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Approach to the agitated or violent patient

Last updated: June 21, 2021

Summarytoggle arrow icon

Agitation is a common, nonspecific symptom of many medical, psychiatric, psychosocial, and substance-related conditions. Initial management should aim to ensure the safety of of the patient and staff and identify and treat critical causes of agitation. Once safety measures are initiated, deescalation techniques should be prioritized to help the patient calm down, avoid progression to aggressive and/or violent behavior, and allow a full medical and psychiatric evaluation. Stabilization, treatment of critical illnesses, alleviation of distressing symptoms, prevention of complications, and maintenance of patient dignity are major priorities for care. Calming medications (e.g., sedatives, tranquilizers) and physical restraints should be restricted to the goal of preventing harm to the patient or others if deescalation techniques are ineffective. Diagnostic studies may be required to evaluate for suspected underlying causes or complications. Optimal management requires familiarity with local institutional protocols and, in some cases, the involvement of a behavioral emergency response team.

  • Agitation: a state of heightened arousal that can manifest in a variety of ways, from subtle increases in psychomotor activity to aggressive and/or violent behavior
    • May be caused by a psychiatric disorder, substance use, or occur as a result of a general medical condition, e.g., hypoglycemia or traumatic brain injury
    • There may also be no underlying medical reason and it may simply be a reaction to stressful or extreme circumstances.
  • Excited delirium (also known as agitated delirium): There is significant controversy surrounding the term.
    • It is recognized by the American College of Emergency Physicians (ACEP) and National Association of Medical Examiners as a medical syndrome that is characterized by: [1][2][3][4]
    • Several authorities, including other medical societies, e.g., the American Psychiatric Association (APA) and American Medical Association (AMA), have questioned the validity of this syndrome based on the following: [5]
      • Lack of precision, specificity, and high-quality supportive evidence for the diagnostic criteria and management recommendations [6][7]
      • Poorly reproducible independent association of the syndrome with mortality [8]
      • The potential for misuse of this label in legal and out-of-hospital contexts [3][9]
      • Allegations of bias in the literature [4][10]
      • See “Tips & Links” for the full report of the AMA's Council of Science and Public Health (CSAPH) on this issue.
  • More than 50% of emergency care providers in the US report having experienced patient aggression and/or physical assault. [11][12]
  • Patient risk factors for violent behavior include: [11]
    • Male gender
    • Substance use (including alcohol)
    • Psychiatric illness
    • Prior history of violence (especially incarceration for violent offenses) [13]

Epidemiological data refers to the US, unless otherwise specified.

Causes of agitation [11][12][14]
Etiology
General medical conditions Endocrinological causes
Infectious causes
Metabolic causes
Neurological causes
Trauma
Other
Substance-related causes
Psychiatric disease

If there is no known history of psychiatric illness or current symptoms differ from previous presentations of a known psychiatric disease, suspect a medical or substance-related cause. [14][15]

Medical or substance-related causes [14]

Psychiatric causes

Red flags [14]

The following features increase the risk of a serious medical etiology of agitation:

Patients with any red flag symptoms should be immediately evaluated by a clinician.

Management recommendations in this article are primarily consistent with the 2012 and 2020 American Academy of Emergency Psychiatrists (AAEP) Best Practices in the Evaluation and Treatment of Agitation (BETA) consensus statements. [12][14][16][17][18]

Maintaining objectivity

  • It is essential for providers to consider as much of a patient's background and history as possible before reaching conclusions about the etiology.
  • Providers should be aware of the following when considering whether to treat agitation as a medical issue:

Approach [14]

Patients with agitation can be the source of significant health provider distress due to clinical uncertainty and potential threats to safety. They are also frequently in vulnerable positions and/or subject to neglect. Maintaining patient and provider safety while respecting patient dignity and autonomy can be very challenging and at times traumatic. Be cognizant of biases, call for help, avoid making rushed clinical decisions, and take time to debrief after each intervention.

Patient and staff safety when managing agitated patients [11][13][16]

Follow local security protocols and call for help if patient or staff safety is under threat.

  • Prioritize early assessment to prevent escalation.
  • Consider early engagement of security staff and/or a behavioral emergency response team.
  • Assign the patient to a secure, monitored room or location to minimize the risk to self and others.
  • If possible, reduce environmental triggers, e.g., bright light and noise.
  • Keep a reasonable distance until it is safe to approach the patient.
  • Ensure the patient is unarmed and secure any items that might serve as weapons.
  • When dealing with an armed patient, evacuate the area and consider the early involvement of law enforcement. [22]
  • Ensure that providers have an open escape path and do not block exits.

Do not approach patients alone if they have signs of potential for violence and/or multiple risk factors for violent behavior. [13]

Interventions for acute stabilization [12]

Consider the following in patients with suspected medical causes of agitation and/or patients in need of sedation because they are endangering themselves or others.

  • IV access in agitated patients
    • Obtain IV access as soon as possible if necessary for diagnostic and/or therapeutic interventions.
    • In uncooperative patients, use an IM medication first to calm the patient and facilitate safe IV access (see “Pharmacotherapy”).
    • Consider the following approach for patients with refractory agitation who require immediate IV access for essential interventions:
      • Use extra personnel to assist with immobilizing the patient.
      • Immobilize the joints immediately proximal and distal to the point of access.
      • Attempt IV placement only once the patient is securely immobilized.
      • Once the IV line is in place, immediately administer an IV calming medication and secure the IV line.

Attempt IM sedation prior to IV placement in uncooperative patients. Call for help if agitation is refractory and urgent IV access is still required. Do not attempt IV placement alone.

Early identification of potential for violence [11][12][24][25]

  • Verbal signs
    • Expression of frustration or anger
    • Loud, threatening, or insulting speech
    • Repetitive mumbling
  • Behavioral signs
    • Suspicious or angry affect
    • Staring or avoidance of eye contact
    • Pacing and/or restlessness
    • Threatening gestures
    • Signs of anxiety or agitation
  • Other patient factors
    • Evidence of drug or alcohol use
    • Presence of a weapon

Rapid risk assessment [11][12][14]

  • Call an attending as early as possible and always follow hospital protocol.
  • Approach each patient based on their individual risk assessment.
Level of agitation [12][14][16][26]
Category Definition and typical characteristics Recommended approach
Mild agitation
  • Physical or verbal signs of agitation, but patient is not aggressive or violent
    • Pacing and/or restlessness
    • Easily angered
    • Confused
    • Redirectable and cooperative
  1. Initiate deescalation techniques.
  2. Consider an oral calming medication, if necessary.
  3. Proceed with medical evaluation and consider diagnostic testing as indicated.
Moderate agitation
  • Extremely or continuously agitated: physically or verbally threatening, but not violent
    • Continuous pacing and/or restlessness
    • Confused and/or unable to cooperate
    • Disruptive but not imminently dangerous
    • Requires continuous redirection
  1. Initiate deescalation techniques.
  2. Consider an oral or parenteral calming medication.
  3. Proceed to manage as mild or severe agitation based on the patient's response.
Severe agitation
  • Actively aggressive or violent
    • Striking at staff, other patients, or objects
    • Repeated credible threats of harm to self or others
    • Not redirectable
    • Requires restraints
  1. Consider initiating deescalation techniques depending on patient's level of cooperation, but prioritize staff and patient safety.
  2. Call for help and/or activate the behavioral emergency response team.
  3. Consider immediate parental calming medications and, if necessary, physical restraints.
  4. Proceed with medical evaluation as soon as it is safe.

Frequently reassess the level of agitation and response to interventions.

These include etiologies that are rapidly reversible and/or pose an imminent threat to life.

Immediate assessment [12][14][15]

If an immediately life-threatening cause is strongly suspected in an uncooperative patient not responding to deescalation techniques, consider calming medication and, if necessary, physical restraint to enable further evaluation and treatment. [14]

Critical causes of agitation

Suggestive findings Immediate intervention

Hypoxia

Hypercarbia

Hypoglycemia

  • Serum or fingerstick glucose ≤ 70 mg/dL (≤ 3.9 mmol/L)

Hypothermia

  • Core body temperature < 35.0°C (95.0°F)
  • Initiate active and/or passive rewarming, as indicated.
  • See “Treatment” in “Hypothermia.”

Hyperthermia

  • Elevated body temperature
  • History of heat exposure and/or excessive physical activity
  • Clinical features of drug-induced hyperthermia

Shock

Pain

Sepsis

  • History of infectious symptoms
  • ≥ 2 positive SIRS or qSOFA criteria

Seizure

Wernicke encephalopathy
  • Evidence of chronic alcohol use or poor nutritional status
  • Confusion, oculomotor dysfunction, or gait ataxia [31]

Acute urinary retention

Subsequent medical evaluation [14][15]

Obtain the following as soon as safely possible:

  • Full patient and corroborative history
  • Complete physical exam, including mental status exam
  • Focused diagnostic testing based on the suspected underlying cause of agitation
  • Consider formal psychiatric evaluation based on findings, if the patient is medically stable.

Patients with a known psychiatric disorder, with no concerning history or physical exam findings, and whose symptoms are consistent with those of their preexisting psychiatric disease are unlikely to require further diagnostic workup. [12][14][15]

Diagnostic testing [12]

Basic studies

Routine laboratory studies are not recommended. Diagnostic testing should be tailored to each patient based on clinical features, history, and physical examination findings. [32]

Additional studies

Additional diagnostic evaluation in the agitated patient [12][14]
Laboratory studies
Imaging
Other studies

Consider a more extensive diagnostic workup in patients with: atypical presentations of known psychiatric illnesses, age > 45 years without prior psychiatric illness, or immune deficiency. [12]

Noncoercive verbal and nonverbal techniques are used to help the patient calm down and cooperate with medical evaluation and treatment. This approach can relieve the symptoms of agitation, decreasing the need for coercive measures and potential for violence and associated harm to patients and staff. [11][16]

Approach [16]

  • Attempt deescalation in patients who are potentially cooperative and not actively violent.
  • Designate a single care provider to verbally interact with the patient in order to avoid confusing the patient and creating a perceived threat.
  • Approach the patient in a quiet and safe physical environment.
  • Ensure staff members are close by in case help is needed.

Deescalation techniques [16]

Principles and techniques for deescalation [16]
Principles Techniques
Avoid escalation Be mindful of personal space
  • Keep a distance of at least two arms' length.
  • Ensure a clear exit path for both the clinician and patient.
Maintain a nonconfrontational demeanor and body language
  • Keep your hands visible and relaxed.
  • Do not stand directly in front of the patient.
  • Avoid prolonged eye contact and staring.
  • Maintain an open and calm manner and expression.
  • Avoid threatening, condescending, or insulting language and anything that might cause the patient to feel humiliated.
Engage the patient verbally Provide structure and reassurance
  • Introduce yourself and explain your role and intention to help.
  • Ask how the patient prefers to be addressed.
  • Explain what to expect.
Use concise, simple, and repetitive language
  • Keep your sentences short and use simple words.
  • Give the patient time to process information and respond.
  • Repeat your message until it is heard and understood.
Build cooperation and trust Identify feelings and desires
  • Ask what the patient wants.
  • Use targeted questions based on information provided by the patient and/or the medical record.
Listen actively
  • Restate and verbally acknowledge the information provided by the patient.
  • Try to understand the patient's subjective experience.
Validate perceptions and emotions
  • Acknowledge the patient's feelings.
  • Seek out points on which you can agree, like specific facts or general truths and principles.
  • On points of disagreement, be honest but understanding.
Defuse the situation Clarify rules and limits
  • Set working conditions.
  • Tell the patient when their behavior is causing you or other staff members to feel threatened or upset.
  • Inform the patient that violent or abusive behavior will not be accepted.
Help the patient stay in control
  • Tell the patient what you need them to do to enable their care.
  • Explain how to get attention and communicate needs.
  • Indicate how to deal with contingencies.
Offer choices and optimism
  • Allow the patient to choose between different acceptable options.
  • Offer comforting measures: e.g., food, drink, or phone access.
  • If medication is necessary, involve the patient in decisions, e.g., the type of medication or route of administration.
  • Provide an honest and realistic but hopeful outlook.
After involuntary intervention Debrief
  • Attempt to restore the clinician-patient relationship.
  • Allow the patient to explain their view.
  • Explain why the intervention was necessary.
  • Engage the patient in planning for future contingencies.
  • Debrief others who witnessed the event, including family members and staff.

Involuntary medications or physical restraint should only be used if a serious attempt at deescalation has failed to ensure the safety of the patient and staff. [16]

Consider calming medication if there is an insufficient response to nonpharmacological measures, with the overarching goal of relieving distress, treating underlying conditions, and permitting a safe medical and psychiatric evaluation.

Do not administer medication involuntarily unless it is to prevent imminent self-harm or harm to others. [14]

Safe and ethical use [12][33]

  • Consider whether the medication is helpful for managing the underlying condition and counsel patients accordingly:
  • The use of medication purely as a restraint (i.e., to limit freedom and control behavior) is strongly discouraged unless there is a clear danger to the patient or others. [18]
  • A patient's right to refuse medication must be respected in all other circumstances unless there is a valid court order for treatment. [34]
  • Use the lowest dose needed to calm the patient and avoid oversedation.
  • To avoid drug accumulation and overdose, be aware of expected drug effects and side effects.
    • Consider drug pharmacokinetic properties when evaluating the response to medications.
    • Allow time for each medication dose to take effect before repeat dosing or combination therapy.
  • Monitor all patients for:
    • Oversedation
    • Hemodynamic instability
    • Respiratory compromise
  • Be prepared for airway management in agitated patients and consider prophylactic airway protection in those requiring heavy sedation.

Calming medications of all classes have the potential to cause oversedation, hemodynamic instability, and respiratory compromise, especially if used in combination. Careful titration and monitoring are recommended.

Route of administration [12][33][35]

  • When possible, involve the patient in the choice.
  • Use oral medication whenever possible.
  • Parenteral administration may be necessary for uncooperative patients.
    • IM medication: Time to onset and maximum effect may be variable due to factors affecting absorption.
    • IV medication: can provide more rapid and reliable sedation than IM or oral medication [33]

Consider orally disintegrating tablets (ODTs) or sublingual tablets when available!

Repeated dosing of calming medications through the intramuscular route may lead to overdose due to less predictable absorption and drug accumulation. Obtain IV access in the agitated patient as soon as safely possible.

Drug class

Medication for agitation based on suspected cause [12][17]
Etiology Recommended drug class Important considerations
Undifferentiated
Delirium
Substance-related Alcohol or benzodiazepine withdrawal
CNS depressant intoxication (including alcohol)
CNS stimulant or sympathomimetic toxicity
Psychosis

Agents and dosages [11][12][17][42]

For severe agitation consider combining IM typical antipsychotics (e.g., haloperidol) with short-acting IV benzodiazepines (e.g., midazolam) under careful observation. [12]

Benzodiazepines

Benzodiazepines for the treatment of agitation [11][12][17][42]
Indication and dosage
Pharmacokinetics Specific considerations
Lorazepam
  • Mild agitation: 1–2 mg PO once; may repeat after 2 hours
  • Moderate–severe agitation: 1–2 mg IM/IV once; may repeat after 2 hours
  • Time to onset
    • PO: 20–30 minutes
    • IM: 15–30 minutes
    • IV: 1–5 minutes
  • Time to maximum concentration
    • PO: 2 hours
    • IM: ≤ 3 hours
  • Duration of action: 6–8 hours [11]
  • Maximal dose: 10–12 mg/day
  • Beware of drug accumulation with frequent dosing.
  • Most significant adverse effect: respiratory suppression at high doses or when used in patients exposed to other CNS depressants (e.g., alcohol)
Midazolam
  • Moderate agitation
    • 2.5–5 mg IM once; may repeat after 5–10 minutes
    • OR 1–2.5 mg IV once; may repeat after 3–5 minutes
  • Severe agitation
    • 10 mg IM once; may repeat after 5–10 minutes
    • OR 2–5 mg IV once; may repeat after 3–5 minutes
  • Time of onset
    • IM: 15 minutes
    • IV: 1–5 minutes
  • Time to maximum concentration
    • IM: 30–60 minutes
    • IV: 3–5 minutes
  • Duration of action: ∼ 2 hours [11]
  • Maximal dose: not clearly defined

Antipsychotics

Second-generation antipsychotics for the treatment of agitation
Indication and dosage
Pharmacokinetics Specific considerations
Olanzapine
  • Mild agitation: 5 mg PO/SL once; may repeat after 2 hours
  • Moderate agitation: 5–10 mg PO/SL once; may repeat after 2 hours
  • Severe agitation: 10 mg IM once; may repeat after 2 hours
  • Time of onset
    • PO: ≤ 60 minutes
    • IM: 15–45 minutes
  • Time to maximum concentration
    • PO: 6 hours
    • IM: 15–45 minutes
  • Maximal dose
    • PO: 20 mg/day
    • IM: 30 mg/day

Risperidone

  • Mild agitation: 1 mg PO/SL once; may repeat every 4–6 hours
  • Moderate agitation: 2 mg PO/SL once; may repeat every 4–6 hours
  • Time of onset: ≤ 60 minutes
  • Time to maximum concentration: 60 minutes
  • Maximal dose: not clearly established, but generally should not exceed > 6–10 mg/day [17]
Ziprasidone
  • Severe agitation: 10–20 mg IM once; may repeat after 2–4 hours
  • Time of onset: 15–30 minutes
  • Time to maximum concentration: < 60 minutes
  • Maximal dose: 40 mg/day

Anticipate common adverse effects of all antipsychotics such as extrapyramidal symptoms (e.g., akathisia, acute dystonia), QTc prolongation, and orthostatic hypotension.

First-generation antipsychotics for the treatment of agitation
Medication Indication and dosage Pharmacokinetics Specific considerations
Haloperidol
  • Mild agitation: 2.5 mg PO once; may repeat after 0.5–4 hours [12][17]
  • Moderate agitation
    • 5 mg PO once; may repeat after 0.5–4 hours
    • OR 2.5 mg IM once; may repeat every ≥ 15 minutes until adequate effect, then every 0.5–6 hours
  • Severe agitation
    • 5 mg IM once; may repeat every ≥ 15 minutes until adequate effect, then every 0.5–6 hours
  • Extreme situations (controversial): 2–5 mg IV once; consider repeating in 0.5–6 hours [17][43][44][45]
  • Time of onset
    • PO/IM: 30 minutes
    • IV: 3–20 minutes
  • Time to maximum concentration
    • PO: 2–6 hours
    • IM: 30–60 minutes
    • IV: 30 minutes
  • Maximal dose
    • PO/IM: 20–30 mg/day
    • IV: 10 mg/day [17]
Droperidol
  • Time of onset: 15 minutes
  • Time to maximum concentration: ≤ 30 minutes

Haloperidol administered intravenously (IV) may be associated with high rates of adverse effects (e.g., extrapyramidal symptoms, QTc prolongation, torsades de pointes) and is likely best reserved for extreme situations. Alternate routes (PO or IM) are generally considered safer. [17][43][44][45]

Dissociative anesthetics

Dissociating anesthetics for the treatment of agitation
Medication Indication and dosage Pharmacokinetics Specific considerations
Ketamine
  • Severe agitation
    • 4–5 mg/kg IM once; may repeat once at 2–3 mg/kg IM if no initial effect after 10–25 minutes
    • OR 1–2 mg/kg IV once; if no initial effect after 5–10 minutes, may repeat 0.5–1 mg/kg IV once
  • Time of onset
    • IM: 3–4 minutes
    • IV: 1–2 minutes
  • Time to maximum concentration:
    • IM: 5–30 minutes
    • IV: 1–5 minutes [46]

The following recommendations are consistent with the 2008 Joint Commission standards on restraints and seclusion (and their 2020 revision), the 2008 Centers for Medicare & Medicaid Services (CMS) restraint and seclusion guidelines, the 2012 AAEP BETA consensus statement, and the 2020 American College of Emergency Physicians (ACEP) policy statement on the use of restraints. [18][34][50][51][52]

Definitions [18]

  • Restraints (manual, physical, or mechanical): methods, materials, devices, or equipment that impair or limit free movement of a patient's extremities, body, or head
  • Seclusion: measures taken to confine a patient involuntarily to a location from which physical barriers prevent them from leaving, specifically for the purpose of protecting them or others from violence and harm

Ethical use [12][34][50][51][51][53]

  • Seclusion and restraints are clearly associated with significant harm and should be limited to very specific circumstances. [18]
    • Use only to prevent imminent harm to the patient or others. [11]
    • Consider only if less coercive measures (i.e., deescalation techniques or pharmacotherapy) have failed.
  • Apply the least restrictive method possible.
  • Maintain patient privacy and dignity as much as possible during the application of restraints.
  • Frequently reassess the indications for ongoing restraint or seclusion.
  • Discontinue as soon as possible, i.e., when the patient has regained self-control and no longer poses a threat to their own safety or others. [34]

Physical restraints can cause significant harm, including long-term psychological trauma and death. They should only be considered to enable crucial diagnostics and treatment and/or prevent harm to the patient and others. They should never be used for punishment, discipline, retaliation, or provider convenience! [8][34]

Use calming medications before or immediately after applying restraints to reduce the risk of injury, complications from the patient's efforts to resist restraints, and the negative psychological consequences of restraint and coercion. [12][54]

Legal considerations [34][50]

  • Physical restraints are medical interventions that require a formal order from the treating clinician.
  • Clearly document the following: [11][50]
    • Full medical and behavioral evaluation by an authorized clinician
    • Previous unsuccessful attempts to deescalate the situation
    • Indication for restraints: e.g., suspected medical condition, violent attack
    • Method(s) of restraint used
  • If ongoing restraints are necessary, orders need to be revised regularly.
    • Follow the frequency required by regional law and local hospital policy.
    • The 2008 Joint Commission standards recommend the following minimum intervals, unless local and regional laws are more restrictive: [50]
      • Care providers should reevaluate the need for ongoing restraints at least every 4 hours for adults.
      • The most responsible clinician should repeat the full medical and behavioral evaluation at least every 24 hours.

Always follow regional laws and local hospital protocol. Hospitals are obligated to have specific policies on restraint and seclusion that must be in accordance with regional law, including regulating authority to order restraints, patient monitoring, and circumstances that allow the discontinuation of restraints.

Safe application of restraints [11][12]

Preparation

  • At least 5 trained providers should work as a team.
    • 4 team members to immobilize major joints, i.e., the elbows and knees.
    • 1 team member to ensure immobility of the head and patency of the airway (preferably the team lead)
  • Select a team leader who gives orders and communicates with the patient.
  • Use appropriate personal protective equipment, especially if the patient is spitting or biting.
  • Brief the team about the situation before entering together.
  • Choose appropriate restraints.
    • Leather restraints are preferred for actively violent patients.
    • Soft restraints may be considered for partially cooperative, nonviolent patients.

If possible, the treating clinician should avoid actively applying the restraints in order to preserve the clinician-patient relationship. [11]

Approaching the patient

  • Ensure other team members are visible to the patient.
  • Maintain a calm, nonthreatening demeanor.
  • Inform the patient of your intent, explain the necessity, and ask for cooperation.
  • If the patient does not cooperate, firmly explain the procedure and follow local hospital restraint protocol.

Procedure

  • Place the patient in a supine position, with the head of the bed elevated.
  • Assist other team members in immobilizing extremities as needed while restraints are applied.
  • Apply restraints to all four extremities and secure them to the bed frame.
    • Restrain one arm at head level with the elbow flexed, the other arm below the waist with the elbow extended.
    • Tie each leg to the contralateral side of the bed.
  • Consider further restraint as necessary, e.g.:
    • Applying an oxygen face mask can help prevent biting and spitting. [12]
    • Chest restraints can be applied loosely to help immobilize the trunk.

Do not restrain patients in the prone position, as this can result in asphyxiation and death. If chest restraints are used, ensure that they do not impede chest expansion and adequate ventilation. [11]

Monitoring and ongoing care [11]

  • Place the patient under continuous observation.
  • Frequently check vital signs and respiratory status, mental and cognitive status, level of agitation, and possible complications of efforts to resist restraints.
  • Consider continuous pulse oximetry and cardiac monitoring, especially if factors associated with increased risk for sudden death under restraints are present, e.g.: [55][56][57]
  • Check and reposition the patient frequently to prevent pressure sores, circulatory obstruction, or nerve entrapment.
  • Ensure adequate hydration and nutrition and address patient’s comfort and toilet needs.

The level of monitoring should be decided based on an individual risk assessment in accordance with local hospital protocols and regional laws.

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