Psychosocial, Behavioral & Cognitive · Topic 2 of 7

Acute Agitation & Restraints

Psychosocial · behavioral emergencies

Acute Agitation & Restraints

De-escalate, treat the cause, medicate to calm. Restraint is the last resort: never PRN; violent restraint needs a 1-hour face-to-face and 4-hour renewals.

Key numbers

Never write restraint orders PRNNo PRN orders

Face-to-face evaluation within 1 hour≤ 1 h

Renew violent-restraint orders every 4 hours4 h, max 24 h

01 · The ruleFace-to-face evaluation within 1 hour

Restraint or seclusion for violent or self-destructive behavior needs a face-to-face evaluation within 1 hour by a physician, licensed practitioner or trained RN: condition, response to the intervention, and need to continue.

02 · The ruleRenew violent-restraint orders every 4 hours

Violent or self-destructive restraint orders last up to 4 hours in adults (2 hours ages 9–17, 1 hour under 9), renewable to 24 hours; then a practitioner must see the patient before a new order.

03 · The ruleNever write restraint orders PRN

Restraint and seclusion orders must never be written as standing or as-needed (PRN) orders; each episode needs its own order from a licensed practitioner permitted by hospital policy and state law.

The rules

Know these

Non-violent restraint follows hospital policyThe CMS 1-hour face-to-face and 4-hour/24-hour order limits apply only to restraint for violent or self-destructive behavior; renewal of non-violent (medical) restraint, such as protecting lines in delirium, follows hospital policy.

Remove restraints at the earliest possible timeDiscontinue restraint or seclusion as early as possible regardless of the time left on the order, use the least restrictive effective method, and notify the attending as soon as possible if another clinician ordered it.

What it is

Core idea

A drug can be a chemical restraintA medication counts as a restraint when it is used to restrict behavior or movement and is not a standard treatment or dose for the patient's condition.

Diagnosis & monitoring

Work-up

Haloperidol and droperidol prolong the QTcHaloperidol and droperidol prolong the QTc (droperidol carries a boxed warning for torsades); check the ECG and correct potassium and magnesium, and use continuous ECG monitoring when haloperidol is given IV.

Do right now

In this order

First moves

Verbal de-escalation first; restraint last

→

Look for a medical cause of agitation

→

Severe agitation: droperidol or atypical plus midazolam

→

Face-to-face evaluation within 1 hour≤ 1 h

Why each step

Verbal de-escalation first; restraint lastVerbal de-escalation is first-line; restraint or seclusion is allowed only for the immediate physical safety of the patient or others after less restrictive measures fail — never for coercion, discipline, convenience or retaliation.

Look for a medical cause of agitationMake a provisional diagnosis of the cause — delirium, hypoxia, hypoglycemia, intoxication, withdrawal, psychosis — and target treatment to it; agitation from delirium or a medical illness is treated by fixing the illness first.

Severe agitation: droperidol or atypical plus midazolamFor severe ED agitation, ACEP (Level B) prefers droperidol or an atypical antipsychotic combined with midazolam for speed; if one agent, droperidol or an atypical (not midazolam alone); haloperidol with or without lorazepam is acceptable.

Face-to-face evaluation within 1 hourRestraint or seclusion for violent or self-destructive behavior needs a face-to-face evaluation within 1 hour by a physician, licensed practitioner or trained RN: condition, response to the intervention, and need to continue.

Management

Orders

Offer oral medication firstInvolve the patient in choosing medication; oral agents are preferred over intramuscular when the patient will cooperate, and the goal is to calm the patient, not to induce sleep.

Benzodiazepines for stimulant toxicity and alcohol withdrawalBenzodiazepines are first-line for agitation from stimulant intoxication and alcohol withdrawal; for agitation during alcohol intoxication, an antipsychotic (haloperidol) is preferred to avoid compounding respiratory depression.

Ketamine when safety is immediately threatenedWhen the safety of the patient, bystanders or staff is at immediate risk, ACEP suggests considering IV or IM ketamine for rapid control (Level C, consensus) — with airway and hemodynamic monitoring.

Agitated delirium: avoid benzodiazepines and restraintsIn delirium, physical restraints and tethers worsen agitation; prefer a sitter, avoid benzodiazepines unless the cause is alcohol or benzodiazepine withdrawal, and use low-dose antipsychotic only for dangerous agitation.

Red flags & don'ts

Avoid harm

No IM olanzapine with a parenteral benzodiazepine interactionDo not give intramuscular olanzapine together with a parenteral benzodiazepine — the combination risks excessive sedation and cardiorespiratory depression.

Violent or non-violent restraint?

Commonly confused

Typical use	Assaultive or self-harming patient
1-hour face-to-face	Required (practitioner or trained RN)
Order length (adults)	Up to 4 hours, renewable to 24 hours
After 24 hours	Practitioner must see and assess before a new order
PRN or standing order	Never

More detail

Reference

Show 5 reference facts

Seclusion (involuntary confinement alone in a room) is permitted only for violent or self-destructive behavior; simultaneous restraint and seclusion requires continuous in-person or audio-video monitoring.

Report to CMS by the next business day any death during restraint or seclusion, within 24 hours after removal, or within 1 week when restraint likely contributed; soft wrist-only restraint deaths are logged internally.

Staff applying restraints must be trained to recognize physical and psychological distress, including positional asphyxia, and to identify when restraint is no longer necessary.

For agitation with known psychosis, an antipsychotic addresses the underlying illness; second-generation agents cause less acute dystonia and akathisia than haloperidol or droperidol.

ACEP makes no recommendation for specific agents in patients older than 65 or in the out-of-hospital setting; in older adults, antipsychotics and benzodiazepines carry added delirium, fall and mortality risk.

Pearl

Talk first, treat the cause, calm — don't sedate to sleep; restraint buys safety, never convenience.

Sources · 42 CFR § 482.13(e)–(g) — Condition of participation: Patient's rights (restraint or seclusion; staff training; death reporting) — eCFR · ACEP Clinical Policy: Critical Issues in the Evaluation and Management of Adult Out-of-Hospital or ED Patients Presenting With Severe Agitation. Ann Emerg Med 2024 (approved Oct 2023) · ACEP Now — ACEP's New Clinical Policy on Severe Agitation (Level B/C recommendations quoted) · Wilson MP et al. The psychopharmacology of agitation: consensus statement of the AAEP Project BETA Psychopharmacology Workgroup. West J Emerg Med 2012;13:26–34 · Richmond JS et al. Verbal de-escalation of the agitated patient: Project BETA De-escalation Workgroup. West J Emerg Med 2012;13:17–25 · Zyprexa / Zyprexa IntraMuscular (olanzapine) prescribing information §5.7 — DailyMed · Merck Manual Professional — Delirium (management of agitation) · American Geriatrics Society 2023 Updated AGS Beers Criteria. J Am Geriatr Soc 2023;71:2052–2081 · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).