Managing Psychiatric Emergencies

---
name: managing-psychiatric-emergencies
language: en
description: Guides acute psychiatric assessment including safety evaluation and involuntary hold criteria. Use when evaluating psychiatric emergencies, assessing suicidality, or initiating involuntary holds.
tags:
  - management
  - emergency-medicine
  - valuation
metadata:
  author: casemark
  practice_areas:
    - Emergency Medicine
  document_types:
    - Management Report
  skill_modes:
    - Management
    - Coordination
---

# Managing Psychiatric Emergencies

Guides acute psychiatric assessment in the emergency department, including structured suicide risk evaluation, agitation management, involuntary hold criteria, and medical clearance documentation.

## Why This Skill Exists

Psychiatric emergencies account for 12% of all ED visits and are increasing annually. These cases carry unique medicolegal risk: suicide within 72 hours of ED discharge is a leading cause of malpractice verdicts, with average payouts exceeding $1.5 million. Conversely, inappropriate involuntary detention exposes facilities to civil rights litigation. Emergency physicians must simultaneously manage medical clearance (ruling out organic causes of psychiatric symptoms), safety risk stratification, and disposition that balances patient autonomy with duty to protect.

Agitation management in the ED carries its own mortality risk—excited delirium, physical restraint-associated positional asphyxia, and oversedation can all result in patient death. Evidence-based de-escalation protocols reduce both patient harm and staff injury by 50-80%.

---

## Checkpoint A: Pre-Draft Intake (Mandatory)

1. What is the chief complaint (suicidal ideation, homicidal ideation, psychosis, agitation, altered mental status, substance intoxication)?
2. Has the patient been medically screened and cleared (vital signs, glucose, toxicology, basic labs)?
3. Is the patient currently agitated, and what is the severity (BARS or RASS scale)?
4. Is there active suicidal or homicidal ideation? If suicidal: does the patient have a plan, means, intent, and timeline?
5. What is the patient's psychiatric history (prior attempts, hospitalizations, diagnoses, medications)?
6. Is there substance use (acute intoxication, withdrawal, chronic use)?
7. Does the patient have capacity to make medical decisions?
8. Are collateral sources available (family, outpatient treater, prior records)?

### Documents to Request

- Previous psychiatric records and medication history
- Prior suicide attempt documentation
- Current outpatient treater contact information
- Toxicology screen results (urine drug screen, blood alcohol level)
- Medical clearance labs (BMP, CBC, TSH, urinalysis, pregnancy test)
- Prior involuntary hold documentation
- Safety plan from previous encounters
- Medication administration record (for patients on psychiatric medications)

---

## Step 1: Medical Clearance — Rule Out Organic Causes

Before attributing symptoms to a psychiatric etiology, exclude medical mimics:

| Organic Cause | Screening Test | Psychiatric Mimic |
|---|---|---|
| Hypoglycemia | Point-of-care glucose | Agitation, confusion, bizarre behavior |
| Thyroid storm/myxedema | TSH (if new presentation) | Mania, psychosis, depression, catatonia |
| Urinary tract infection | Urinalysis (elderly) | Delirium, paranoia, agitation |
| Intracranial pathology | CT head (new psychosis >40, focal neuro, headache, trauma) | Psychosis, personality change, catatonia |
| Substance intoxication | UDS, BAL, extended panel | Psychosis, mania, paranoia, hallucinations |
| Anticholinergic toxicity | Clinical (mydriasis, dry skin, urinary retention, tachycardia) | Agitation, visual hallucinations, delirium |
| Hepatic encephalopathy | Ammonia, LFTs | Confusion, personality change, asterixis |
| Serotonin syndrome | Clinical (clonus, hyperthermia, hyperreflexia, agitation) | Agitation, altered mental status |

**Red flags for organic etiology**: Age >40 with new-onset psychosis, vital sign abnormalities, focal neurologic findings, visual hallucinations (psychiatric hallucinations are more commonly auditory), fluctuating consciousness, and no prior psychiatric history.

---

## Step 2: Suicide Risk Assessment

### Columbia Suicide Severity Rating Scale (C-SSRS) Screening

1. Have you wished you were dead or wished you could go to sleep and not wake up? (Passive ideation)
2. Have you actually had any thoughts of killing yourself? (Active ideation)
3. Have you been thinking about how you might do this? (Method)
4. Have you had these thoughts and had some intention of acting on them? (Intent)
5. Have you started to work out or worked out the details of how to kill yourself? (Plan)
6. Have you ever done anything, started to do anything, or prepared to do anything to end your life? (Behavior—lifetime)

### Risk Stratification

| Risk Level | Features | Disposition |
|---|---|---|
| Low | Passive ideation without plan, strong protective factors, stable support, engaged in outpatient care | May discharge with safety plan, crisis line numbers, next-day follow-up confirmed |
| Moderate | Active ideation with vague plan, ambivalent intent, some protective factors, history of attempt >1 year ago | Psychiatric consultation, consider observation vs. voluntary admission |
| High | Active ideation with specific plan, stated intent, access to means, recent attempt, hopelessness, psychosis, substance intoxication | Involuntary hold if patient refuses voluntary; 1:1 observation, means restriction |
| Imminent | Active attempt in progress or just interrupted, command auditory hallucinations to harm self | Immediate safety interventions, 1:1, involuntary hold, likely inpatient admission |

### Protective Factors to Document

- Reasons for living (children, religious beliefs, future plans)
- Engaged outpatient treatment
- Social support
- Ability to contract for safety (limited evidence but commonly used)
- Absence of substance use

---

## Step 3: Agitation Management — De-Escalation First

### Verbal De-Escalation (STAMP Protocol)

1. **S**it down—reduce confrontational posture
2. **T**one—speak slowly, calmly, and at low volume
3. **A**cknowledge—validate the patient's distress without agreeing with delusions
4. **M**eet needs—offer food, water, phone call, blanket, pain management
5. **P**lan—explain what will happen next in simple terms

### Pharmacologic Management of Agitation

| Scenario | First-Line | Dose | Route | Caution |
|---|---|---|---|---|
| Undifferentiated agitation | Midazolam | 5 mg IM | IM preferred for speed | Respiratory depression risk |
| Known psychosis/schizophrenia | Olanzapine | 10 mg IM | IM | Do NOT combine with IM benzodiazepines (respiratory arrest risk) |
| Alcohol intoxication with agitation | Midazolam or haloperidol + diphenhydramine | 5 mg IM / 5 mg + 50 mg IM | IM | Haloperidol: check QTc, watch for dystonia |
| Stimulant intoxication (cocaine, meth) | Midazolam or lorazepam | 5-10 mg IM/IV | IM or IV | Benzodiazepines are first-line; avoid antipsychotics (may lower seizure threshold) |
| Excited delirium | Ketamine | 4-5 mg/kg IM | IM | Fastest sedation onset; prepare for intubation |

### Physical Restraint Documentation Requirements

If physical restraints are necessary:
1. Document behavior that necessitated restraints (threat to self or others, failed de-escalation)
2. Physician order with time and duration (must be renewed per state law, typically every 1-4 hours)
3. Continuous monitoring (vitals every 15 min, neurovascular checks, respiratory status)
4. Supine position with one arm up, one arm down (reduces positional asphyxia)
5. Never restrain prone
6. Reassess for restraint removal at each check

---

## Step 4: Involuntary Hold Criteria and Documentation

Requirements vary by state but generally require all three:

1. **Mental illness**: Documented psychiatric condition or substance-induced state
2. **Danger**: Imminent danger to self or others, or gravely disabled (unable to provide for basic needs)
3. **Least restrictive alternative**: Voluntary treatment was offered and refused, or patient lacks capacity to accept

Document with specificity: "Patient states 'I am going to jump off the parking garage tonight' [specific threat], has identified the location [plan], refused voluntary admission [least restrictive failed], and has a diagnosis of major depressive disorder with psychotic features [mental illness]. Patient meets criteria for involuntary psychiatric hold per [state statute]."

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## Step 5: Disposition and Safety Planning

### For Patients Being Discharged

1. Complete a written safety plan (Stanley-Brown Safety Planning Intervention):
   - Warning signs that a crisis is developing
   - Internal coping strategies
   - People and social settings that provide distraction
   - People to ask for help (names and numbers)
   - Professionals and agencies to contact (therapist, crisis line: 988)
   - Making the environment safe (lethal means counseling)
2. Document means restriction counseling (firearm storage, medication lock-up, bridge barriers)
3. Confirm next-day or within-48-hour follow-up appointment
4. Provide crisis resources: 988 Suicide and Crisis Lifeline, Crisis Text Line (text HOME to 741741)
5. Engage family/support person in safety plan if patient consents

---

## Checkpoint B: Post-Draft Alignment (Mandatory)

1. Has medical clearance adequately ruled out organic causes of psychiatric symptoms?
2. Is the suicide risk assessment documented with a validated tool (C-SSRS or equivalent)?
3. Is the disposition decision clearly supported by the risk stratification level?
4. For involuntary holds: are all three legal criteria documented with specificity?
5. For discharges: is a written safety plan completed and means counseling documented?

---

## Quality Audit

| # | Criterion | Pass/Fail |
|---|---|---|
| 1 | Medical screening exam completed with vital signs and glucose | |
| 2 | Organic causes of psychiatric symptoms systematically excluded | |
| 3 | Suicide risk assessed with validated tool and risk level documented | |
| 4 | Homicidal ideation specifically assessed and documented | |
| 5 | Agitation managed with de-escalation attempted before medications | |
| 6 | Chemical sedation medications, doses, and monitoring documented | |
| 7 | Physical restraint use documented with continuous monitoring | |
| 8 | Capacity assessment documented for patients refusing treatment | |
| 9 | Involuntary hold meets state-specific legal criteria with documentation | |
| 10 | Collateral information obtained from family/outpatient treaters | |
| 11 | Safety plan completed and provided for discharged patients | |
| 12 | Means restriction counseling documented | |
| 13 | Follow-up appointment confirmed before discharge | |
| 14 | Crisis resources provided (988, Crisis Text Line) | |

---

## Guidelines

1. **Medical clearance is not optional**—up to 10% of patients presenting with "psychiatric" complaints have an underlying organic etiology; new-onset psychosis over age 40 mandates neuroimaging
2. **Never combine IM olanzapine and IM benzodiazepines**—the combination has caused fatal cardiorespiratory arrest; wait at least 1 hour between administrations
3. **Suicidal patients should not be left alone** in the ED—1:1 observation, remove all potential ligature points and sharps from the room, provide a paper gown if necessary
4. **Lethal means counseling is the single most effective suicide prevention intervention** available in the ED—document it even for low-risk patients with any ideation
5. **The duty to warn (Tarasoff)** applies in most states when a patient makes a credible, specific threat against an identifiable victim—document the threat, notify the intended victim, and notify law enforcement
6. **Ketamine for excited delirium** provides the fastest reliable sedation (2-5 minutes IM) and should be available in all EDs—prepare for potential intubation in 0.8% of IM doses
7. **Psychiatric boarding** (ED hold >4 hours awaiting bed) is associated with increased patient elopement, staff assault, and medical complications—document boarding duration and escalation efforts
8. **Alcohol intoxication is not a psychiatric diagnosis**—patients must be reassessed when sober before psychiatric evaluation is meaningful; document serial clinical sobriety assessments