Approach to the agitated or violent patient

Last updated: November 28, 2023

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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 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 only be used to prevent 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.

Definitiontoggle arrow icon

  • 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.

Epidemiologytoggle arrow icon

  • More than 50% of emergency care providers in the US report having experienced patient aggression and/or physical assault. [2][3]
  • Patient risk factors for violent behavior include: [2]
    • Male gender
    • Substance use (including alcohol)
    • Psychiatric illness
    • Prior history of violence (especially incarceration for violent offenses) [4]

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

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. [5][6]

Clinical featurestoggle arrow icon

Medical or substance-related causes [5]

Psychiatric causes

Red flags [5]

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.

Managementtoggle arrow icon

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. [3][5][7][8][9]

Maintaining objectivity

Be aware of the following when considering whether to treat agitation as a medical issue:

Gather as much information as possible before reaching conclusions about the etiology of agitation and be aware of provider biases, prejudices, and clinical uncertainty.

Prior to intervention [5]

  • Identify patients with signs of potential for violence.
  • Ensure patient and staff safety when managing agitated patients.
  • If necessary, call security staff or activate the behavioral emergency response team.
    • A multidisciplinary rapid response team that can be deployed anywhere in the hospital to provide immediate intervention in behavioral crises.
    • Usually includes a psychiatry-trained clinician and security personnel as well as members from other relevant services (e.g., social worker or pastoral support)
    • Although conventions vary, the call for this team is often "code white."

Patients with agitation may be a threat to their own safety or those of others. Call for help whenever possible.

During intervention [5]

Patients with agitation are often vulnerable and/or subject to neglect and abuse. Maintaining patient and provider safety while respecting patient dignity and autonomy can be very challenging and often distressing to all involved. Avoid making rushed decisions.

Following intervention [5]

  • Closely monitor the patient for complications of:
  • Continue further medical evaluation based on the suspected cause of agitation as soon as safely possible.
  • Consider a psychiatry consult.
  • Consider a temporary involuntary hospital admission based on an individual's risk to themselves and/or others in accordance with local laws and policies. [10][11][12]
  • Participate in a team debriefing session if possible.

Patient and staff safety when managing agitated patients [2][4][7]

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. [13]
  • Ensure that providers have an open escape path and do not block exits.

Do not approach patients alone if there are signs of potential for violence and/or multiple risk factors for violent behavior. [4]

Acute stabilization measures [3]

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.

Airway management in agitated patients

Risk assessment and mitigationtoggle arrow icon

Early identification of potential for violence [2][3][15][16]

  • 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 [2][3][5]

  • Call an attending as early as possible and always follow hospital protocol.
  • Approach each patient based on their individual risk assessment.
  • The following classification is loosely based on the Behavioral Activity Rating Scale (BARS).
Level of agitation [3][5][7]
Category Definition and typical characteristics Recommended approach

Mild agitation

≈ BARS 5

  • 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

≈ BARS 6

  • 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

≈ BARS 7

  • 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 parenteral 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.

Managing critical causes of agitationtoggle arrow icon

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

Immediate assessment [3][5][6]

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. [5]

Management of critical causes of agitation

Suggestive findings Immediate intervention




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


  • Core body temperature < 35.0°C (95.0°F)


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




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


Wernicke encephalopathy

Acute urinary retention

Diagnostic approachtoggle arrow icon

Subsequent medical evaluation [5][6]

Obtain the following as soon as safely possible:

Patients with a known psychiatric disorder, with no concerning history or physical examination findings, and whose symptoms are consistent with those of their preexisting psychiatric disease are unlikely to require further diagnostic workup. [3][5][6]

Diagnostic testing [3]

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. [22]

Additional studies

Additional diagnostic evaluation in the agitated patient [3][5]
Laboratory studies
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. [3]

Deescalationtoggle arrow icon

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. [2][7]

Approach [7]

  • 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 [7]

Principles and techniques for deescalation [7]
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. [7]

Pharmacotherapytoggle arrow icon

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.


Ethical use [3][9][23][24]

  • Consider whether the medication is helpful for:
    • Treatment of the condition itself
    • Alleviation of symptoms
    • Prevention of complications
  • Counsel patients about the risks and benefits of pharmacotherapy whenever possible.
  • Avoid using medication to restrain freedom and control behavior unless there is:
    • A clear danger to the patient or others
    • A valid court order for treatment
  • Respect the patient's right to refuse medication in all other circumstances.
  • When possible, involve the patient in the choice of agent and route.

Do not administer medication involuntarily unless it is to prevent imminent self-harm or harm to others, or it is mandated by a valid court order. [5][24]

Safety [3][23][25]

  • Dosage
    • Use the lowest dose needed to calm the patient and avoid oversedation.
    • Reduce dosages as needed, e.g., for older age, impaired drug metabolism, comorbidities.
    • Whenever possible, use oral medication: e.g., orally disintegrating tablets (ODTs), sublingual tablets.
    • 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 [23]
  • Monitor all patients for:
  • Prevent complications
    • Avoid drug accumulation and overdose using careful titration.
    • Allow time for each dose to take effect before repeat dosing or combination therapy.
    • Be prepared for airway management in agitated patients and consider prophylactic airway protection in those requiring heavy sedation.

Calming medications of all classes can potentially cause oversedation, hemodynamic instability, and respiratory compromise, especially if used in combination.

Repeated dosing of intramuscular medication can lead to overdose due to less predictable absorption and drug accumulation. Obtain IV access in the agitated patient as soon as safely possible.

Choice of drug class

Medication for agitation based on suspected cause [3][8]
Etiology Recommended drug class Important considerations
Substance-related Alcohol or benzodiazepine withdrawal
CNS depressant intoxication (including alcohol)
Stimulant intoxication
Severe or refractory agitation or violence
  • Intensive monitoring recommended if combining drug classes.
  • Ketamine may be considered as an alternative first-line agent in young adults with severe agitation. [2][3][22][28]

For severe agitation, consider combining IM typical antipsychotics (e.g., haloperidol) with short-acting IV benzodiazepines (e.g., midazolam) under careful observation. [3]

Benzodiazepinestoggle arrow icon

The following suggested agents and dosages are consistent with the 2012 and 2020 AAEP best practices and expert reviews in the literature. Follow local hospital policy whenever available, as dosage recommendations vary widely. [2][3][8][29]

General principles [3][8][29][30][31]

Beware of drug accumulation with frequent dosing; respiratory suppression can occur if benzodiazepines are prescribed at high doses or when used in patients exposed to other CNS depressants (e.g., alcohol). [8][29]

Lorazepam [3][8][29][30][31]

  • Clinical applications: treatment of acute undifferentiated agitation and/or alcohol withdrawal; adjunctive treatment of psychosis
  • Mild agitation
    • Adults: 1–2 mg PO once; may repeat after 2 hours
    • Older adults: 0.25–0.5 mg PO; may repeat after 2 hours
  • Moderate–severe agitation
    • Adults: 1–2 mg IM/IV once; may repeat after 2 hours
    • Older adults: 0.25–0.5 mg IM/IV once; may repeat after 2 hours
  • Maximum dose
    • Adults: 10–12 mg/day
    • Older adults: 2 mg/day

Midazolam [3][8][29][30][31]

  • Clinical applications: treatment of acute undifferentiated agitation, alcohol withdrawal, and/or stimulant intoxication; adjunctive treatment of psychosis
  • 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
  • Maximum dose
  • Specific considerations: Use in older adults is not well established and parenteral routes may be harmful in these patients. [32]

Diazepam [8][18][29]

Antipsychoticstoggle arrow icon

The following suggested agents and dosages are consistent with the 2012 and 2020 AAEP best practices and expert reviews in the literature. Follow local hospital policy whenever available as dosage recommendations vary widely. [2][3][8][29]

General principles

  • Consider dose reduction for at-risk patients: e.g., older age, impaired drug metabolism, cardiac disease, high risk of hypotension.
  • Consult a clinical pharmacist if uncertain about the optimal agent and dosage.
  • IM antipsychotics and are usually effective within an hour.
  • Compared to IM antipsychotics, PO antipsychotics have a slightly slower onset, but a much slower Tmax.
  • IV antipsychotics have the fastest effect but may be associated with a higher risk of adverse effects.
  • The duration of action of antipsychotics in agitated patients is unclear and may be highly variable.

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

Beware of drug accumulation with frequent dosing. Avoid repeat dosing before the expected time to effect of each drug.

Second-generation antipsychotics [2][3][8][30]

Second-generation antipsychotics are preferred over first-generation antipsychotics for the treatment of agitation due to delirium and psychosis.



Ziprasidone [35][36]

First-generation antipsychotics [2][3][8][30]


  • Older adults: 0.25–0.5 mg PO/IM once; may repeat after 0.5–4 hours [3][8]
  • Adults with mild agitation: 2.5 mg PO once; may repeat after 0.5–4 hours [3][8]
  • Adults with 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
  • Adults with 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 [8][37][38][39]
  • Maximum dose [8]
    • PO/IM: 20–30 mg/day
    • IV: 10 mg/day
    • Older adults: 3 mg/day
  • Specific considerations

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. [8][37][38][39]

Droperidol [40][41]

Dissociative anestheticstoggle arrow icon

The following suggested agents and dosages are consistent with the 2012 and 2020 AAEP best practices and expert reviews in the literature. Follow local hospital policy whenever available, as dosage recommendations vary widely. [2][3][8][29]

Ketamine [2][3][22][26][28]

Consider dose reduction for at-risk patients: e.g., older age, impaired drug metabolism, cardiac disease, high risk of hypotension. Consult a clinical pharmacist if uncertain about the optimal agent and dosage.

  • Clinical application: rapid short-term control of severe refractory agitation and/or violence [2][42][43]
  • Dosage
    • 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
  • Pharmacokinetics
    • Ketamine is effective within minutes.
    • IM ketamine has a comparable onset, but slower Tmax than IV ketamine. [44]
    • The duration of action, when used for agitation, is ∼ 20 minutes. [2][42][43]
  • Specific considerations

Physical restraintstoggle arrow icon

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. [9][24][46][47][48]

Definitions [9]

  • 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 [3][24][46][47][47][49]

  • Severely limit the use of seclusion and restraints, as they can cause significant harm. [9]
    • Use only to prevent imminent harm to the patient or others due to agitation. [2]
    • Consider only if less coercive measures (i.e., deescalation techniques or pharmacotherapy) have failed.
  • Apply the least restrictive method possible.
  • Maximize patient privacy and dignity during restraint application.
  • Frequently reassess the indications for ongoing restraint or seclusion.
  • Discontinue as soon as possible, i.e., when the patient has regained self-control and is no longer a threat to themselves or others. [24]

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! [24][50]

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. [3][51]

Safe application of restraints [2][3]


  • 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. [2]

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.


  • 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. [3]
    • 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. [2]

Monitoring and ongoing care [2]

  • 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.: [52][53][54]
  • 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.

Legal considerations [24][46]

  • Physical restraints are medical interventions that require a formal order from the treating clinician.
  • Clearly document the following: [2][46]
    • 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: [46]
      • Care providers should reevaluate the need for ongoing restraints at least every 4 hours for adults.
      • The clinician with the most responsibility for the patient 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.

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Referencestoggle arrow icon

  1. Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Elsevier Health Sciences ; 2018
  2. Roppolo LP, Morris DW, Khan F, et al. Improving the management of acutely agitated patients in the emergency department through implementation of Project BETA (Best Practices in the Evaluation and Treatment of Agitation). J Am Coll Emerg Physicians Open. 2020; 1 (5): p.898-907.doi: 10.1002/emp2.12138 . | Open in Read by QxMD
  3. Nordstrom K, Zun L, Wilson M, et al. Medical Evaluation and Triage of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Medical Evaluation Workgroup. Western Journal of Emergency Medicine. 2012; 13 (1): p.3-10.doi: 10.5811/westjem.2011.9.6863 . | Open in Read by QxMD
  4. Wilson M, Nordstrom K, Anderson E, et al. American Association for Emergency Psychiatry Task Force on Medical Clearance of Adult Psychiatric Patients. Part II: Controversies over Medical Assessment, and Consensus Recommendations. Western Journal of Emergency Medicine. 2017; 18 (4): p.640-646.doi: 10.5811/westjem.2017.3.32259 . | Open in Read by QxMD
  5. $Contributor Disclosures - Approach to the agitated or violent patient. All of the relevant financial relationships listed for these individuals have been mitigated: Jan Schlebes (medical editor, is a shareholder in Fresenius SE & Co KGaA). None of the other individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy:.
  6. Nazarian DJ, Broder JS, Thiessen MEW, et al. Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department. Ann Emerg Med. 2017; 69 (4): p.480-498.doi: 10.1016/j.annemergmed.2017.01.036 . | Open in Read by QxMD
  7. Merlin M, Carluccio A, Raswant N, DosSantos F, Ohman-Strickland P, Lehrfeld D. Comparison of Prehospital Glucose with or without IV Thiamine. Western Journal of Emergency Medicine. 2011; 13 (5): p.406-409.doi: 10.5811/westjem.2012.1.6760 . | Open in Read by QxMD
  8. Alvanzo et al.. The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management. Journal of Addiction Medicine. 2020; 14 (3S): p.1-72.doi: 10.1097/adm.0000000000000668 . | Open in Read by QxMD
  9. Villeneuve E, Gosselin S, Hoffman RS. There is No Contraindication to Emergent Glucose Administration. Ann Emerg Med. 2017; 69 (3): p.376-377.doi: 10.1016/j.annemergmed.2016.10.021 . | Open in Read by QxMD
  10. Lapoint J, Grock A, Herbert M, Jhun P. In reply: There is No Contraindication to Emergent Glucose Administration. Ann Emerg Med. 2017; 69 (3): p.377-378.doi: 10.1016/j.annemergmed.2016.10.020 . | Open in Read by QxMD
  11. Sinha S, Kataria A, Kolla BP, Thusius N, Loukianova LL. Wernicke Encephalopathy—Clinical Pearls. Mayo Clinic Proceedings. 2019; 94 (6): p.1065-1072.doi: 10.1016/j.mayocp.2019.02.018 . | Open in Read by QxMD
  12. ACEP Task Force Report on Hyperactive Delirium with Severe Agitation in Emergency Settings. Updated: June 23, 2021. Accessed: November 7, 2023.
  13. ACEP Reaffirms Positions on Hyperactive Delirium. Updated: October 12, 2023. Accessed: November 7, 2023.
  14. ACMT Position Statement: End the Use of the Term “Excited Delirium”. Updated: May 1, 2023. Accessed: November 7, 2023.
  15. Position Statement on Concerns About Use of the Term “Excited Delirium” and Appropriate Medical Management in Out-of-Hospital Contexts. Updated: December 1, 2020. Accessed: May 14, 2021.
  16. Wilson M, Pepper D, Currier G, Holloman G, Feifel D. The Psychopharmacology of Agitation: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup. West J Emerg Med. 2012; 13 (1): p.26-34.doi: 10.5811/westjem.2011.9.6866 . | Open in Read by QxMD
  17. Hui D. Benzodiazepines for agitation in patients with delirium: selecting the right patient, right time, and right indication.. Current opinion in supportive and palliative care. 2018; 12 (4): p.489-494.doi: 10.1097/SPC.0000000000000395 . | Open in Read by QxMD
  18. Marcantonio ER. Delirium in Hospitalized Older Adults. N Engl J Med. 2017; 377 (15): p.1456-1466.doi: 10.1056/nejmcp1605501 . | Open in Read by QxMD
  19. Clinical Practice Guideline for Postoperative Delirium in Older Adults. Updated: October 10, 2014. Accessed: November 19, 2020.
  20. Bloch F, Karoui I, Boutalha S, Defouilloy C, Dubaele J-M. Tolerability of Midazolam to treat acute agitation in elderly demented patients: A systematic review. J Clin Pharm Ther. 2019; 44 (2): p.143-147.doi: 10.1111/jcpt.12785 . | Open in Read by QxMD
  21. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  22. Nelson LS, Howland M, Lewin NA, Smith SW, Goldfrank LR, Hoffman RS. Goldfrank's Toxicologic Emergencies, 11th edition. McGraw-Hill Education ; 2019
  23. Page CB, Parker LE, Rashford SJ, Kulawickrama S, Isoardi KZ, Isbister GK. Prospective study of the safety and effectiveness of droperidol in elderly patients for pre‐hospital acute behavioural disturbance. Emergency Medicine Australasia. 2020; 32 (5): p.731-736.doi: 10.1111/1742-6723.13496 . | Open in Read by QxMD
  24. Perkins J, Ho JD, Vilke GM, DeMers G. American Academy of Emergency Medicine Position Statement: Safety of Droperidol Use in the Emergency Department. J Emerg Med. 2015; 49 (1): p.91-97.doi: 10.1016/j.jemermed.2014.12.024 . | Open in Read by QxMD
  25. Rais AR, Williams K, Rais T, Singh T, Tamburrino M. Use of intramuscular ziprasidone for the control of acute psychosis or agitation in an inpatient geriatric population: an open-label study.. Psychiatry (Edgmont (Pa. : Township)). 2010; 7 (1): p.17-24.
  26. Barak Y, Mazeh D, Plopski I, Baruch Y. Intramuscular Ziprasidone Treatment of Acute Psychotic Agitation in Elderly Patients With Schizophrenia. The American Journal of Geriatric Psychiatry. 2006; 14 (7): p.629-633.doi: 10.1097/01.jgp.0000216325.42721.99 . | Open in Read by QxMD
  27. Tisdale JE, Chung MK, Campbell KB, et al. Drug-Induced Arrhythmias: A Scientific Statement From the American Heart Association.. Circulation. 2020; 142 (15): p.e214-e233.doi: 10.1161/CIR.0000000000000905 . | Open in Read by QxMD
  28. Vanneman MW, Madhok J, Weimer JM, Dalia AA. Perioperative implications of the 2020 American Heart Association scientific statement on drug induced arrhythmias—a focused review. J Cardiothorac Vasc Anesth. 2021.doi: 10.1053/j.jvca.2021.05.008 . | Open in Read by QxMD
  29. Beach SR, Gross AF, Hartney KE, Taylor JB, Rundell JR. Intravenous haloperidol: A systematic review of side effects and recommendations for clinical use. Gen Hosp Psychiatry. 2020; 67: p.42-50.doi: 10.1016/j.genhosppsych.2020.08.008 . | Open in Read by QxMD
  30. Mo H, Campbell M, Fertel B, et al. Ketamine Safety and Use in the Emergency Department for Pain and Agitation/Delirium: A Health System Experience. West J Emerg Med. 2020; 21 (2): p.272-281.doi: 10.5811/westjem.2019.10.43067 . | Open in Read by QxMD
  31. Green SM, Roback MG, Kennedy RM, Krauss B. Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation: 2011 Update. Ann Emerg Med. 2011; 57 (5): p.449-461.doi: 10.1016/j.annemergmed.2010.11.030 . | Open in Read by QxMD
  32. Lin J, Figuerado Y, Montgomery A, et al. Efficacy of ketamine for initial control of acute agitation in the emergency department: A randomized study. Am J Emerg Med. 2020.doi: 10.1016/j.ajem.2020.04.013 . | Open in Read by QxMD
  33. Riddell J, Tran A, Bengiamin R, Hendey GW, Armenian P. Ketamine as a first-line treatment for severely agitated emergency department patients. Am J Emerg Med. 2017; 35 (7): p.1000-1004.doi: 10.1016/j.ajem.2017.02.026 . | Open in Read by QxMD
  34. Craven R. Ketamine. Anaesthesia. 2007; 62 (s1): p.48-53.doi: 10.1111/j.1365-2044.2007.05298.x . | Open in Read by QxMD
  35. Mankowitz SL, Regenberg P, Kaldan J, Cole JB. Ketamine for Rapid Sedation of Agitated Patients in the Prehospital and Emergency Department Settings: A Systematic Review and Proportional Meta-Analysis. J Emerg Med. 2018; 55 (5): p.670-681.doi: 10.1016/j.jemermed.2018.07.017 . | Open in Read by QxMD
  36. Roca RP, Charen B, Boronow J. Ensuring Staff Safety When Treating Potentially Violent Patients. JAMA. 2016; 316 (24): p.2669.doi: 10.1001/jama.2016.18260 . | Open in Read by QxMD
  37. Richmond J, Berlin J, Fishkind A, et al. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012; 13 (1): p.17-25.doi: 10.5811/westjem.2011.9.6864 . | Open in Read by QxMD
  38. Knox DK, Holloman GH Jr. Use and Avoidance of Seclusion and Restraint: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Seclusion and Restraint Workgroup. West J Emerg Med. 2012; 13 (1): p.35-40.doi: 10.5811/westjem.2011.9.6867 . | Open in Read by QxMD
  39. Lachner C, Maniaci MJ, Vadeboncoeur TF, et al. Are pre-existing psychiatric disorders the only reason for involuntary holds in the emergency department?. International journal of emergency medicine. 2020; 13 (1): p.4.doi: 10.1186/s12245-020-0265-4 . | Open in Read by QxMD
  40. Dawson NL, Lachner C, Vadeboncoeur TF, et al. Violent behavior by emergency department patients with an involuntary hold status.. Am J Emerg Med. 2018; 36 (3): p.392-395.doi: 10.1016/j.ajem.2017.08.039 . | Open in Read by QxMD
  41. Saya A, Brugnoli C, Piazzi G, et al. Criteria, Procedures, and Future Prospects of Involuntary Treatment in Psychiatry Around the World: A Narrative Review.. Frontiers in psychiatry. 2019; 10: p.271.doi: 10.3389/fpsyt.2019.00271 . | Open in Read by QxMD
  42. Behnam M, Tillotson RD, Davis SM, Hobbs GR. Violence in the Emergency Department: A National Survey of Emergency Medicine Residents and Attending Physicians. J Emerg Med. 2011; 40 (5): p.565-579.doi: 10.1016/j.jemermed.2009.11.007 . | Open in Read by QxMD
  43. Merelman A, Perlmutter M, Strayer R. Alternatives to Rapid Sequence Intubation: Contemporary Airway Management with Ketamine. Western Journal of Emergency Medicine. 2019; 20 (3): p.466-471.doi: 10.5811/westjem.2019.4.42753 . | Open in Read by QxMD
  44. Luck L, Jackson D, Usher K. STAMP: components of observable behaviour that indicate potential for patient violence in emergency departments. J Adv Nurs. 2007; 59 (1): p.11-19.doi: 10.1111/j.1365-2648.2007.04308.x . | Open in Read by QxMD
  45. Violence: occupational hazards in hospitals. Updated: April 1, 2002. Accessed: March 21, 2021.
  46. Martínez-Raga J, Amore M, Di Sciascio G, et al. 1st International Experts’ Meeting on Agitation: Conclusions Regarding the Current and Ideal Management Paradigm of Agitation. Frontiers in Psychiatry. 2018; 9.doi: 10.3389/fpsyt.2018.00054 . | Open in Read by QxMD
  47. Hospitals-restraints/seclusion interpretive guidelines & update state operations manual (SOM). Updated: April 11, 2008. Accessed: March 16, 2021.
  48. Nashef L, So EL, Ryvlin P, Tomson T. Unifying the definitions of sudden unexpected death in epilepsy. Epilepsia. 2011; 53 (2): p.227-233.doi: 10.1111/j.1528-1167.2011.03358.x . | Open in Read by QxMD
  49. Beck K, Hindley G, Borgan F, et al. Association of Ketamine With Psychiatric Symptoms and Implications for Its Therapeutic Use and for Understanding Schizophrenia. JAMA Network Open. 2020; 3 (5): p.e204693.doi: 10.1001/jamanetworkopen.2020.4693 . | Open in Read by QxMD
  50. Joint commission standards on restraint and seclusion. Updated: January 1, 2009. Accessed: March 16, 2021.
  51. $Policy statement on use of patient restraints.
  52. $Prepublication Requirements - EP Revisions Related to CMS Final Rules.
  53. Masters KJ. Physical Restraint: A Historical Review and Current Practice. Psychiatr Ann. 2017; 47 (1): p.52-55.doi: 10.3928/00485713-20161129-01 . | Open in Read by QxMD
  54. Strömmer EMF, Leith W, Zeegers MP, Freeman MD. The role of restraint in fatal excited delirium: a research synthesis and pooled analysis. Forensic Science, Medicine and Pathology. 2020; 16 (4): p.680-692.doi: 10.1007/s12024-020-00291-8 . | Open in Read by QxMD
  55. Wong AH, Ray JM, Rosenberg A, et al. Experiences of Individuals Who Were Physically Restrained in the Emergency Department.. JAMA network open. 2020; 3 (1): p.e1919381.doi: 10.1001/jamanetworkopen.2019.19381 . | Open in Read by QxMD
  56. Stratton SJ, Rogers C, Brickett K, Gruzinski G. Factors associated with sudden death of individuals requiring restraint for excited delirium.. Am J Emerg Med. 2001; 19 (3): p.187-91.doi: 10.1053/ajem.2001.22665 . | Open in Read by QxMD
  57. Hick JL, Smith SW, Lynch MT. Metabolic acidosis in restraint-associated cardiac arrest: a case series.. Acad Emerg Med. 1999; 6 (3): p.239-43.doi: 10.1111/j.1553-2712.1999.tb00164.x . | Open in Read by QxMD
  58. Otahbachi M, Cevik C, Bagdure S, Nugent K. Excited delirium, restraints, and unexpected death: a review of pathogenesis.. Am J Forensic Med Pathol. 2010; 31 (2): p.107-12.doi: 10.1097/PAF.0b013e3181d76cdd . | Open in Read by QxMD

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