Acute agitation and rapid tranquillisation ladder (MEQ)

(i) Immediate assessment and de-escalation. Scene safety: adequate staff, clear exits, remove weapons/audience, one calm lead communicator (Project BETA principles — respect space, concise language, offer choices). ABCDE already partly reassuring (oxygenating, afebrile, glucose normal) but continue continuous observation for hyperthermia and collapse if SBD evolves. Re-offer oral medication if momentarily safer. Focused history: mania symptoms, lithium cessation, stimulant use, head injury, seizure. Emergency MSE: threat content, command hallucinations, suicidality, attention. Collateral. Targeted medical clearance already includes ECG QTc — document rationale for any further labs (CK if restraint/exertion).^[1][2]

(ii) Critique and safer RT pathway. Do not give IM olanzapine and IM lorazepam together or in the same syringe. Parenteral benzodiazepine with IM olanzapine risks profound respiratory depression and hypotension. Safer plan: continue de-escalation; if IM required, use a single agent. Reasonable options depending on setting: IM lorazepam 1–2 mg, IM olanzapine 5–10 mg alone (then wait ≥1 hour before any parenteral BZD), IM aripiprazole ~9.75 mg, or TREC-backed IM haloperidol 5 mg + promethazine 25–50 mg if cardiac risk allows (QTc currently acceptable). In ANZ ED undifferentiated SBD, IM droperidol 5–10 mg is evidence-supported first-line with monitoring. Post-dose: continuous observation; RR, SpO2, BP, HR, consciousness every 15 minutes for ≥1 hour; endpoint calm and rousable.^[1][3][4]

(iii) Cause-matched agents. Primary mania/psychosis: antipsychotic ± promethazine combination pathway; reinstate definitive mood treatment later (not RT). Stimulant SBD: ANZ ED droperidol/midazolam evidence; medical monitoring for hyperthermia/arrhythmia. Alcohol/sedative withdrawal: benzodiazepines treat the pathophysiology — antipsychotic alone is inadequate. Always re-check combination ban when mixing classes.^[1][3]

(iv) Capacity and law. Assess capacity for specific decisions (oral meds, remaining for care): understand, retain, use/weigh, communicate. Mania/stimulant intoxication may impair capacity but assessment must be explicit. If incapacitous with serious risk, use emergency treatment principles and local Mental Health Act for ongoing care, documenting least-restrictive alternatives tried. Do not invent section numbers for other jurisdictions.^[5][1]

(v) Documentation and disposition. Document: risks, de-escalation attempts, capacity, legal basis, agent/dose/route/time, monitoring, response, complications, debrief. Disposition: medical observation if toxicity/SBD physiology; psychiatric admission (voluntary if possible; involuntary if criteria met) for manic relapse with violence risk; only discharge if risk reduced, supports present, follow-up timed — unlikely immediately after this presentation.^[1]