Behavioral and Psychiatric Emergencies: Suicide Risk, Psychosis and Medical Clearance

A behavioral emergency is an acute change in behavior that puts the patient, bystanders or staff at risk. Think severe agitation, aggression, suicidal behavior, psychosis, or behavior caused by a medical or toxic process. The DSM-5-TR splits it in two. Delirium is a disturbance of attention and awareness. It builds over hours to days, and it fluctuates. Psychotic disorders bring hallucinations or delusions, with attention and orientation largely intact. Delirium is a medical finding until proven otherwise.

Severe agitation is a hyperadrenergic state, and it is dangerous. Catecholamines keep flowing and the muscles keep working. Keep that up and you can get hyperthermia, rhabdomyolysis, acidosis and arrhythmia. The risk rises the longer the episode lasts (ACEP 2021 task force). So sedation protects the patient and the team. It does not treat the psychiatric diagnosis. For the sedation pathway in more depth, see severe agitation.

• Primary psychiatric: schizophrenia, bipolar mania, major depression with suicidal thinking, substance-induced psychosis.
• Medical: hypoglycemia, hypoxia, infection, stroke or other CNS lesion, head injury, eclampsia, thyroid storm, and seizure activity including non-convulsive status.
• Toxic and withdrawal: sympathomimetics, anticholinergics, serotonergic drugs, phencyclidine, alcohol and benzodiazepine withdrawal, and opioid toxicity.

Typical Presentations

• Psychosis: hallucinations or delusions, disorganized speech, fear or paranoia. Usually, orientation and attention hold up.
• Delirium: inattention, disorganized thinking, altered level of alertness that fluctuates over hours. Orientation often slips.
• Suicidal behavior: a wish to die, a plan, access to means, a recent attempt, or intoxication that lowers inhibition.
• Severe agitation: shouting, combative or fleeing behavior, high motor activity, sweating and tachycardia. Delirium is often mixed in.

Red Flags

• Breathing: SpO₂ below 90%, rising EtCO₂, or sedation with shallow breathing.
• Glucose: below 70 mg/dL (3.9 mmol/L), or not measured in an altered patient.
• Temperature: fever or rising temperature with rigidity, clonus or confusion (neuroleptic malignant syndrome, serotonin toxicity, sepsis).
• Heart: QTc over 500 ms on the 12-lead ECG, torsades, hypotension, or an irregular rhythm. Droperidol and ziprasidone have stricter limits (see ALS Management).
• Consciousness: comatose, or not responding to voice after sedation.

Manage the danger and rule out medical causes at the same time. The checks below take minutes. What they show can change the drug you pick.

Suicide Screening

• ASQ (Ask Suicide-Screening Questions): Four brief questions, about 20 seconds. NIMH describes it as validated for youth and adults, designed for ages 8 and up. The Joint Commission approves it for all ages. Under age 8, no screening tool is validated. A full mental health evaluation is recommended instead.
• C-SSRS (Columbia Suicide Severity Rating Scale): A structured risk assessment. It covers the wish to be dead, suicidal thoughts, method, intent, plan and recent behavior. Use the version your protocol names.
• Means and safety: Ask about firearms, medications and other means at home. Where possible, remove the means or lock them away, and document the removal. Involve family or a caregiver with the patient's consent. A written safety plan goes with the patient to the next provider.
• 988 Suicide & Crisis Lifeline: Call or text 988 (US) for crisis counseling and a warm handoff. That includes patients being discharged or waiting for a bed. 988lifeline.org
• Action: A positive ASQ needs a clinician suicide risk assessment before the patient leaves the provider's care. Recent behavior, a plan or access to means calls for immediate safety measures, per protocol.

Medical clearance means the work-up is finished, and nothing medical that needs treatment or admission turned up. The history and exam set which tests you run, per local protocol. The ED work-up and the risk-assessment tools for suicidal ideation are covered in ACEP's 2017 clinical policy on the adult psychiatric patient in the emergency department.

• Delirium vs. psychosis: Check attention (count backward from 20) and level of alertness. Fluctuating attention points to delirium. Clear attention with false beliefs favors psychosis, but only after medical causes are excluded.
• Serotonin toxicity vs. neuroleptic malignant syndrome: Serotonin toxicity hits abruptly, with clonus and hyperreflexia after a serotonergic drug. NMS builds over days after a dopamine-blocking drug, and it causes lead-pipe rigidity.
• Anticholinergic toxicity: dry skin, mydriasis, urinary retention, tachycardia and visual hallucinations. See toxidromes.
• Sympathomimetic or stimulant intoxication: Cocaine and methamphetamine bring hypertension, tachycardia, hyperthermia and high-energy agitation. With hyperthermia, hypertension, tachycardia or chest pain, reach for a benzodiazepine first, plus active cooling. See toxidromes. Antipsychotics come second. They lower the seizure threshold, impair heat loss and prolong QT. Check the QTc and temperature first.
• Catatonia: mutism, staring, posturing, waxy flexibility or negativism. Benzodiazepines are the first treatment. Antipsychotics can worsen catatonia and raise the risk of neuroleptic malignant syndrome. Avoid them until the diagnosis is clear.
• Postpartum psychosis: Confusion, agitation or psychosis in the weeks after delivery is a medical emergency. Keep it that way until eclampsia, sepsis, hemorrhage, and thyroid or other medical causes are excluded.
• Hallucinogen and synthetic cannabinoid intoxication: agitation, psychosis, tachycardia, hyperthermia and seizures. Benzodiazepines and supportive care treat the symptoms, per protocol.
• Hypoglycemia and hypoxia: Both cause confusion and agitation. Correct them first. See hypoglycemia.
• Opioid toxicity: A sedated, obtunded patient with small pupils and slow breathing needs naloxone. Not more sedation. See opioid overdose.

Scene safety comes first. When violence is present, call law enforcement, per local protocol. Don't walk up on a patient who is about to hurt someone.

1. Keep an exit and a safe distance: one calm speaker, low voice, no sudden movement. Reduce crowding and stimulation.
2. Use verbal de-escalation first: calm, respectful speech, a quiet space, water or basic needs when that is safe, and the same speaker throughout. ACEP 2021 says try de-escalation first when it is feasible. It does not replace force or sedation when the danger is immediate.
3. Look for medical causes: airway, breathing, pulse, temperature and blood glucose if your protocol allows it. Ask about drugs, alcohol, insulin, seizures and injury.
4. Give oxygen to keep SpO₂ at the protocol target, and assist breathing if it is shallow.
5. Protect from self-harm: remove weapons and sharps from reach. Ask about access to means at home. If suicidal intent is voiced, keep the patient in view.
6. Restrain only as a last resort: use the least restrictive method for the shortest time, and never leave the patient face-down. Restraint carries a risk of positional asphyxia. Continuous monitoring is required, and sedation is the next step.
7. Bring the patient's own medicines and any written safety plan to the ED.
8. Document the behavior, time, what calmed or triggered the patient, any assessment of decision-making ability, and any force used.

Doses vary by protocol; follow local protocols and medical direction. ACEP's 2024 clinical policy covers adults with severe agitation in out-of-hospital and ED settings. Your protocol picks the field agent. The doses below follow the product labels and the ACEP 2021 task force report. Sedation pathway detail is in severe agitation. Everything below is above BLS scope.

• IV or IO access (Paramedic/RN/CCT): Establish access before any sedative combination. Then a second drug can go in without delay.
• Monitor and 12-lead ECG (Paramedic/RN/CCT): continuous SpO₂, EtCO₂ and rhythm, and a QTc before any QT-prolonging drug. Droperidol and ziprasidone come with stricter label limits (see Special Populations).
• Glucose and thiamine (Paramedic/RN/CCT): dextrose 10 g IV (D10 100 mL) if glucose is below 70 mg/dL (dextrose). When alcohol use is suspected, give thiamine IV, dose per protocol; do not delay dextrose for thiamine.
• Benzodiazepine first for withdrawal, seizure, or sympathomimetic toxicity (Paramedic/RN/CCT): Dose by symptoms, per protocol. Lorazepam or diazepam are the first choices in alcohol withdrawal, per the ASAM 2020 guideline.
• Haloperidol 2–5 mg IM, 5 mg typical (Paramedic/RN/CCT): the labeled agitation range is 2–5 mg IM, repeated no sooner than hourly, with a label maximum of 20 mg/day. Reassess sedation at 15 minutes before any repeat dose. Adding lorazepam 2 mg IV or IM is a protocol choice. The haloperidol label does not address it. IV use is not labeled for agitation. The label also ties IV administration to higher QTc and torsades risk. It is contraindicated in Parkinson disease and dementia with Lewy bodies. See haloperidol.
• Droperidol (ED use per protocol; field use only if your protocol authorizes it): the label's maximum initial dose is 2.5 mg IM or slow IV, with 1.25 mg additional doses only if needed. The labeled indication is perioperative nausea and vomiting, so agitation use is off-label. The 5–10 mg doses in the ED agitation literature (cited in the ACEP 2021 task force report) sit above the label. Get a 12-lead ECG first. The label contraindicates droperidol when the QTc is over 440 ms in men or 450 ms in women. Other label risk factors include bradycardia, hypokalemia, hypomagnesemia, alcohol abuse, age over 65, and other QT-prolonging drugs including benzodiazepines and IV opioids. Monitor the ECG for 2–3 hours after the dose. The boxed warning reserves it for patients who did not respond to other treatments. See droperidol.
• Olanzapine 10 mg IM (Paramedic/RN/CCT): This is the label dose. The label also allows 5 or 7.5 mg when clinically warranted, 5 mg for geriatric patients, and 2.5 mg for debilitated patients or those prone to hypotension. The label does not evaluate injections given sooner than 2 hours after the first dose, or sooner than 4 hours after the second. It also does not evaluate total daily doses above 30 mg. Check orthostatic BP before any repeat. See olanzapine.
• Ziprasidone 10–20 mg IM (Paramedic/RN/CCT): Labeled for acute agitation in schizophrenia. 10 mg may repeat every 2 hours and 20 mg every 4 hours, with a maximum of 40 mg/day. Use beyond three consecutive days has not been studied. It is contraindicated with known QT prolongation, recent acute MI, uncompensated heart failure, or other QT-prolonging drugs. Get a baseline ECG and correct potassium and magnesium first. See ziprasidone.
• Midazolam 5 mg IM (Paramedic/RN/CCT, off-label for agitation): The ED agitation literature and the ACEP 2021 task force report use 5–10 mg IM. Capnography and airway equipment are required. Pairing it with an antipsychotic is a protocol decision, made after a QTc check. See midazolam.
• Ketamine about 4 mg/kg IM (Paramedic/RN/CCT, when safety requires): ACEP 2021 reports the fastest and most reliable sedation at about 4 mg/kg IM. Regimens of 2–5 mg/kg are reported too. Protocols set the dose and an absolute maximum. Expect dissociation, and plan the airway. ACEP 2021 cites laryngospasm in about 1.3% and hypersalivation in about 19% after ketamine in a systematic review. Some patients need intubation. Have suction and airway equipment ready. IV use is protocol-dependent. See ketamine.
• Naloxone for opioid toxicity (Paramedic/RN/CCT): 0.2–2 mg IV, IO or IM, or 2–4 mg IN, every 2–3 minutes, titrated to breathing. Ventilate first. See naloxone.
• Acute dystonia after an antipsychotic (Paramedic/RN/CCT): benztropine 1–2 mg IV or IM per protocol, or diphenhydramine 10–50 mg IV or deep IM (label; up to 100 mg if required; maximum 400 mg/day).

Once sedation is on board, the work-up keeps going. Find the cause, treat it, then decide where the patient goes.

• Labs and imaging: glucose, electrolytes, renal function, CBC, ethanol and toxicology as the history indicates; CK when rhabdomyolysis is suspected; pregnancy test in females of reproductive age. Imaging for head injury, focal signs or fever with neck stiffness (lumbar puncture per the treating team).
• Persistent confusion after sedation: Consider non-convulsive status epilepticus (EEG) and drug effect before you attribute it to a psychiatric cause.
• Airway loss: Sedation that causes hypoventilation or aspiration risk needs airway support. If the airway cannot be protected, use rapid sequence intubation.
• Psychiatric consult and holds: Start early. State law sets the involuntary hold criteria and forms. Document the danger behind the hold, and follow local protocol and policy.
• Boarding: Reassess suicide risk and sedation at every handoff. Hospital policy sets the observation level and the safe-room standard.
• ICU delirium: Treat the cause first. Reserve antipsychotics for distress or danger, per ICU protocol. See analgosedation.

• Destination: Suspected medical cause? The ED comes first. A patient whose medical work-up is complete and who needs psychiatric care goes where local protocol directs, which may be a psychiatric emergency service.
• Monitoring: continuous SpO₂ and EtCO₂ after any sedative, and continuous rhythm monitoring when a QT-prolonging drug was given. Recheck blood pressure after olanzapine or ziprasidone (orthostatic drop).
• Restraint in the vehicle: two crew members or more, continuous observation, never face-down. If restraint is going to last more than a short time, sedation is the next step.
• Handoff: the time and dose of every sedative, glucose, the QTc, the suicide screen result, weapons and means found, the medical work-up results, and any hold.
• Crew safety: search the patient for weapons and keep an exit clear. When a threat cannot be controlled, stop and request law enforcement, per protocol.

• Pediatrics: The ACEP 2024 policy covers adults only. Pediatric agents and doses are protocol-only, with weight-based dosing and an adult cap (see weight-based dosing and pediatric vital signs). ASQ is designed for ages 8 and up. Under 8, a full mental health evaluation is the route. Ketamine for severe agitation in children is for online medical direction or specialist use only (see ketamine).
• Pregnancy: The ACEP 2024 policy covers adults only. Treat the medical causes first, eclampsia included, and postpartum hemorrhage or sepsis in the weeks after delivery. Drug choice is a risk-benefit call, made with medical direction. Haloperidol labeling notes extrapyramidal and withdrawal symptoms in neonates exposed late in pregnancy. Describe risk in narrative terms, not letter categories.
• Lactation: Antipsychotics and benzodiazepines pass into breast milk. Decide with medical direction, and document the choice.
• Older Adults: use the lower labeled doses: olanzapine 5 mg IM for geriatric patients, and reduced doses of other agents per protocol. Expect lower totals. Orthostatic hypotension and falls are more likely. Age over 65 is also a QT risk factor for droperidol. Antipsychotic boxed warnings cover increased mortality in dementia-related psychosis.
• Renal Impairment: Use IM ziprasidone with caution in impaired renal function. Its cyclodextrin excipient is cleared by renal filtration (label).
• Hepatic Impairment: When liver disease limits other benzodiazepines, lorazepam is often chosen (see lorazepam).
• Parkinson disease or dementia with Lewy bodies: haloperidol is contraindicated (label). Choose another agent per medical direction.
• Patients on QT-prolonging drugs or with long QT: Droperidol is contraindicated with a QTc over 440 ms in men or 450 ms in women, and with congenital long QT. Ziprasidone is contraindicated with known QT prolongation, recent MI, uncompensated heart failure, or other QT-prolonging drugs. Haloperidol carries a torsades warning, and the risk is higher with IV use. Check the QTc, and correct potassium and magnesium, before any antipsychotic.

• Error: Treating delirium as psychosis with an antipsychotic alone. Check glucose, SpO₂, temperature and toxins first. Reassess before a second dose.
• Error: Giving droperidol with no QTc, or treating 5–10 mg as the labeled dose. The label boxes it for QT prolongation and torsades. Its labeled initial dose is 2.5 mg IM or slow IV. Confirm the QTc first (contraindicated above 440 ms in men or 450 ms in women), and monitor for 2–3 hours.
• Error: Giving IM olanzapine with a parenteral benzodiazepine. The label says concomitant use is not recommended, because of cardiorespiratory depression. Use it only with medical direction, capnography and airway equipment. Or choose another agent.
• Error: Restraint without sedation. In severe agitation, ACEP 2021 cites an odds ratio of 7.4 for fatality with restraint. Sedate promptly, keep the patient out of the prone position, and monitor continuously.
• Error: Re-dosing without a reassessment. Reassess sedation at 15 minutes. Check orthostatic BP before any olanzapine repeat. Do not exceed 30 mg/day for olanzapine or 40 mg/day for ziprasidone.
• Error: Giving flumazenil to a patient on benzodiazepines, or in a mixed overdose. It can precipitate seizures and withdrawal (see flumazenil).
• Error: Calling the picture excited delirium. ACEP's 2021 task force notes the term is not a recognized DSM or ICD diagnosis. Use hyperactive delirium or severe agitation. Then describe the findings.
• Error: discharging an ASQ-positive patient without a documented clinician risk assessment.