Acute agitation and rapid tranquillisation

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Target exams

Red flags

• Agitation is organic until a focused assessment proves otherwise — bedside glucose and full vital signs precede any sedative; the patient sedated and restrained for a psychiatric illness that is in fact hypoglycaemia, hypoxia, sepsis or an intracranial bleed is the avoidable death
• Never combine intramuscular olanzapine with a parenteral benzodiazepine — the additive sedation, hypotension and respiratory depression is the classic pharmacological error and is contraindicated by the manufacturer and by Project BETA
• Hyperthermia with agitation is excited delirium until proven otherwise — this is a time-critical medical emergency: active cooling, high-dose benzodiazepine, treat hyperkalaemia and acidosis, and never maintain prone restraint, which is associated with sudden death
• Check the QT before droperidol or haloperidol in any patient with cardiac disease, electrolyte disturbance, a QT-prolonging drug, or a personal or family history of syncope — torsades de pointes is the rare but fatal complication
• Physical restraint is a last resort, time-limited, and released as chemical sedation takes effect — prolonged or prone restraint is associated with rhabdomyolysis, positional asphyxia and sudden death
• Alcohol or benzodiazepine withdrawal is the one agitation where a benzodiazepine is first-line — a dopamine antagonist given alone to a withdrawing patient does not control the withdrawal and risks precipitating delirium tremens