First, you need to decide where in the ED acutely psychotic patients need to go: Can they simply wait in the general waiting area with a family member until they can be seen, should
they be secured in a locked room, do they need to be restrained, or do they need to go to the medical side (if the psychiatric ED is separate from the medical ED)?

Symptoms of psychosis are often very disturbing to patients and may lead to poor judgments regarding safe behavior. Agitation is a combination of physical signs involving aimless movements that suggest internal emotional distress. Staring intensely, hand wringing, fidgeting, pacing, clenched fists, shadowboxing, posturing, and pounding on doors or walls are all signs of agitation. Some patients may arrive agitated or combative, whereas others are calm until they recognize that their families have coaxed them into going to the ED under false pretenses. Patients might agree to an evaluation if they perceive that you are at least considering “letting them go” after the evaluation. Never promise that you will let a patient go if the patient talks with you, but inform the patient that talking with you is a sine qua non for possible release.

A series of treatments can be offered to decrease a patient’s distress. Offers of food and drink, warm blankets, a trip to the restroom, or a more comfortable place to wait may decrease anxiety and help you to form an alliance. Acknowledge the patient’s power to make decisions and provide information about the ED process in a calm voice. Clear limit-setting about safe behaviors in the ED also sets the stage for offers of medication if the patient is unable to behave in a safe manner. If a patient appears agitated, keep yourself safe by maintaining at least an arm’s distance from the patient, meet in a location where you can leave the room quickly, and limit the items in the room that could be picked up or thrown.

If a patient requires medication, follow the principles below for acute treatment with medications (see next paragraph and EM Card Acute Behavioral Disturbance in Appendix A for some commonly used regimens). If done correctly, medications are a safe way to protect patients, caregivers, and other patients from injury. Appropriate use of medication also reduces the time that a patient might spend in physical restraints. Physical restraint,
a last resort in the management of acute agitation, can be necessary and lifesaving for extremely agitated patients.

Whenever possible, use oral medications in cooperative patients. A show of force might convince patients to cooperate and not risk a fight. Experts disagree if benzodiazepines alone are as effective for agitation as antipsychotics with or without a benzodiazepine. Several second-generation antipsychotics are now available in intramuscular (IM) preparations (i.e., aripiprazole, olanzapine, and ziprasidone). I am more likely to use second-generation antipsychotics in the ED setting if schizophrenia is the reason for agitation (consistent with Lukens et al., 2006). Otherwise, I use the haloperidol-lorazepam combination, which has an excellent track record regarding both safety and efficacy for any acute behavioral emergency. In some situations, it is probably safer to use benzodiazepines alone—e.g., antipsychotics increase risk for neuroleptic malignant syndrome (NMS) in patients with amphetamine intoxication. Make sure not to use antipsychotics if catatonia or NMS is a possibility. Also, do not use “rapid neuroleptization” (i.e., the use of large loading doses of antipsychotics), as this strategy does not confer any benefit. Note that agitated patients in alcohol or benzodiazepine withdrawal might need substantially higher doses of benzodiazepines than commonly recommended for acute agitation from other causes.