ABCs
- Ensure staff + patient safety
- Maintain personal space
- If violent → call for help immediately
- Check vitals + RBS
- Treat reversible causes:
- Hypoglycemia
- Hypoxia
- Pain
- Dehydration
- Urinary retention
- De-escalation (FIRST LINE)
- Calm, non-threatening approach
- Do not argue
- Validate feelings, reassure
- Offer simple choices
- Reduce stimuli (noise, light)
- Consider family/sitter if appropriate
Differential (DIMS-RAT)
- Delirium / Dementia / Depression
- Infection (UTI, sepsis, meningitis)
- Metabolic (glucose, Na, CO₂, thyroid, liver)
- Structural (stroke, seizure, tumor)
- Retention (urine/stool)
- Alcohol / Drugs
- Toxins / Medications
HPI & examination
- Collateral from staff/family
- Reason for admission / prolonged stay
- Previous agitation episodes
- Risk factors
- CVA, dementia, psychiatric illness
- Alcohol use/withdrawal
- Sensory impairment
- Review
- Medications (new/missed)
- Infection or metabolic triggers
Management
- Non-Pharmacologic (Always First)
- Reorientation + reassurance
- Optimize environment
- Close observation
- Investigations (If Indicated)
- CBC, U&E
- VBG
- Urinalysis
- Septic workup if febrile
- CT brain if trauma / focal signs
- Escalation
- Persistent aggression or danger → call for help
- Failure of de-escalation + medications
- Suspected delirium (infection/metabolic)
- Consider Psychiatry/Geriatrics consult
- ICU if severe withdrawal or unstable
- Pharmacological
| Scenario | Clues | Management |
|---|---|---|
| General agitation/delirium | Unsafe behavior, no specific cause | Haloperidol 0.5–1 mg PO/IV/IM Check ECG for QTc before Repeat q30 min if needed (max 5 mg/day) Avoid in Parkinson’s / Lewy body |
| Alcohol withdrawal (mild–moderate) | CIWA <8–15 | Thiamine 100 mg IV BEFORE glucose Diazepam 5 mg OR Lorazepam 2 mg IV |
| Alcohol withdrawal (moderate–severe) | CIWA >8 | Thiamine 100 mg IV BEFORE glucose Diazepam 5–10 mg OR Lorazepam 2–4 mg |
| Severe withdrawal/delirium tremens | CIWA >20 or poor response | Thiamine 100 mg IV BEFORE glucose Escalate → ICU |
| Elderly/frail | High sensitivity | Use lower doses (e.g., Diazepam 2 mg / Lorazepam 0.5 mg) Start low, go slow |
Studying for R1? The IM Rapid Review covers this in the same format — see the sample chapter.
Last reviewed · May 2026