Why this matters: Agitation is a clinical emergency when it threatens the patient, family or healthcare team, or when intense activity causes hyperthermia, acidosis, rhabdomyolysis, exhaustion and sudden cardiac arrest. The emergency team must protect everyone while looking for hypoxia, hypoglycaemia, head injury, sepsis, intoxication, withdrawal, psychosis, mania, pain or medication toxicity.
Scope and safety: This guide is educational. Sedation, restraint and involuntary treatment must follow Uganda law, facility policy, trained-team scope and senior medical direction. Use the least restrictive safe option, document the reason, monitor continuously and never use sedation to punish, silence or replace a medical assessment.
Learning outcomes
- Define agitation, aggression and acute behavioural disturbance (ABD) and recognise immediate danger signs.
- Use scene safety, verbal de-escalation and a medical differential before medication.
- Plan safe sedation: indication, drug choice, route, monitoring, airway readiness and reassessment.
- Recognise excited delirium-like physiology, hyperthermia, acidosis, rhabdomyolysis and sudden collapse.
- Apply ethical, legal, safeguarding and documentation principles to restraint and emergency treatment.
1. Definitions and severity
| Presentation | Typical behaviour | Clinical priority |
|---|---|---|
| Mild agitation | Restlessness, irritability, pacing, raised voice or anxiety. | Identify triggers, offer choices and prevent escalation. |
| Moderate agitation | Threats, shouting, invading space, refusing assessment or pushing equipment away. | Team de-escalation, safe environment, medical screen and early senior help. |
| Severe aggression | Striking, kicking, biting, throwing objects, weapon access or attempts to abscond into danger. | Protect people, call trained security/clinical team, use least-restrictive emergency plan. |
| Acute behavioural disturbance | Extreme agitation with abnormal strength, pain insensitivity, hyperthermia, sweating, incoherence, intoxication or prolonged struggle. | Time-critical medical emergency: rapid control, sedation by trained team, cooling, glucose/oxygen/ECG and critical-care transfer. |
2. Causes: “medical until proven otherwise”
| Cause group | Examples | Clues to ask/check |
|---|---|---|
| Hypoxia/metabolic | Hypoxia, hypoglycaemia, hyperglycaemia, electrolyte disturbance, renal/liver failure. | SpO2, glucose, temperature, hydration, urine, diabetes/renal history. |
| Neurological | Head injury, stroke, seizure/post-ictal state, meningitis, raised intracranial pressure. | Trauma, headache, focal signs, unequal pupils, fever, seizure history. |
| Substances | Stimulants, cannabis, hallucinogens, alcohol, opioids, sedatives and withdrawal. | Last use, amount, co-ingestions, pupils, sweating, tremor, respiratory rate. |
| Psychiatric | Psychosis, mania, severe depression, personality crisis or trauma reaction. | Baseline function, hallucinations/delusions, mood, sleep, self-harm/violence risk. |
| Physical distress | Pain, urinary retention, constipation, hunger, sleep deprivation, hypothermia/hyperthermia. | Injury, abdomen/bladder, environment, recent procedures or medication change. |
| Medication effects | Akathisia, anticholinergic delirium, serotonin syndrome, NMS, steroid psychosis. | New/increased medicine, missed doses, fever/rigidity/clonus, dry skin/pupils. |
3. Scene safety and team preparation
- Identify weapons, exits, hazards, bystanders, security and available escape routes before approaching.
- Use a calm, visible team; nominate one lead communicator and one team leader.
- Remove unnecessary equipment and spectators; keep the patient away from corners or dangerous heights.
- Maintain personal space, do not block the exit, avoid sudden touch and keep hands visible.
- Request trained help early if threats, weapons, intoxication, ABD or repeated escalation are present.
- Agree the escalation plan before contact: de-escalation, oral medication, parenteral sedation, restraint, transport and airway rescue.
4. Verbal de-escalation
- Introduce yourself and role: use the patient’s preferred name, a respectful tone and simple language.
- Listen first: ask what is upsetting them, reflect the emotion and acknowledge fear without agreeing with unsafe beliefs.
- Offer choices: quiet room or open area, male/female staff where possible, oral medicine or assessment, family/support person if safe.
- Set one clear boundary: “I want to help; I cannot allow hitting. If you keep moving toward staff, we will need to use the safety plan.”
- Reduce stimulation: dim noise, remove unnecessary staff, give time to answer and avoid arguing, mocking or rapid questioning.
- Plan an exit: do not promise secrecy, discharge or a specific outcome you cannot deliver.
“CALM”: Connect respectfully; Acknowledge distress; Limit stimulation and set boundaries; Make a safe plan and monitor.
5. Immediate risk assessment
| Risk | Questions/observations | Response |
|---|---|---|
| Violence | Threats, weapon access, target, past violence, escalating posture, clenched fists. | Increase distance, call trained help/security, remove means and agree a team plan. |
| Self-harm | Suicidal thoughts, plan, access to means, recent attempt, command hallucinations. | Constant observation, remove means, urgent mental-health/medical assessment. |
| Medical collapse | Fever, sweating, abnormal breathing, collapse, rigidity, seizure, severe pain or confusion. | ABCDE, glucose, oxygen/ventilation, temperature, ECG, cooling and urgent transfer. |
| Vulnerability | Child, pregnancy, older adult, disability, communication barrier, trauma history. | Adapt approach, safeguard, use interpreter/support and avoid unnecessary force. |
6. Rapid medical assessment during agitation
- Airway: Can the patient speak? Is there vomiting, trauma, swelling or reduced consciousness?
- Breathing: Count RR, check SpO2, work of breathing and ETCO2 when available. Severe agitation can mask hypoxia.
- Circulation: Pulse, BP, temperature, ECG, perfusion, bleeding and IV access.
- Disability: AVPU/GCS, glucose, pupils, seizure/post-ictal state, focal neurological deficit.
- Exposure: trauma, hyperthermia, rash, needle marks, medications, pregnancy and environmental causes.
Red flags for a medical emergency: new onset in an older adult, fluctuating attention, abnormal vital signs, fever/hypothermia, hypoxia, severe headache, head injury, seizure, rigid muscles, clonus, chest pain, extreme exertion, collapse or a sudden change after a medicine/substance.
7. Escalation and consent
Seek consent whenever possible. If the patient lacks capacity and immediate treatment is needed to prevent serious harm, act within emergency law and policy, use the minimum force/time required and involve a senior clinician. Explain what is happening even if the patient cannot respond. Document capacity, risk, alternatives offered, staff involved, proportionality and review.
8. When medication is needed
Use medication when immediate danger persists despite de-escalation, when severe agitation prevents life-saving assessment/treatment, or when ABD physiology is causing exhaustion and collapse. Choose the least restrictive effective medicine and route, give only by trained staff under protocol, and reassess rather than stacking unrecorded doses.
| Option | When it may help | Important cautions |
|---|---|---|
| Oral medication | Cooperative patient who can swallow and has time for effect. | Slower onset; confirm ingestion, avoid hidden medication and keep observing. |
| Benzodiazepine (e.g., midazolam/lorazepam/diazepam) | Severe anxiety/agitation, stimulant intoxication, alcohol withdrawal, seizures. | Respiratory depression, hypotension, paradoxical agitation; danger increases with opioids/alcohol and respiratory disease. |
| Antipsychotic (e.g., haloperidol/olanzapine) | Psychosis or mania when clinically appropriate. | QT prolongation, dystonia, akathisia, NMS, hypotension and sedation; check medical causes and interactions. |
| Ketamine | Extreme violence/ABD requiring rapid control when other measures are unsafe or ineffective. | Hypersalivation, vomiting, laryngospasm, emergence reaction and hypertension; requires advanced airway readiness. |
| Combination therapy | Selected severe cases under a senior protocol. | Additive respiratory/cardiovascular depression and medication error; use only with continuous monitoring. |
Medication safety: Do not provide a generic dose schedule in place of local protocol. Verify age/weight, indication, allergies, pregnancy, intoxication, cardiac disease, recent sedatives and available rescue equipment.
9. Sedation administration and monitoring
- Record baseline RR, SpO2, pulse, BP, temperature, glucose, mental state and airway risk.
- Prepare oxygen, suction, BVM, airway adjuncts, capnography, ECG, BP cuff, IV/IO access and reversal/resuscitation support.
- Assign one clinician to monitor the patient continuously; the proceduralist should not be the sole observer.
- Administer the selected medicine by the authorised route, note exact time/dose/concentration and avoid rapid unplanned repetition.
- Reassess every few minutes: response, agitation score, airway tone, RR, SpO2, ETCO2, pulse, BP, temperature and adverse effects.
- After control, continue observation because delayed respiratory depression, recurrent agitation or aspiration can occur.
| Monitor | What deterioration looks like | Immediate response |
|---|---|---|
| Airway | Snoring, gurgling, drooling, swelling, loss of tone. | Reposition, suction, adjunct, BVM/advanced airway help. |
| Breathing | Slow/shallow breaths, rising ETCO2, falling SpO2, cyanosis. | Oxygen/ventilate, stop sedatives, call resuscitation team. |
| Circulation | Hypotension, bradycardia, dysrhythmia, poor perfusion. | Monitor ECG/BP, IV/IO access, fluids/advanced support and cause review. |
| Temperature/metabolic | Hyperthermia, acidosis, severe sweating, rigidity, rhabdomyolysis. | Cooling, glucose/ECG/ABG/CK/renal assessment and critical-care transfer. |
10. Physical restraint: last resort
- Use only when necessary to prevent immediate harm and after de-escalation/less restrictive measures fail or cannot be attempted.
- Use trained staff, a team leader and coordinated commands; never improvise a prone restraint or compress the neck/chest.
- Keep the airway accessible; avoid pressure on the chest/abdomen and release restraints as soon as safe.
- Continuously observe breathing, circulation, consciousness, skin colour, limb perfusion and distress; restraints do not replace sedation or medical assessment.
- Search for injury, document the reason, duration, staff, technique, monitoring, review and debrief the patient/team.
11. Common emergency syndromes to recognise
| Syndrome | Clues | Priority |
|---|---|---|
| Stimulant toxicity/ABD | Extreme activity, sweating, dilated pupils, tachycardia, hypertension, hyperthermia. | Rapid control, cooling, glucose/ECG, benzodiazepine-led protocol and critical-care review. |
| Alcohol withdrawal | Tremor, sweating, anxiety, hallucinations, seizures, autonomic instability. | Seizure precautions, thiamine/glucose considerations and supervised withdrawal treatment. |
| Serotonin syndrome | Agitation, diarrhoea, sweating, tremor, clonus/hyperreflexia, fever. | Stop serotonergic exposure, cooling, seizure/airway support and toxicology review. |
| NMS | Recent dopamine blocker, rigidity, hyperthermia, altered consciousness, unstable BP/pulse. | Emergency transfer, cooling, fluids and critical-care treatment. |
| Delirium | Fluctuating attention, disorientation, visual hallucinations, acute medical illness. | Search for hypoxia, infection, glucose, toxins, retention and pain; do not assume primary psychosis. |
12. Special populations
- Children: involve safeguarding, use age-appropriate communication and weight-based protocol; look for pain, injury, hypoxia or abuse.
- Older adults: new agitation is delirium until proven otherwise; reduce noise, check infection/medicines and use lower doses if sedation is authorised.
- Pregnancy: protect patient and fetus, use left lateral displacement where appropriate and involve obstetric/senior teams.
- Autism/intellectual disability: ask carers about baseline communication, sensory triggers, calming strategies and pain expression.
- Trauma/head injury: agitation may reflect hypoxia, intracranial injury or shock; protect the airway and avoid masking neurological change.
- Substance dependence: avoid stigma, anticipate withdrawal and respiratory depression, and provide naloxone/withdrawal care according to protocol.
13. Clinical scenarios
Scenario 1 — Hypoglycaemia: A shouting patient threatens staff. Glucose is 2.1 mmol/L. Treat the hypoglycaemia and reassess before sedation; the behaviour was a medical symptom.
Scenario 2 — Stimulant-related ABD: A patient is sweating, hyperthermic and fighting after suspected cocaine use. Protect the team, reduce stimulation, call senior help, give protocol-led rapid sedation with airway readiness, cool and monitor ECG/temperature/renal risk.
Scenario 3 — Akathisia: A patient on a new antipsychotic paces, says they feel unbearable inner restlessness and has suicidal thoughts. Consider akathisia, do not simply increase the antipsychotic, maintain safety and arrange urgent review.
Scenario 4 — Delirium: An older patient becomes suddenly agitated overnight with fever and fluctuating attention. Check oxygenation, glucose, infection, urine retention, medicines and pain; involve family and avoid unnecessary restraint.
Scenario 5 — Sedation complication: After parenteral sedation, the patient becomes snoring and bradypnoeic. Stop further doses, jaw thrust, suction, oxygen/BVM, capnography and resuscitation-team escalation.
14. Documentation and handover
- Baseline behaviour, mental state, capacity, triggers, threats, weapons and risk to self/others.
- Medical assessment: airway, breathing, circulation, glucose, temperature, trauma, substances and medicines.
- De-escalation offered, choices, consent/refusal and why escalation was necessary.
- Medication name/concentration/route/dose/time, monitoring, response and adverse effects.
- Restraint type, reason, staff, start/stop time, body position, circulation/airway observations and review.
- Safeguarding, family/support, police/security involvement, receiving clinician and follow-up plan.
15. Revision questions
- Why is acute agitation a medical emergency rather than simply a behavioural problem?
- List six reversible medical causes of aggression.
- What are the first steps in verbal de-escalation?
- When is emergency sedation justified?
- What equipment must be ready before parenteral sedation?
- Why is physical restraint a last resort?
- What signs suggest ABD physiology and rhabdomyolysis risk?
- How can akathisia be mistaken for worsening psychosis?
- What observations are required after sedation?
- What must be documented after restraint?
16. Key take-home points
- Protect people while searching for hypoxia, hypoglycaemia, trauma, toxicity, withdrawal, delirium and psychiatric illness.
- De-escalation, clear boundaries and a calm team prevent many confrontations.
- If sedation is needed, prepare airway rescue, monitor continuously and reassess after every dose.
- Extreme agitation with hyperthermia, sweating, acidosis or collapse is time-critical ABD.
- Use restraint only when necessary, proportionately and with continuous observation.
Selected authoritative resources
- Royal College of Emergency Medicine: Acute Behavioural Disturbance in Emergency Departments.
- Resuscitation Council UK ABCDE approach.
- RCEM procedural sedation monitoring guidance.
For EMT practice: The goal is safe control and treatment, not domination. Respectful communication, rapid medical assessment, proportionate intervention and continuous monitoring protect both patient and team.