Managing Acute Psychiatric Crises

Checkpoint A: Pre-Draft Intake (Mandatory)

1. What is the nature of the crisis? (acute agitation, psychotic decompensation, active suicidal behavior, homicidal threat, catatonia, severe self-harm, delirium, intoxication/withdrawal) — default: assess immediately
2. What is the setting? (emergency department, inpatient psychiatric unit, outpatient clinic, community, correctional) — default: identify
3. Is the patient medically cleared? — default: assess concurrently with behavioral management
4. Is the patient known to the treatment team or a new presentation? — default: obtain history rapidly
5. What is the patient's current medication regimen? — default: obtain immediately
6. Are there known allergies or adverse reactions to emergency medications? — default: verify before administering
7. Are there special populations considerations? (pregnancy, elderly, pediatric, intellectually disabled, known cardiac disease) — default: assess
8. What de-escalation resources are immediately available? (trained staff, safe environment, show of support team) — default: mobilize

Documents to Request

• Most recent psychiatric evaluation and medication list
• Prior crisis documentation and response to previous interventions
• Allergy list and adverse medication reaction history
• Advance directives or psychiatric advance directives (PADs)
• Medical history relevant to emergency medication selection (QTc prolongation risk, respiratory disease, hepatic impairment)
• Vital signs including temperature (rule out NMS, serotonin syndrome, infection)
• Urine drug screen and blood alcohol level
• Point-of-care glucose (hypoglycemia is a medical emergency that mimics psychiatric crisis)

Step 1: Rapid Safety Assessment and Triage

Immediate safety priorities (first 60 seconds):

• Assess for weapons or objects that could be used as weapons
• Ensure clear exit routes for staff and patient
• Remove bystanders from the area
• Call for additional staff support if needed (show of support)
• Assess for medical emergency requiring immediate intervention (anaphylaxis, seizure, cardiac arrest, overdose)

Medical clearance priorities (concurrent with behavioral management):

• Point-of-care glucose (rule out hypoglycemia — treat with glucose if <60 mg/dL)
• Vital signs (tachycardia, hyperthermia suggest medical etiology: NMS, serotonin syndrome, thyroid storm, sepsis, intoxication)
• Pulse oximetry (hypoxia can cause agitation)
• Mental status: Is this delirium or psychiatric agitation? The distinction drives all subsequent management
  • Delirium indicators: Acute onset, fluctuating course, inattention, altered level of consciousness, visual hallucinations, disorientation. Treat the MEDICAL CAUSE, not just the agitation.
  • Psychiatric agitation indicators: Alert, oriented, coherent (even if psychotic), stable vitals, no evidence of medical illness

Agitation severity assessment (use BARS — Behavioral Activity Rating Scale or equivalent): 1 = Difficult or unable to rouse 2 = Asleep but responds to verbal/tactile stimulation 3 = Drowsy, appears sedated 4 = Quiet and awake 5 = Signs of overt activity, calms with verbal instructions 6 = Extremely or continuously active, not requiring restraint 7 = Violent, requires restraint

Step 2: Verbal De-Escalation (First-Line Intervention)

Verbal de-escalation should ALWAYS be attempted before medication or physical intervention unless there is imminent risk of harm that does not permit delay.

AAEP 10 Key Elements of De-Escalation:

1. Respect personal space (maintain arm's-length distance minimum)
2. Do not be provocative (avoid crossing arms, pointing, making demands)
3. Establish verbal contact (one person speaks, others remain quiet)
4. Be concise and use simple language
5. Identify wants and feelings ("I can see you're upset. What do you need right now?")
6. Listen closely and empathize ("That sounds really frustrating")
7. Agree or agree to disagree (find common ground)
8. Lay down the law and set clear limits ("I want to help you, but I can't do that if you're threatening the staff")
9. Offer choices and optimism ("Would you prefer to take a pill or have a drink of water and sit down?")
10. Debrief patient and staff after the event

Environmental modifications:

• Reduce stimulation (dim lights, reduce noise, limit number of people)
• Offer comfort measures (blanket, food, drink, phone call)
• Move to a quieter area if the patient is willing
• Offer PRN oral medication as a choice

Step 3: Pharmacological Management of Acute Agitation

Principle: Calming, not sedation. The goal is to achieve a calm, cooperative, awake patient — not unconsciousness.

First-Line: Offer Oral Medications

• Olanzapine ODT (orally disintegrating tablet) 5-10mg: Rapid absorption, effective for psychotic and non-psychotic agitation. Onset: 15-45 minutes.
• Risperidone ODT 1-2mg: Alternative to olanzapine, less sedating. Onset: 30-60 minutes.
• Lorazepam 1-2mg PO: For non-psychotic agitation, alcohol withdrawal, benzodiazepine withdrawal, anxiety-driven agitation. Onset: 30-60 minutes.
• Combination: Olanzapine 5mg + Lorazepam 1mg PO: Effective, well-tolerated.

Second-Line: Parenteral Medications (if oral refused or insufficient)

• Olanzapine 10mg IM: Effective for psychotic agitation. Do NOT combine with IM benzodiazepines (respiratory depression risk). Onset: 15-30 minutes. May repeat x1 after 2 hours.
• Ziprasidone 10-20mg IM: Alternative to olanzapine. Check QTc if possible (QTc prolongation risk). Onset: 15-30 minutes. May repeat 10mg after 2 hours.
• Haloperidol 5mg IM + Lorazepam 2mg IM + Diphenhydramine 50mg IM ("B52"): Traditional combination, effective but more sedating. EPS risk with haloperidol.
• Haloperidol 5-10mg IM: For severe psychotic agitation when antipsychotic monotherapy is preferred. Monitor for acute dystonia (treat with benztropine 1-2mg IM or diphenhydramine 50mg IM).
• Lorazepam 2mg IM: For non-psychotic agitation, substance withdrawal, when antipsychotics are contraindicated. Onset: 15-30 minutes.
• Droperidol 5-10mg IM: Rapid onset (3-10 minutes), very effective, but requires cardiac monitoring (FDA Black Box Warning for QTc prolongation).
• Ketamine 4-5mg/kg IM: For extreme, refractory agitation when other agents have failed. Rapid onset (3-5 minutes). Requires advanced airway support.

Special Populations

• Elderly: Reduce all doses by 50%. Avoid haloperidol if possible (EPS risk). Low-dose olanzapine 2.5mg or lorazepam 0.5-1mg.
• Pregnancy: Haloperidol is relatively safest antipsychotic. Avoid benzodiazepines in first trimester. Diphenhydramine is generally safe.
• Known cardiac disease / QTc prolongation: Avoid haloperidol IV, ziprasidone, droperidol. Prefer olanzapine or lorazepam.
• Substance intoxication — stimulants: Benzodiazepines first-line (lorazepam 2mg IV/IM). Avoid antipsychotics initially (lower seizure threshold, worsen hyperthermia).
• Alcohol withdrawal: Benzodiazepines (lorazepam or chlordiazepoxide) per CIWA protocol.
• Catatonia: Lorazepam 1-2mg IV challenge (not antipsychotics — antipsychotics can worsen catatonia and precipitate NMS).

Step 4: Seclusion and Restraint Documentation

Seclusion and restraint are last-resort interventions. CMS Conditions of Participation (42 CFR 482.13) require:

Order requirements:

• Physician or LIP order required (standing orders prohibited)
• Face-to-face evaluation within 1 hour of initiation
• Time limits: 4 hours adults, 2 hours adolescents (9-17), 1 hour children (<9)
• Orders must be renewed at time limit intervals; no PRN or standing orders
• Order must document the clinical justification (behavioral description, not just "agitated")

Monitoring requirements:

• Continuous observation (1:1) during restraint
• Vital signs per institutional protocol (typically every 15 minutes)
• Circulation, sensation, and movement checks of restrained extremities
• Hydration, nutrition, toileting needs addressed at regular intervals
• Range of motion offered every 2 hours
• Ongoing assessment for readiness to discontinue restraint

Documentation:

• Behavior that necessitated restraint (specific behavioral description)
• Alternatives attempted before restraint (de-escalation, medication offered)
• Type of restraint (4-point, 2-point, physical hold, seclusion room)
• Time initiated and time discontinued
• Patient's response during restraint
• Face-to-face evaluation findings
• Plan for de-escalation and restraint reduction
• Post-restraint debriefing with patient and staff

Step 5: Disposition and Transition Planning

After acute crisis stabilization:

• Reassess psychiatric diagnosis and risk level
• Determine appropriate disposition: continue inpatient, transfer to higher level of care, step down to voluntary status, discharge with outpatient follow-up
• Complete updated suicide risk assessment (C-SSRS) before disposition change
• Update or create safety plan
• Ensure follow-up appointment is scheduled (within 24-72 hours for high-risk patients)
• Document the crisis event in the longitudinal treatment record
• File incident reports per institutional policy
• Complete regulatory reporting (restraint/seclusion events, injuries)
• Conduct post-crisis debriefing with treatment team and patient

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Was medical etiology assessed and ruled out before treating as psychiatric agitation?
2. Was de-escalation attempted and documented before medication or restraint?
3. Are medication choices appropriate for the specific type of agitation and patient population?
4. Is seclusion/restraint documentation complete with all CMS-required elements?
5. Is the disposition plan documented with appropriate follow-up?

Quality Audit

• Rapid safety assessment documented (weapons, exit routes, staffing)
• Medical clearance initiated concurrently (glucose, vitals, pulse oximetry)
• Delirium vs. psychiatric agitation differentiated and documented
• Verbal de-escalation attempted and documented before pharmacologic intervention
• Medication selection appropriate for agitation type and patient population
• Medication doses appropriate (reduced for elderly, pregnancy, renal/hepatic impairment)
• Contraindicated combinations avoided (IM olanzapine + IM benzodiazepine)
• Post-medication monitoring documented (vitals, sedation level, respiratory status)
• Seclusion/restraint order meets CMS requirements (physician order, time-limited, no PRN)
• Face-to-face evaluation within 1 hour of restraint initiation documented
• Continuous observation documented during restraint
• Restraint discontinuation criteria and plan documented
• Post-crisis debriefing completed with patient and staff
• Incident report filed per institutional policy

Guidelines

1. Always rule out medical causes of agitation before treating as psychiatric — hypoglycemia, hypoxia, delirium, intoxication, sepsis, and head injury present as agitation and require medical, not psychiatric, intervention.
2. Never combine IM olanzapine with IM benzodiazepines — the combination carries significant risk of respiratory depression, hypotension, and death per FDA warning.
3. Verbal de-escalation is the first-line intervention for all acute agitation — document that it was attempted even when it is unsuccessful.
4. For suspected catatonia, administer lorazepam IV challenge before antipsychotics — antipsychotics can worsen catatonia and precipitate neuroleptic malignant syndrome.
5. Seclusion and restraint are interventions of last resort — document the alternatives attempted and the specific behavior that necessitated the intervention, per CMS requirements.
6. Monitor vital signs during and after chemical restraint — respiratory depression from medication combinations is the leading cause of death in behavioral emergencies.
7. Debrief all crisis events with both the patient and the treatment team — post-crisis debriefing improves therapeutic alliance, reduces future crises, and identifies system improvements.
8. Check QTc before administering IV haloperidol, ziprasidone, or droperidol when clinically feasible — QTc prolongation leading to Torsades de Pointes is a known cause of sudden cardiac death with these agents.