Severe manic crisis: work-up, RT/seclusion, antimanic algorithm (MEQ)

(i) Episode and risk. Operational diagnosis: bipolar I disorder, current episode manic, severe, with psychotic features (grandiose delusions; duration 8 days; marked impairment; hospitalisation indicated). Risk domains: violence to staff/public, property damage, financial catastrophe, sexual disinhibition, absconding, vulnerability, driving, possible suicide if mixed features evolve, forensic sequelae. Capacity for treatment likely impaired; consider least-restrictive involuntary pathway under local law.^[3]

(ii) Medical work-up. Even with known bipolar illness: observations already partly reassuring (afebrile, normal glucose/SpO2) but complete FBC, U&E/eGFR, calcium, LFT, TFT, ECG, pregnancy test if relevant, UDS. Review for withdrawal, occult infection, or other medical contributors to agitation. Escalate neuroimaging/EEG/autoimmune work-up if atypical features appear. Baselines are mandatory before re-starting lithium/SGA.^[7][3]

(iii) Behavioural emergency. De-escalate: one spokesperson, low stimulation, clear simple choices, offer oral medication first.^[2] If parenteral RT needed after failed oral offer: examples within protocol — lorazepam 1–2 mg IM, or promethazine 25–50 mg IM, or haloperidol 5 mg IM with anticholinergic availability, or olanzapine 5–10 mg IM — never IM olanzapine plus parenteral benzodiazepine. Post-RT: continuous observation of airway, RR, SpO2, BP, conscious level. Seclusion only if still unsafe: time-limited, continuous observation, documented authorisation, avoid prolonged prone restraint, regular reviews, debrief, and ensure antimanic cover is started so seclusion is not the treatment.^[2]

(iv) Pharmacotherapy. Stop sertraline (polarity-unsafe; may have contributed to switch/escalation).^[5][3] After baselines: re-start lithium (e.g. 450–900 mg/day titrated) aiming for 12-hour trough about 0.8–1.2 mmol/L in acute mania; level at 5–7 days; educate on toxicity (coarse tremor, ataxia, vomiting, confusion) and interactions.^[4][3] Add SGA for severe psychotic mania — e.g. olanzapine 10–20 mg/day oral (or other evidence-based SGA). Combination is appropriate for severe illness.^[1][3] Short-term benzodiazepine for sleep/arousal. Consider valproate only if lithium unsuitable and pregnancy risk managed; loading ~20–30 mg/kg/day is a selected-protocol option, not automatic. ECT if extreme ongoing risk or non-response. Lithium "loading" means supervised faster titration with levels — not reckless boluses without renal baselines.^[4][3]

(v) Maintenance and psychosocial. Before discharge: continue effective regimen into early recovery; simplify toward lithium-first prevention when tolerated (BALANCE context); metabolic and lithium monitoring schedule; psychoeducation; sleep regularity; early-warning signs with partner; crisis contacts; substance advice; outpatient follow-up timed before discharge.^[6][3]