Agitation: documentation that holds up

The agitated patient is a medical screen before a psychiatric one. The defensible chart documents the vital signs (including temperature and glucose), that a medical cause was considered, the de-escalation attempt, and — if sedation is used — the dose and the monitoring, because hyperthermia and over-sedation kill.

01What's at stake

"Psych" is a diagnosis of exclusion in the acutely agitated patient. Hypoglycemia, hypoxia, head injury, CNS infection, sepsis, non-convulsive status, intoxication, and withdrawal all masquerade as agitation. And severe agitation with hyperthermia (historically termed excited delirium) can progress to sudden cardiac arrest — while the restraint-and-sedation used to control it can cause positional asphyxia or over-sedation. The two anchors are a medical screen and monitored, titrated sedation.

02Can't-miss causes

• Medical: hypoglycemia, hypoxia/hypercarbia, head injury, CNS infection, sepsis, non-convulsive status epilepticus, metabolic (Na, thyroid), hypertensive encephalopathy.
• Toxic / withdrawal: sympathomimetics, anticholinergics, serotonin syndrome, alcohol/benzodiazepine withdrawal, serotonergic/antipsychotic toxicity.
• Hyperthermia / severe hyperactive delirium — the lethal can't-miss; sudden tranquility before arrest.
• Primary psychiatric — only after the above are addressed.

03Assessment — screen everyone

• Vital signs including temperature and a fingerstick glucose on every agitated patient — these catch the lethal reversibles. → medical screen
• Hyperthermia, tachycardia, diaphoresis, profound agitation? → hyperthermic delirium / sympathomimetic / serotonin syndrome
• Focal deficit, head trauma, neck stiffness, abnormal pupils? → intracranial / CNS infection
• Older age, new onset, abnormal vitals? → delirium with a medical cause
• Collateral history, medications, substances. → tox / withdrawal

04Management

• Safety first (staff and patient), then verbal de-escalation as the first-line intervention.
• Medication when needed — benzodiazepines (esp. for alcohol/sedative withdrawal and stimulant toxicity), antipsychotics, or ketamine for severe/dangerous agitation — always with monitoring (cardiorespiratory, pulse ox, capnography for deep sedation).
• Avoid prolonged struggle/restraint without sedation (positional asphyxia); reassess restrained patients frequently.
• Hyperthermic delirium: aggressive cooling, sedation (benzodiazepines/ketamine), IV fluids, and monitoring for rhabdomyolysis/acidosis.
• Don't sign off "medically cleared" until the screen and the cause are addressed and the patient is safe.

05What to document

06Where charts fail

• Labeling agitation "psych" without a temperature, glucose, and medical screen.
• Missing hyperthermic delirium (and not cooling/monitoring).
• Sedating without documenting the dose, route, and monitoring — or prolonged restraint without reassessment.
• Anchoring on intoxication and missing head injury, sepsis, or non-convulsive status.
• Writing "medically cleared" before the cause is actually addressed.

07Sources

• Nordstrom K, Zun LS, Wilson MP, et al. Medical evaluation and triage of the agitated patient: consensus statement of the American Association for Emergency Psychiatry (Project BETA). West J Emerg Med. 2012;13(1):3-10.
• Wilson MP, Pepper D, Currier GW, et al. The psychopharmacology of agitation: consensus statement (Project BETA). West J Emerg Med. 2012;13(1):26-34.
• Gottlieb M, Long B, Koyfman A. Approach to the agitated emergency department patient. J Emerg Med. 2018;54(4):447-457.
• Vilke GM, DeBard ML, Chan TC, et al. Excited delirium syndrome: defining based on a review of the literature. J Emerg Med. 2012;43(5):897-905.

© 2026 Kim Trinh, MD. All rights reserved. Educational only — synthesized from primary literature and consensus guidelines. Synthetic examples. Not medical advice — apply local protocol and judgment.