 min · redose at half initial dose if still BARS ≥ 5
Step 4 · IV access + workup once safe
- POC glucose, ECG (QTc before more antipsychotic), CBC, BMP, Ca, Mg, LFT, lactate, CK, troponin, UA, UDS, EtOH, β-hCG
- CT head if new focal deficit, head trauma, persistent AMS, or first-time presentation > 40 y
- LP if fever + meningismus or immunocompromise
- If withdrawal suspected → CIWA + benzo titration; if hypoglycemia → D10 100 mL IV
Step 5 · Monitor & avoid harm
- Continuous SpO₂ + cardiac telemetry · capnography after IM ketamine or stacked benzos
- Vitals q5 min × 30 min → q15 min × 1 h → q30 min × 2 h → q1 h until calm & ambulatory
- Minimum monitored observation: 2 h after droperidol/haloperidol/olanzapine IM, 4 h after IM ketamine or "B52", 6 h if stacked sedation or co-ingestion
- Repeat ECG (QTc) at 1 h after any butyrophenone; hold further antipsychotic if QTc > 500 ms
- Never prone-restrain · release physical restraints as soon as chemically sedated · reassess restraint need q15 min and document
- Watch for: oversedation, airway loss, dystonia (Diphenhydramine 25–50 mg IV / Benztropine 1–2 mg), akathisia, QT prolongation, NMS, laryngospasm (ketamine), emergence reaction (low-dose midazolam)
Step 6 · Reassessment & medical clearance
- Patient must be: awake, protecting airway, oriented to person/place/time, ambulating at baseline, tolerating PO
- Normal repeat vitals × 2 consecutive sets · resolved tachycardia · normal mental status exam
- Review labs: glucose, Na, Ca, lactate, CK (rule out rhabdo), troponin, UDS, EtOH, β-hCG, ECG/QTc
- Targeted re-exam: neuro (focal deficits), skin (track marks, trauma), temp trend (hyperthermia → excited delirium pathway)
Step 7 · Disposition
ICU admission
- Intubated or required airway support post-sedation
- Ketamine dissociative dose with ongoing apnea/laryngospasm risk
- Excited delirium with hyperthermia (> 39 °C), rhabdo (CK > 5000), acidosis (pH < 7.2), or hyper-K⁺
- Hemodynamic instability, refractory agitation requiring continuous sedation infusion
- Serotonin syndrome / NMS / severe withdrawal needing drip benzos or dexmedetomidine
Medical floor / step-down
- Identified organic cause requiring inpatient treatment (sepsis, ICH, meningitis, metabolic)
- Persistent AMS not explained by sedation
- Mild rhabdo or dehydration needing IV fluids > 6 h
Psychiatry consult / inpatient psych
- Medically cleared AND any of: suicidal/homicidal ideation, command hallucinations, inability to care for self, first-break psychosis, involuntary hold criteria
- Consult once re-orientable; do not consult while still chemically restrained
- If awaiting bed: 1:1 sitter, ligature-safe room, q1 h reassessment, scheduled PO antipsychotic ± PRN
Discharge criteria
- Returned to baseline mental status, ambulatory, tolerating PO, normal vitals
- No suicidal/homicidal intent, has capacity, reliable adult escort
- Reversible trigger identified and resolved (e.g., hypoglycemia corrected, intoxication cleared)
- Follow-up arranged: PCP, outpatient psych, crisis line, safety plan documented
Documentation
- Capacity assessment, threat to self/others, medical clearance note
- Voluntary vs involuntary hold status with statutory criteria
- All restraints (chemical + physical): indication, type, time on/off, reassessments