Version July 2025
ECG: electrocardiogram; FSBG: fingerstick blood glucose; IM: intramuscular; IV: intravenous; SL: sublingually; TCA: tricyclic antidepressant.
* Medical cause of agitation can include hypoglycemia, hypoxia, intoxication, withdrawal, intracranial lesions, infection, and others. Check FSBG when feasible. Establish IV access depending on patient condition and potential for medical etiology.
¶ Symptoms of sympathomimetic intoxication or sedative-hypnotic withdrawal include diaphoresis, mydriasis, tachycardia, hyperthermia. Symptoms of anticholinergic delirium include mydriasis, dry axilla/lips, tachycardia, mumbling speech, partially redirectable.
Δ In an older adult (≥65 years of age), reduce the initial antipsychotic dose by half.
◊ If concern for anticholinergic delirium, can administer physostigmine 0.5 to 2 mg IV after obtaining ECG and placing patient on cardiac monitor. Do not give physostigmine if possibility of TCA overdose or QRS interval > 100 msec. Refer to UpToDate content on anticholinergic poisoning. If concern for alcohol withdrawal delirium, can administer phenobarbital 10 mg/kg IV instead of a benzodiazepine. Refer to UpToDate content on treatment of moderate-severe alcohol withdrawal.
§ Do not use antipsychotic agents if concern for anticholinergic delirium. Antipsychotic agents can prolong QTc interval and impair heat dissipation.
¥ There is a potential risk of excess sedation and respiratory depression from co-administering olanzapine IV/IM and a parenteral benzodiazepine. If both are needed, we suggest separating these doses by at least 60 minutes.
‡ If patient has mild agitation, start with lower dose in the range provided.
† Quetiapine may be a preferable option in patients with dementia with Lewy bodies disease or Parkinson disease.
** Refer to UpToDate content for suggestions on how to apply restraints (eg, do not place patient in prone position).
