Code Gray

The agitated patient is screaming, the nurse wants you to do something, and you have about 90 seconds before this gets physical. What do you do first? What do you do last? And what happens when the patient wakes up?

A 42-year-old man is brought to the ED by police after being found yelling at traffic. He is pacing, sweating, pupils dilated, HR 118, BP 148/92. He refuses to sit down and is clenching his fists. Verbal de-escalation has failed. He swings at a technician. After physical restraint and IM lorazepam 2 mg, what is the correct next step?
The restraint and sedation bought you time, not answers. You still do not know WHY this patient is agitated. Think of it like putting out a fire and then looking for the gas leak. Could be stimulant intoxication, psychosis, delirium, mania, or a medical emergency. Once the patient is calm enough to talk, reassess: What caused this? Can this patient make decisions? Keeping someone restrained indefinitely without reassessment violates patient rights. Calling police is not a medical decision. Involuntary admission requires a formal capacity assessment first. Restrain, sedate, reassess. In that order.

The De-escalation Ladder

Every step is a last resort for the step above it. You climb the ladder only when the rung below fails. The goal is always to get back down.

STEP 1
Verbal De-escalation
First. Always first. Low voice, open posture, stand at an angle (not face-to-face). Offer choices: "Would you like water or to sit down?" Acknowledge the emotion: "I can see you are upset." Never challenge, never threaten, never corner.
A patient is pacing and shouting "Get away from me!" Which verbal approach is most appropriate?
STEP 2
Voluntary Oral Medication
If talking alone is not working, offer oral medication: "I have something that will help you feel calmer. Would you like to try it?" Oral lorazepam (1-2 mg) or oral olanzapine (5-10 mg). Patient keeps autonomy. Still no force.
The patient refuses the oral medication and says "I don't trust pills." Verbal de-escalation is still failing. What is the next appropriate step?
STEP 3
Chemical Sedation (IM)
When the patient is a danger and refuses oral meds. IM lorazepam, IM haloperidol, IM olanzapine, or IM ketamine. Combination of haloperidol + lorazepam is the classic "B52" cocktail (Benadryl 50 + haloperidol 5 + lorazepam 2). Monitor airway, vitals, pulse ox.
You give IM haloperidol. Twenty minutes later the patient has a rigid neck, eyes rolling upward, and jaw locked open. What happened?
STEP 4
Physical Restraint
Absolute last resort. 4-point leather restraints with the patient supine. Check circulation and range of motion every 15 minutes. Physician must evaluate within 1 hour and renew the order every 4 hours. Remove restraints as soon as safely possible. Never restrain prone (risk of positional asphyxia).
A restrained patient has been calm for the last 2 hours. The nurse asks if they can remove the restraints. What is the correct answer?
The Ladder Rule: Verbal first. Meds second. Force last. Document every step. The goal is always to step back down the ladder as soon as possible.
Board Trap: "Keep the patient restrained until a court order is obtained" sounds reasonable but is wrong. Restraints are emergency measures, not legal holds. Remove them the moment the danger resolves. Court orders are for involuntary commitment, not for keeping someone tied to a bed.

After the Storm

The patient is calm. Now the real medicine starts: why were they agitated, and what happens next?

Common Causes of Acute Agitation

Substance Intoxication
Stimulants (cocaine, meth, bath salts): dilated pupils, tachycardia, hypertension, diaphoresis, psychomotor agitation.
PCP: vertical nystagmus, superhuman strength, aggression, analgesia.
Alcohol withdrawal: tremor, tachycardia, seizures, visual hallucinations (DTs).
Acute Psychosis
Auditory hallucinations, paranoid delusions, disorganized speech. Often younger patients (schizophrenia onset 18-25). Command hallucinations are the most dangerous: "The voice told me to hurt them."
Mania
Grandiosity, pressured speech, decreased need for sleep, reckless behavior, flight of ideas. Key: manic patients are irritable more often than euphoric in the ED.
Delirium
Waxing and waning consciousness is the hallmark. Acute onset, inattention, disorganized thinking. Always look for the medical cause: infection, metabolic, medications, hypoxia. Especially in elderly patients.
Tap: STAMP the cause S = Stimulants · T = Thought disorder (psychosis) · A = Affective (mania) · M = Medical (delirium) · P = Personality/other. Always rule out Medical before calling it Psych.

Flip the Villain: Cause & Management

Tap each card to reveal the management approach

💥
Stimulant Intoxication
Cocaine · Meth · Bath Salts · PCP
Stimulant Agitation

Clues: Dilated pupils, tachycardia, diaphoresis, hypertension, psychomotor agitation. PCP adds vertical nystagmus and analgesia.

Danger: Seizure risk, hyperthermia, rhabdomyolysis if restrained while fighting.

Rx: IM lorazepam (benzo first line). Treat sympathetic overdrive. Do NOT use haloperidol alone for stimulants (lowers seizure threshold).
😵
Acute Psychosis
Schizophrenia · First-break · Command hallucinations
Psychotic Agitation

Clues: Auditory hallucinations, paranoid delusions, disorganized speech. Often 18-25 year olds. Command hallucinations are the highest-risk clue.

Danger: Patient may be responding to voices instructing harm to self or others.

Rx: IM haloperidol or IM olanzapine. Benzos can augment (but never IM olanzapine + IM benzo). Admit for stabilization.
🤔
Delirium
Waxing & waning · Medical emergency
Delirious Agitation

Clues: Acute onset, waxing and waning consciousness, inattention, disorganized thinking. Visual hallucinations. Often elderly with medical trigger.

Danger: The agitation is the symptom. The real threat is the underlying cause (sepsis, hypoxia, metabolic, meds).

Rx: Treat the CAUSE first. Low-dose haloperidol for acute agitation. Avoid benzos (worsen delirium). Non-pharmacologic reorientation.
⚡
Mania
Bipolar · Irritable > euphoric in ED
Manic Agitation

Clues: Pressured speech, grandiosity, decreased sleep, flight of ideas. Key board fact: in the ED, manic patients are irritable more often than euphoric.

Danger: Impulsive self-harm, risky behavior, insight lacking.

Rx: IM olanzapine or IM haloperidol for acute agitation. Long-term: mood stabilizer (lithium, valproate). Safety evaluation for danger.
💊
Hypoglycemia
Classic "altered drunk" · Check glucose first
Metabolic Agitation

Clues: Diaphoresis, tachycardia, altered behavior, confusion. Patient may smell of alcohol or seem intoxicated. Glucose <60 mg/dL confirms it.

Danger: If untreated for minutes: seizures, brain injury, death. Fastest cause to fix.

Rx: Dextrose IV (D50 in adults, D10 in pediatrics). If no IV access: glucagon IM. Recheck glucose. Find the cause of the hypoglycemia.
🍸
Alcohol Withdrawal
DTs · Seizures · Timeline matters
Withdrawal Agitation

Clues: Tremor, diaphoresis, tachycardia, hypertension. Timeline: 6-24h minor; 24-72h seizures; 48-96h delirium tremens (DTs) with visual hallucinations.

Danger: DTs are life-threatening without treatment. Seizures can be fatal.

Rx: IV/PO benzodiazepines (lorazepam or diazepam), CIWA protocol. Thiamine BEFORE glucose (Wernicke prevention). Monitor closely.
Tap: Remember B52 B52 = Benadryl 50 mg + Haldol 5 mg + Ativan 2 mg. The Benadryl blocks Haldol's dystonia side effect. NEVER sub IM olanzapine for Haldol here. IM olanzapine + IM benzo = respiratory collapse.

Clinical Findings Gallery

Tap any image to enlarge

Leather wrist restraint
Physical Restraint Device
Akathisia motor restlessness
Akathisia (Antipsychotic SE)
Haloperidol medication
Haloperidol (Haldol)
Delirium illustration
Delirium: Waxing & Waning
Tap: Capacity = CUAR Communicate choice · Understand the diagnosis/treatment · Appreciate how it applies to them · Reason through risks and benefits. All 4 required. Not just "stating what you want."

Capacity Assessment: The 4 Criteria

A patient has decision-making capacity if they can do all four:

C
Communicate
Can clearly state a choice and maintain it consistently
U
Understand
Comprehends the diagnosis, proposed treatment, and alternatives
A
Appreciate
Recognizes how the information applies to their own situation
R
Reason
Can weigh risks and benefits and explain their reasoning
Capacity is decision-specific and time-specific. A patient who lacks capacity at 2 AM while intoxicated may have full capacity at 8 AM when sober. Always reassess. Capacity is NOT the same as competency (which is a legal determination by a judge).

Chemical Restraint Options

IM Lorazepam
BENZODIAZEPINE
Dose: 1-2 mg IM. Onset: 15-30 min.
Best for: Alcohol/benzo withdrawal, stimulant agitation, seizure risk
Watch for: respiratory depression, paradoxical agitation in elderly
IM Haloperidol
TYPICAL ANTIPSYCHOTIC
Dose: 5 mg IM. Onset: 20-40 min.
Best for: Psychotic agitation, delirium
Watch for: acute dystonia, QTc prolongation, NMS
IM Olanzapine
ATYPICAL ANTIPSYCHOTIC
Dose: 10 mg IM. Onset: 15-30 min.
Best for: Psychosis, mania, undifferentiated agitation
Do NOT combine with IM benzodiazepines (hypotension/respiratory depression risk)
IM Ketamine
DISSOCIATIVE ANESTHETIC
Dose: 4 mg/kg IM. Onset: 3-5 min.
Best for: Extreme agitation, excited delirium, need for rapid sedation
Watch for: laryngospasm, emergence reactions, increased secretions
Board Trap: IM olanzapine + IM lorazepam given together can cause fatal respiratory depression and hypotension. If you need an antipsychotic + benzo combo, use the "B52": Benadryl 50 mg + Haldol 5 mg + Ativan 2 mg (diphenhydramine + haloperidol + lorazepam). The Benadryl prevents dystonia from the Haldol. Never olanzapine + lorazepam. This is a tested question.

Admit or Discharge?

The sedation has worn off. The patient is awake. Now what? Walk through the decision tree, then eliminate premature actions in the game below.

The previously agitated patient is now alert and calm. First question: Is there an underlying medical cause?
Medical cause found (e.g., infection, hypoglycemia, drug toxicity). After treating the medical issue, is the agitation resolved?
No medical cause. Does the patient have decision-making capacity right now?
Patient has capacity. Are they still a danger to self, danger to others, or gravely disabled?
Patient lacks capacity. Is the lack of capacity reversible (e.g., intoxication wearing off)?
Treat and discharge

Medical cause resolved the agitation. Treat the medical issue (antibiotics, glucose, naloxone, etc.), reassess capacity, and discharge with follow-up. No psychiatric hold needed.

Medical admission + psych consult

Medical issue is being treated but the agitation/danger persists. Admit to medicine with a psychiatry consult. Psychiatric hold may be needed if the patient meets criteria (danger to self/others/gravely disabled).

Discharge with safety plan

Patient has capacity, is no longer dangerous, and is not gravely disabled. You cannot hold them against their will. Offer outpatient follow-up, crisis resources, and a safety plan. Document the capacity assessment thoroughly.

Tarasoff duty: warn the identified target

When a patient with capacity makes a credible threat against an identifiable person, you have a duty to warn that specific person and notify law enforcement. This overrides confidentiality. Also initiate involuntary hold if the patient meets danger criteria. Document everything.

Involuntary psychiatric hold

Patient meets criteria: danger to self, danger to others, or gravely disabled. Initiate involuntary hold (varies by state: 5150 in CA, 302 in PA). Requires physician certification. Patient has the right to a hearing within 72 hours.

Hold and reassess when sober

If intoxication is the cause, hold the patient until they are sober and reassess capacity and dangerousness. Many patients are safe to discharge once the intoxication clears. Do not make permanent decisions (involuntary admission) based on temporary impairment.

Involuntary hold + guardian/surrogate decision-making

Chronic incapacity (severe schizophrenia, advanced dementia) requires a surrogate decision-maker. If there is no healthcare proxy, pursue court-appointed guardian. Involuntary hold if the patient meets danger criteria. Long-term planning with social work.

Tap: Tarasoff rule Specific threat + identifiable victim = duty to WARN that person AND notify police. Confidentiality ends here. Having capacity makes the threat MORE credible, not less. Document everything.
Tap: 3 criteria for involuntary hold Danger to SELF · Danger to OTHERS · Gravely disabled (cannot meet basic needs of food, clothing, shelter due to psychiatric illness). ALL three count. Violence is not required.

Elimination Round

The patient received IM lorazepam and is now sleeping. Eliminate the premature or incorrect actions one by one.

A 36-year-old woman was brought in agitated, demanding to see a doctor, with dilated pupils and HR 112. She threatened a nurse. Verbal de-escalation failed. She was physically restrained and given IM lorazepam. She is now sedated and sleeping.
Start involuntary admission
PREMATURE?
Notify police
PREMATURE?
Keep restrained until court order
PREMATURE?
Wait, then reassess
CORRECT STEP?
Round 1: This patient was sedated 10 minutes ago and has not been evaluated for underlying cause. Which action is MOST premature right now?
Correct answer: Wait for sedation to wear off, then reassess. You cannot make disposition decisions while the patient is sedated. The cause of agitation determines the plan. If it was stimulant intoxication, the patient may be safe to discharge once sober. If it was psychosis, they may need admission. Involuntary holds, police notification, and prolonged restraint are all premature without a post-sedation evaluation and capacity assessment.

The Quiz

5 agitated patients just rolled into your ED. De-escalate, medicate, and disposition correctly.

Bone Wizardry · Psychiatry / Agitated Patient