**Psychiatric Emergencies: Excited Delirium, Chemical Restraint, Suicide Risk Assessment**

Psychiatric Emergencies: Excited Delirium, Chemical Restraint, Suicide Risk Assessment

A practical guide for nurses, EMTs, and clinicians in emergency and psychiatric settings.

What Is This?

Psychiatric emergencies require rapid, safe, and evidence-based interventions to prevent harm to patients and providers. This guide covers: - Excited delirium (ExDS): A life-threatening hyperadrenergic state with agitation, hyperthermia, and sudden death risk.
- Chemical restraint: Pharmacologic agents used to manage acute agitation when verbal de-escalation fails.
- Suicide risk assessment: A structured approach to evaluate imminent self-harm risk and guide intervention.

Why use this today?
Psychiatric emergencies are rising (e.g., 1 in 8 ED visits involve mental health crises). Misdiagnosis or improper restraint can lead to patient death, legal liability, or provider injury. This guide ensures safe, rapid, and legally defensible care.

Why It Matters

• Patient safety: Excited delirium has a 10% mortality rate if untreated. Suicide is the 10th leading cause of death in the U.S.
• Provider safety: Agitated patients injure 1 in 4 healthcare workers annually.
• Legal/ethical: Improper restraint (physical or chemical) can result in lawsuits, loss of licensure, or criminal charges.
• System impact: Psychiatric holds and ED boarding strain healthcare resources.

Core Concepts

1. Excited Delirium (ExDS)

Definition: A syndrome of hyperthermia, agitation, delirium, and autonomic dysfunction, often linked to stimulant use (e.g., cocaine, methamphetamine), psychiatric illness, or metabolic derangements.

Key features (use the "BREACH" mnemonic):
- Bizarre behavior (e.g., superhuman strength, paranoia) - Resistance to pain (e.g., not reacting to pepper spray) - Elevated temperature (>38°C/100.4°F) - Agitation (combative, incoherent speech) - Confusion/disorientation (unaware of surroundings) - Hyperadrenergic state (tachycardia, hypertension, dilated pupils)

Pathophysiology:
- Dopamine surge (from drugs or psychosis) → agitation, paranoia.
- Sympathetic overdrive → hyperthermia, rhabdomyolysis, cardiac arrest.
- Metabolic acidosis → sudden death (often during restraint).

Differential diagnosis (rule out first):
- Hypoglycemia (check glucose) - Hypoxia (check SpO₂) - Traumatic brain injury (CT if history of head trauma) - Serotonin syndrome (if on SSRIs/MAOIs) - Neuroleptic malignant syndrome (NMS) (if on antipsychotics)

2. Chemical Restraint

Definition: Pharmacologic agents used to rapidly sedate an agitated patient when verbal de-escalation fails. Goal: Reduce harm without over-sedation.

When to use:
- Patient is violent or imminently dangerous (to self/others).
- Physical restraint is ineffective or unsafe (e.g., patient is too strong).
- Medical workup is impossible due to agitation.

First-line agents (IM/IV preferred for rapid onset):
| Drug | Dose (Adult) | Onset | Duration | Key Considerations | |-------------------|------------------------|-----------|--------------|-----------------------------------------------| | Midazolam | 2.5–5 mg IM/IV | 3–5 min | 1–2 hrs | Risk of respiratory depression (have naloxone ready). | | Lorazepam | 1–2 mg IM/IV | 15–30 min | 4–6 hrs | Slower onset; better for alcohol withdrawal. | | Haloperidol | 5–10 mg IM/IV | 20–30 min | 4–6 hrs | Risk of QTc prolongation (avoid in cardiac pts). | | Ketamine | 4–5 mg/kg IM | 1–2 min | 10–20 min | Best for severe ExDS; dissociative effects. | | Olanzapine | 10 mg IM | 15–30 min | 2–4 hrs | Avoid in elderly (anticholinergic effects). |

Combination therapy (common protocols):
- "B52" (for severe agitation): Haloperidol 5 mg + Lorazepam 2 mg + Diphenhydramine 50 mg (IM).
- "Ketamine + Midazolam" (for ExDS): Ketamine 4 mg/kg IM + Midazolam 2.5 mg IM (reduces emergence reactions).

Contraindications:
- Ketamine: Avoid in schizophrenia (can worsen psychosis).
- Haloperidol: Avoid in Parkinson’s (worsens EPS) or QTc >500 ms.
- Benzodiazepines: Avoid in COPD (respiratory depression risk).

3. Suicide Risk Assessment

Definition: A structured evaluation to determine imminent risk of self-harm and guide intervention (e.g., hospitalization, safety planning).

Key components (use the "SAD PERSONS" mnemonic):
- Sex (male = higher risk) - Age (<19 or >45) - Depression (or hopelessness) - Previous attempt (strongest predictor) - Ethanol/drug use - Rational thinking loss (psychosis, delirium) - Social support lacking - Organized plan (specific method, time, means) - No spouse/partner - Sickness (chronic illness)

Assessment tools:
1. Columbia-Suicide Severity Rating Scale (C-SSRS) (gold standard):
- Asks about ideation, intent, plan, and behavior.
- Example questions:
- "Have you wished you were dead or wished you could go to sleep and not wake up?"
- "Have you had thoughts of killing yourself?"
- "Have you done anything to prepare to kill yourself?" 2. Patient Health Questionnaire-9 (PHQ-9) (Item 9 screens for suicidal ideation).

Risk stratification:
| Risk Level | Criteria | Action | |---------------|---------------------------------------|----------------------------------------------------------------------------| | Low | Ideation without plan/intent | Safety plan + outpatient follow-up. | | Moderate | Ideation + plan but no intent | Crisis intervention + possible voluntary hospitalization. | | High | Ideation + plan + intent + means | Involuntary hold (if necessary) + immediate psychiatric evaluation. | | Imminent | Active attempt or clear imminent risk | 1:1 observation + restraints if needed + emergency psychiatric consult. |

Legal considerations:
- Duty to warn: If patient names a specific target (e.g., "I’ll kill my boss"), you must report to authorities.
- Involuntary hold: Laws vary by state (e.g., 72-hour hold in California). Document clear, objective evidence of danger.

How It Works (Workflow)

1. Excited Delirium Management

1. Scene safety: Ensure law enforcement backup if patient is violent.
2. Rapid assessment:
3. Check vitals (HR, BP, temp, SpO₂, glucose).
4. Rule out medical causes (e.g., hypoglycemia, hypoxia).
5. De-escalation (if possible):
6. Use calm, non-threatening language.
7. Avoid physical restraint unless absolutely necessary (increases risk of death).
8. Chemical restraint:
9. First-line: Midazolam 5 mg IM or Ketamine 4 mg/kg IM.
10. Second-line: Haloperidol 5–10 mg IM + Lorazepam 2 mg IM.
11. Monitoring:
12. Continuous cardiac monitoring (risk of arrhythmias).
13. Cooling measures if hyperthermic (ice packs, IV fluids).
14. Check for rhabdomyolysis (CK, urine myoglobin).

2. Suicide Risk Assessment

1. Establish rapport: Use open-ended questions (e.g., "Tell me what’s been going on.").
2. Screen for risk factors:
3. Past attempts? (Most predictive factor.)
4. Current plan? (Method, time, access to means.)
5. Protective factors? (Family, job, religious beliefs.)
6. Use a tool: C-SSRS or PHQ-9.
7. Stratify risk: Low/moderate/high/imminent.
8. Intervene:
9. Low/moderate: Safety plan + outpatient follow-up.
10. High/imminent: 1:1 observation + psychiatric consult + possible involuntary hold.

Hands-On / Getting Started

Prerequisites

• Knowledge: Basic pharmacology (benzodiazepines, antipsychotics, ketamine).
• Skills: IV/IM injection, vital sign assessment, de-escalation techniques.
• Equipment:
• For chemical restraint: Midazolam, haloperidol, ketamine, syringes, tourniquet.
• For monitoring: Cardiac monitor, pulse oximeter, thermometer, glucometer.

Step-by-Step: Managing Excited Delirium

Scenario: A 30-year-old male presents to the ED combative, hyperthermic (39°C), and tachycardic (HR 140). He is sweating, paranoid, and resistant to staff. EMS reports he was found naked in the street, screaming about "government tracking devices."

1. Ensure safety:
2. Call security/law enforcement if patient is violent.
3. Remove potential weapons (e.g., IV poles, scissors).
4. Rapid medical assessment:
5. Check glucose (rule out hypoglycemia).
6. Check SpO₂ (rule out hypoxia).
7. Check temperature (confirm hyperthermia).
8. Administer chemical restraint:
9. Option 1 (if IV access): Midazolam 5 mg IV + Haloperidol 5 mg IV.
10. Option 2 (if no IV access): Ketamine 4 mg/kg IM (e.g., 300 mg for 75 kg patient).
11. Monitor closely:
12. Continuous cardiac monitoring (risk of arrhythmias).
13. Cooling measures (ice packs to groin/axilla, IV fluids).
14. Check CK (for rhabdomyolysis).
15. Disposition:
16. Admit to ICU if hyperthermic, tachycardic, or rhabdomyolysis present.
17. Psychiatric evaluation once medically stable.

Step-by-Step: Suicide Risk Assessment

Scenario: A 25-year-old female presents to the ED after overdosing on acetaminophen. She is tearful, withdrawn, and states, "I just want to die."

1. Establish rapport:
2. "I’m really glad you’re here. Can you tell me more about what’s been going on?"
3. Screen for risk factors:
4. Past attempts? "Have you ever tried to hurt yourself before?" (Yes, she cut herself 2 years ago.)
5. Current plan? "Do you have a plan for how you’d do it?" (She has a bottle of pills at home.)
6. Protective factors? "Is there anyone you can call for support?" (She lives alone and has no close friends.)
7. Use C-SSRS:
8. "Have you had thoughts of killing yourself in the past month?" (Yes.)
9. "Have you done anything to prepare?" (She wrote a note and hid the pills.)
10. Stratify risk:
11. High risk (ideation + plan + intent + means).
12. Intervene:
13. 1:1 observation (prevent access to means).
14. Psychiatric consult for possible involuntary hold.
15. Safety plan: Remove pills, provide crisis hotline number.

Common Pitfalls & Mistakes

Excited Delirium

1. Delaying chemical restraint:
2. Mistake: Trying to "talk down" a patient in ExDS for too long.

3. Fix: If patient is hyperthermic, combative, or tachycardic, administer ketamine or midazolam IM within 5 minutes.

4. Using physical restraint alone:

5. Mistake: Relying only on prone restraint or hog-tying (increases risk of positional asphyxia).

6. Fix: Chemical restraint first, then physical if needed (supine, not prone).

7. Ignoring hyperthermia:

8. Mistake: Focusing only on agitation without checking temperature.
9. Fix: Cool immediately (ice packs, IV fluids) if temp >38°C.

Chemical Restraint

1. Over-sedating with benzodiazepines:
2. Mistake: Giving lorazepam 4 mg IV to a frail elderly patient.

3. Fix: Start low (1 mg IV), go slow, and monitor for respiratory depression.

4. Using haloperidol in cardiac patients:

5. Mistake: Giving haloperidol to a patient with QTc 480 ms.
6. Fix: Check ECG first; avoid if QTc >500 ms.

Suicide Risk Assessment

1. Assuming low risk because patient is "just attention-seeking":
2. Mistake: Discharging a patient who overdosed "for attention."

3. Fix: All suicide attempts require psychiatric evaluation, regardless of intent.

4. Not asking about access to means:

5. Mistake: Failing to ask, "Do you have a gun at home?"

6. Fix: Always ask about access to lethal means (guns, pills, ropes).

7. Relying on "no-suicide contracts":

8. Mistake: Having patient sign a verbal contract ("Promise you won’t hurt yourself").
9. Fix: Contracts are not evidence-based; use structured tools (C-SSRS) and safety plans instead.

Best Practices

Excited Delirium

✅ Treat as a medical emergency (not just a psychiatric issue).
✅ Use ketamine first for severe ExDS (rapid onset, preserves respiratory drive).
✅ Monitor for rhabdomyolysis (check CK, urine myoglobin).
✅ Avoid prone restraint (increases risk of sudden death).

Chemical Restraint

✅ Start with IM if no IV access (midazolam or ketamine).
✅ Combine agents (e.g., haloperidol + lorazepam) for synergistic effect.
✅ Have naloxone ready if using benzodiazepines/opioids.
✅ Document justification (e.g., "Patient was combative, threatening staff, and unable to be safely assessed").

Suicide Risk Assessment

✅ Use a structured tool (C-SSRS or PHQ-9).
✅ Ask directly about suicide (e.g., "Are you thinking about killing yourself?").
✅ Assess for protective factors (e.g., family support, religious beliefs).
✅ Document thoroughly (e.g., "Patient denies current plan but has access to firearms at home").

Tools & Frameworks