Behavioral Emergencies, Agitation and Abuse

In depth

The one-page summary above is what the PDF prints. These sections go further.

Suicide risk: what the sources say

• Merck (July 2025 review) risk factors: a previous attempt; detailed planning or steps to carry a plan out (buying a gun, hoarding pills, precautions against discovery); alcohol or drug use, especially recent increases (over one third of people who die by suicide drank beforehand); male sex (US men die nearly 4:1); older age (highest US rates at 75-84 and 85 and over); recent widowhood, separation or divorce; social isolation; a psychiatric disorder (almost 90% of people who die by suicide in some studies). Firearms were 55.33% of US suicides in 2023, then suffocation and poisoning; attempts more often use ingestion because it is less often fatal.
• Asking: Merck calls the fear that asking will plant the idea baseless; the 988 #BeThe1To evidence page cites studies that asking at-risk people does not increase suicidal thoughts and may reduce them. Ask directly ("Are you thinking about suicide?"), then about a plan, timing and access to a method.
• Means: reducing access to a lethal means lowers suicides by that method and usually overall, because people often do not switch (988 evidence page). In the field this means distance between the patient and the firearm or pills, with law enforcement handling weapons.
• Merck: at-risk patients are not left alone until they are in a secure setting; in most US jurisdictions a clinician must notify an empowered agency when suicide is imminently likely; risk stays high in the days to weeks after a hospital discharge. NASEMSO: attempted suicide, stated intent or factors that make the crew suspect intent remove decision-making capacity; the patient may not decline transport. Medical direction and law enforcement run the hold.
• NIMH warning signs (2025): talking about wanting to die, great guilt or shame, being a burden; feeling empty, hopeless, trapped, in unbearable pain, extremely sad, anxious, agitated or full of rage; changing behavior: making a plan or researching ways to die, withdrawing, saying goodbye, giving away important items, making a will, dangerous risks such as driving extremely fast, extreme mood swings, eating or sleeping more or less, more drugs or alcohol. Get help as soon as possible, especially if the behavior is new or has increased. 988: call or text; chat at 988lifeline.org.
• Nonsuicidal self-injury (Merck, April 2026): cutting or burning, repeated in one session, on the forearms and front of thighs, to relieve tension, self-punish or signal distress. The acts are not meant to be lethal, but long-term risk of suicide attempts and suicide is increased and the behavior should not be dismissed; evaluation includes estimating the risk of a suicide attempt. For the crew the decision point is the direct question about current suicidal thoughts: a denial from a sober patient who understands the risks allows a refusal; an admission or suspicion does not.

De-escalation detail (Project BETA, Richmond 2012; pediatric BETA, Gerson 2019)

• The ten domains: respect personal space (at least two arm's lengths; many agitated patients have a trauma history and a crowded space can repeat it); do not be provocative (hands visible, stand at an angle, no staring, no folded arms, nothing humiliating); establish verbal contact (one designated speaker, introduce yourself, ask how the patient wants to be addressed); be concise (short sentences, simple words, time to respond, a message may need repeating a dozen times); identify wants and feelings; listen closely and confirm; agree or agree to disagree; set clear limits matter-of-factly with reasonable consequences; offer choices and optimism (including oral medication); debrief the patient and the crew after any involuntary step. Verbal de-escalation often works in under 5 minutes; a show of force uses a team of 4-6 and is the step after talking fails.
• The clinician manages the urge to argue, retaliate or get defensive; those reactions worsen agitation. In the field, "one calm voice, space, an exit" is the same rule.
• Children and adolescents: start with the caregiver (baseline, triggers, what has calmed the child before, past responses to medication); look for pain, dental pain, constipation, missed home medications, hunger and sensory overload; speak at eye level, short and concrete, visual aids for developmental disability; a calm area without sharps; firm limits, praise for cooperation. Oral medication when possible, IV only if access is already in, IM only for safety; the goal is calm, not sedation. Children with autism are more vulnerable to adverse effects, including from benzodiazepines, so behavioral strategies matter more and an extra dose of a usual medication may beat a new drug. After a drug: akathisia, delirium and NMS can be mistaken for worsening agitation; track cumulative doses; a second dose of the same drug is preferred over stacking new ones.

Sedation: the full NASEMSO list and BETA rationale

• NASEMSO adult doses and onsets: diazepam 5 mg IV (2-5 min) or 10 mg IM (15-30 min); lorazepam 2 mg IV (2-5 min) or 4 mg IM (15-30 min); midazolam 5 mg IV (3-5 min), IM (10-15 min) or IN (3-5 min); droperidol 2.5 mg IV (10 min) or 5-10 mg IM (20 min), an option for high violence risk; haloperidol 5 mg IV (5-10 min) or 5-10 mg IM (10-20 min), limited data and no established optimal dose; olanzapine 10 mg IM (15-30 min) or 10 mg ODT; ziprasidone 10 mg IM (10 min); ketamine 2 mg/kg IV (1 min) or 4 mg/kg IM (3-5 min), an option for high violence risk; diphenhydramine 25-50 mg IM, IV or PO. The numbering is not a hierarchy; choice follows the clinical picture, current medications, allergies, resources and medical direction. NASEMSO asks for a validated agitation scale (RASS, AMSS or BARS, named only here) to stratify risk.
• NASEMSO pediatric doses: diazepam 0.05-0.1 mg/kg IV (max 5 mg) or 0.1-0.2 mg/kg IM (max 10 mg); lorazepam 0.05 mg/kg IV or IM (max 2 mg); midazolam 0.05-0.1 mg/kg IV (max 5 mg), 0.1-0.15 mg/kg IM (max 5 mg) or 0.3 mg/kg IN (max 5 mg); droperidol not routinely recommended; haloperidol 1-3 mg IM at 6-12 years (max 0.15 mg/kg); olanzapine 5 mg IM at 6-11 years (limited data), 10 mg IM at 12-18 years, 5 mg ODT at 6-18 years; ziprasidone 5 mg IM at 6-11 years, 10 mg at 12-18 years; ketamine 1 mg/kg IV or 3 mg/kg IM; diphenhydramine 1 mg/kg (max 25 mg). Example: a 30-kg 9-year-old gets midazolam 3-4.5 mg IM; 120 mg of ketamine would be the adult 4 mg/kg dose; olanzapine 10 mg is the 12-18 dose.
• BETA (Wilson 2012) by cause: alcohol intoxication, avoid medication if possible and avoid benzodiazepines (additive respiratory depression), haloperidol preferred for its long safety record and minimal respiratory effect; alcohol withdrawal, benzodiazepines; stimulant intoxication, benzodiazepines first-line (add a second-generation antipsychotic for amphetamine psychosis); psychosis, an antipsychotic over a benzodiazepine, second-generation preferred, and if one dose is not enough add lorazepam rather than repeating or switching antipsychotics; delirium, find and fix the cause (glucose, hypoxia, electrolytes, withdrawal) and avoid benzodiazepines unless the cause is alcohol or benzodiazepine withdrawal; unknown or mixed cause without psychosis, a benzodiazepine. Medication is for calming, not sleep; oral is offered to a cooperative patient; medication is not a restraint.
• Haloperidol: minimal vital sign effect and low anticholinergic activity but QTc prolongation and torsades, worse IV (the label says the injection is not approved for IV use); caution with hypokalemia, hypomagnesemia, a long QTc or other QT drugs; adding lorazepam or promethazine reduces extrapyramidal effects (BETA). The Mylan label (11/2024) doses 2-5 mg IM for acute agitation, repeatable hourly, maximum 20 mg/day; dystonia occurred in 6.7% versus 0.4% on placebo in the oral-formulation trials in the label; pediatric safety is not established. Medic-med-194: alcohol-intoxicated, QTc 430 ms, head injury excluded, glucose normal: haloperidol 5 mg IM is the BETA and NASEMSO answer; midazolam compounds respiratory depression; olanzapine plus lorazepam is the combination NASEMSO warns against; diphenhydramine sedates without controlling violence and adds anticholinergic confusion.
• Olanzapine IM (Zyprexa label, 10/2026): 10 mg for agitation in schizophrenia or bipolar mania, 5 mg to start in geriatric patients, 2.5 mg if debilitated or hypotension-prone; orthostatic vital signs before any further dose; bradycardia, sinus pauses, hypotension and tachycardia reported; drowsy or dizzy patients stay lying down; a parenteral benzodiazepine is not recommended with it because of excessive sedation and cardiorespiratory depression; alcohol potentiates its orthostatic hypotension. The pediatric BETA gives the same rule as a time window: no olanzapine within 1 hour of a parenteral benzodiazepine.
• Droperidol: NASEMSO keeps it as a high-violence option; the 2012 BETA group advised avoiding it over the FDA QT boxed warning. Local protocol decides. Ketamine: NASEMSO option for high violence risk; the pediatric BETA does not recommend it for agitated children in the ED.
• Monitoring (NASEMSO): cardiac monitor as soon as possible, especially after drugs; every sedated patient watched for hypoventilation and oversedation with capnography; after an antipsychotic watch for dystonia, mydriasis, ataxia, loss of sweating, dry mucous membranes and arrhythmia, particularly QT prolongation. Patients who need physical control should also get pharmacologic treatment, to prevent the metabolic acidosis of delirium with agitated behavior; air transport is not advised; medical direction at any time, especially when transport itself puts everyone at risk. Restraint technique, positional asphyxia and prohibited positions are on emt-by-complaint.

Antipsychotic side effects in the field

• Acute dystonia (Merck, Dec 2025; NASEMSO): oculogyric crisis, torticollis, tongue and jaw spasm, rarely laryngeal dystonia with stridor; benztropine or diphenhydramine IV or IM, and for laryngeal dystonia IV lorazepam with intubation possible. NASEMSO adult diphenhydramine 25-50 mg IV, IM or PO, pediatric 1 mg/kg (max 25 mg), or a benzodiazepine. The dystonic patient is alert, afebrile and not rigid in the limbs; more haloperidol worsens it, physostigmine is for anticholinergic poisoning and does not treat it.
• Neuroleptic malignant syndrome (Merck): muscle rigidity, hyperthermia, autonomic instability and a raised CK, with rhabdomyolysis and kidney injury; more common with first-generation drugs but possible with all; stop the drug, cool rapidly, aggressive support; bromocriptine, amantadine and dantrolene are hospital drugs. Catatonia and NMS can look the same (Park 2017); both get benzodiazepines and antipsychotic withdrawal.
• Every antipsychotic raises mortality in older adults with dementia (Merck; the haloperidol, olanzapine and clozapine labels carry the boxed warning). Dementia with Lewy bodies (Merck, Feb 2025): fluctuating cognition, visual hallucinations that are often threatening, symmetric parkinsonism, REM sleep behavior disorder; extreme antipsychotic sensitivity is typical and traditional antipsychotics even at very low doses acutely worsen extrapyramidal symptoms, so they are avoided. New agitation with fever and dysuria in such a patient is delirium from infection, which NASEMSO excludes from the agitation protocol; family-assisted calming first; the pediatric BETA's rule to avoid diphenhydramine in delirium applies to adults as classic teaching (AGS Beers criteria not opened).
• Clozapine (Clozaril label, 6/2025; Merck): severe neutropenia (ANC under 500/µL, under 1% of patients) with the greatest risk in the first 18 weeks, so fever or a sore throat early in treatment is a count until proven otherwise (fever 38.5 °C or more: the prescriber interrupts the drug and checks the ANC); myocarditis and pericarditis most often in the first 2 months, presenting with chest pain, tachycardia, palpitations, dyspnea, fever and flu-like symptoms, cardiomyopathy after about 8 weeks; orthostatic hypotension, bradycardia and syncope, worst during titration and when restarting after missed doses; dose-related seizures (cumulative incidence about 5% at one year). The crew masks the patient, obtains a 12-lead, watches for hypoperfusion and arrhythmia, and tells the hospital the drug and its start date.
• Pain in schizophrenia (Stubbs 2015, meta-analysis of 17 experimental pain studies, 387 patients): higher pain threshold and tolerance and lower intensity ratings than controls; the effect held in antipsychotic-free patients and was trend-level in treated ones. Clinically: a low pain score cannot overrule a rigid abdomen, a patient lying still, fever and a heart rate of 120, which Merck lists as peritoneal and shock signs; gangrene or perforation can occur within 6 hours in some causes. Opioids and antipsychotics blunting abdominal findings is also on abdomen-gu-dialysis.

Catatonia and eating disorders

• Catatonia (Park 2017; Elwyn 2026; StatPearls 2025 abstract): a neuropsychiatric syndrome with psychiatric (mood disorders, psychosis), neurologic and medical causes; features include catalepsy (a limb stays where it is placed), waxy flexibility, stupor, mutism, negativism, posturing, rigidity, and in the malignant form autonomic dysfunction and fever. It is fatal if untreated: mortality typically exceeded 50% before benzodiazepines and ECT, 9% in a treated series. Complications: dehydration, electrolyte disturbance, aspiration pneumonia, rhabdomyolysis, pressure injury, thromboembolism. Benzodiazepines are first-line and should start within 24 hours; ECT is the second (sometimes first) line; antipsychotics are withdrawn because they can worsen or trigger catatonia, and NMS is virtually indistinguishable at presentation. Elwyn: check glucose and correct hypoglycemia before treatment; food and fluid refusal can hide behind an eating-disorder label. Thornton 2026 red flags in a child: fluid refusal, no urine for 24 hours, a heart rate of 45, temperature under 35.5 °C, a long QTc.
• Field decision (medic-med-238): three days without intake, mutism, posturing, an arm that stays raised, fever and tachycardia is a medical emergency, not refusal of care; the patient cannot care for herself, so she lacks capacity to stay home; a psychiatric crisis unit cannot correct dehydration or autonomic instability; haloperidol "so she cooperates" is the harmful reflex.
• Anorexia nervosa (Merck, Jan 2026): bradycardia, orthostatic hypotension, hypothermia, edema, lanugo, loss of fat and muscle; hypokalemia, hyponatremia, dehydration and metabolic alkalosis, worse with vomiting, laxatives or diuretics; reduced cardiac mass and output, QT prolongation (often from hypokalemia) with ventricular tachyarrhythmia and sudden death; refeeding syndrome (hypophosphatemia) in the most undernourished. Purging signs: eroded enamel, painless salivary gland enlargement; knuckle calluses are classic teaching. Hospitalization for symptomatic hypotension, extreme bradycardia or an arrhythmia, severe or rapid weight loss, or any doubt. Field care: 12-lead for QT, glucose, warming, cautious fluids and glucose, a medical (not behavioral) destination, and no comment on weight or eating.

Functional disorders, flashbacks and hallucinogens

• Functional neurological symptom disorder (Merck, June 2026; StatPearls 2023 abstract): motor or sensory symptoms that arise unconsciously and nonvolitionally, incompatible with known neurologic pathways, often after stress or trauma; not intentionally produced, not deliberately faked. Positive signs: Hoover sign (downward pressure felt under the "paralyzed" heel when the other leg lifts against resistance), weakness in bed that vanishes walking on tiptoe, tremor that stops with distraction, resistance to eye opening in an apparent seizure, tunnel vision. Neurologic and medical disease must be excluded first by a comprehensive evaluation; the explanation validates the symptoms as genuine. The paramedic documents the findings neutrally, does no pain tests, does not call it faking, and transports; a cord lesion is excluded in hospital, and a stroke alert is not triggered by isolated bilateral leg weakness with normal reflexes.
• Dissociative (functional, psychogenic nonepileptic) seizures (Cengiz 2024, 203 presentations): 11-27% of emergency seizure presentations; half ongoing at first contact, prolonged in 23%, clusters in 24%; typical features eye closure, a discontinuous stop-start course and asynchronous movements; on-site physician diagnostic accuracy 12%; benzodiazepines given in about two thirds of ongoing events, often at high doses, 16% unaffected, 13% critically sedated, and 9% of patients given benzodiazepines by EMS were intubated. NASEMSO asks for the typical appearance and baseline duration of the patient's seizures, and warns that more than two benzodiazepine doses carry a high risk of airway compromise (consult medical direction). With a neurologist's care plan, a typical event, normal SpO₂ and a normal capnography waveform, the crew holds further sedation, protects and monitors, transports, and treats only if the event becomes atypical. Sternal rubs and ammonia do not distinguish the two and damage trust.
• PTSD (Merck, April 2026): intrusions and flashbacks in which the person acts or feels as if the event were happening again, triggered by sights, sounds or smells (fireworks for a combat veteran); hypervigilance and an exaggerated startle response. BETA: unexpected touch and a ring of uniforms can read as attack; stay out of reach, hands open, say who you are, orient to place and time, one voice; move away from the noise once he follows simple requests; sedation is for sustained violence, not a startle swing (NASEMSO: verbal reassurance before drugs).
• LSD and other hallucinogens: the StatPearls abstract records no deaths from the drug's direct effects; the danger is injury, co-ingestants and hyperthermia. Care follows NASEMSO (verbal reassurance before any drug) and BETA (quiet, low-stimulation space; a benzodiazepine for intoxication without psychosis; an antipsychotic only for persisting psychosis): one calm person, reassurance, repeated vitals and temperature, a second question about other drugs. One-to-one supervision is classic teaching (StatPearls full text not opened). Restraint and a loud lights-and-sirens transport add stimulus and struggle.

Postpartum psychosis

• Merck (Jan 2026): postpartum blues are very common in the first week, last 2-3 days and up to 2 weeks, with mood swings, crying, irritability and insomnia but no psychosis; postpartum depression lasts more than 2 weeks, affects about 7% of women in the first year and impairs self-care and infant care; hallucinations, delusions or psychotic behavior call for evaluation for postpartum psychosis, which is rare and typically needs psychiatric hospitalization and antipsychotics. Untreated postpartum psychiatric disorders increase the risk of suicide and infanticide, the most severe complications.
• Field care (medic-cj-91): confusion, voices and a delusion about the infant 12 days after birth is a psychiatric emergency, not blues, not depression for next month's visit and not sleep deprivation to nap off. The mother is not left alone with the infant; the crew transports calmly with a support person, checks glucose and vital signs (eclampsia, infection and thyroid disease are the medical look-alikes to report), and hands over the risk to both mother and baby.

Abuse and maltreatment: the EMS role

• NASEMSO Abuse and Maltreatment: clues from caregivers (apathy or overreaction, inconsistent histories, a story that does not match the injury, injuries beyond the patient's abilities, a caregiver who will not let an adult speak or appears controlling, confinement measures); clues from the patient (bruises in various stages of healing, found by a full skin exam; submissive or fearful adults; pattern burns, bruises or scars; medical neglect; unexplained genitourinary trauma or infections; malnourishment or serious dental problems). The EMS job is to document concerns, assess injuries, disclose to the authorities and get the patient and other vulnerable people safe, not to investigate, interview or intervene beyond that. Do not ask a child directed questions; record spontaneous statements. Do not confront a suspected perpetrator. Remove the patient to a safe place even without a medical indication; report at once to law enforcement, in accordance with state law, caregivers who impede assessment or refuse care; report to the hospital, law enforcement or protective services per mandatory reporting law. Describe, do not ascribe: "0.5-inch round burn to back", not "cigarette burn".
• Elder abuse (Merck, Jan 2026; USPSTF 2025): about 1 in 10 US adults over 65; 11% of adults 60 and over abused or neglected in the past year; perpetrators are often adult children; risk rises with isolation, cognitive impairment, dependence and a shared home. Clues: multiple bruises in various stages, unexplained abrasions, pressure ulcers, dehydration, poor hygiene, undiagnosed fractures, genitourinary injury, wrist or ankle restraint marks, stocking-glove burns, withdrawal, a caregiver who infantilizes the patient or insists on giving the history, delayed care, an explanation that does not fit, reluctance to leave the patient alone with clinicians. Interview the patient alone at least in part, ask directly, acknowledge caregiver burden without confrontation, document in the patient's words; APS referral is mandatory in most states (Eldercare Locator 800-677-1116). Upper-arm grip bruising with flinching and a son who answers for her (medic-cj-77) is this pattern, not a clotting disorder or incidental bruising.
• Intimate partner violence (USPSTF June 2025; Merck Aug 2026): Grade B screening of women of reproductive age, including pregnant and postpartum women, in a safe and private setting where no partner can overhear; pregnancy can start physical violence, especially when the partner did not want the pregnancy, and violence that began before conception can continue; positive screens go to multicomponent ongoing support rather than a leaflet. Merck: the midface is the most frequent injury site, forearm and hand fractures are defensive, strangulation is a concern; a partner reluctant to leave the patient alone is a behavioral clue; ask one direct neutral question (has your partner ever threatened you or made you afraid); higher-risk signs are a threat to leave, escalating violence such as choking, partner access to weapons and threats to kill; 64% of police-identified victims had visited an ED in the year before the assault. US hotline 1-800-799-7233. Reporting of adult IPV varies by state. Medic-cj-212: a private "exam in the ambulance", a direct question, objective documentation (location, size, color, her words), a private handover; not a question in front of the partner, not the partner's story charted as fact, not police before she has been asked.
• Human trafficking (NASEMSO; DHS Blue Campaign): coercion into labor or sex; signs include branding or tattoos, padlocks or removed doorknobs on interior doors, intact windows boarded up; deference to someone who controls where she goes and who she talks to, coached or scripted answers, no ID or possessions, not knowing where she is, fear, submissiveness, bruises in various stages, signs of being denied food, water, sleep or care, no freedom of movement. No single indicator proves it. Create a private moment (the assessment in the ambulance), never use the companion as interpreter, ask open questions, offer help without pressure, give the National Human Trafficking Hotline discreetly (1-888-373-7888; text 233733), report per protocol; do not confront or alert the companion, which endangers the patient.

Sexual assault: what the paramedic preserves

• Merck (Aug 2026): evidence is often lost after showering, changing clothes or douching, weakens after 36 hours and, depending on jurisdiction, can be collected up to 7 days after the assault; patients are told not to discard or change clothing, wash, shower, douche, brush teeth, clip nails or use mouthwash; permission is asked before the examination and before each step, and any part may be refused; police are notified only with consent; the record may be used in court, so it is legible and in plain language. NASEMSO: treat injuries, avoid investigating details, document spontaneous statements. MedlinePlus (cited on emt-by-complaint): National Sexual Assault Hotline 800-656-4673, which connects callers to hospitals with trained examiners.
• Drug-facilitated assault: Merck advises offering flunitrazepam and GHB screening when the patient has amnesia for the time around the assault (sudden heavy intoxication after one drink, memory gaps). Who collects a urine sample, in what container and with what labeling and handover is set by local protocol and the receiving examiner program; the DOJ National SAFE Protocol (3rd edition) could not be opened for this page, so its first-responder rules are not restated here. The crew's constant parts are consent, her words verbatim, injuries treated, and transport to a facility with a sexual assault examiner.

Exam pearls

• The first answer to any agitation question is a cause: glucose, SpO₂, temperature, head injury, infection, withdrawal. The second is talk. Drugs come third and restraint never comes alone.
• Alcohol on board: antipsychotic. Stimulants or withdrawal: benzodiazepine. Psychosis: antipsychotic, then lorazepam. Delirium: treat the cause. Olanzapine IM never with a parenteral benzodiazepine.
• Twisted neck and upward gaze after haloperidol is dystonia (diphenhydramine), not agitation and not NMS (fever, whole-body rigidity).
• Capacity questions: suicidal intent removes it; nonsuicidal self-injury does not by itself; a catatonic patient who cannot drink has no capacity to stay home.
• A controlling companion who answers every question is the common thread in elder abuse, partner violence and trafficking; the answer is always a private interview and never a confrontation.