Acute psychosis - Revision history

Danbot: Expand with concise EM-focused content: red flags for organic cause, pharmacologic management options, B52 cocktail

2026-03-21T01:27:48Z

Expand with concise EM-focused content: red flags for organic cause, pharmacologic management options, B52 cocktail

← Revisión anterior		Revisión del 01:27 21 mar 2026
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	==Background==		==Background==
	*~~Caused~~ by ~~many~~ psychiatric ~~as well as~~ medical ~~conditions~~		*Loss of contact with reality characterized by hallucinations, delusions, and/or disordered thinking
			*'''EM priority:''' Rule out medical (organic) causes before attributing to primary psychiatric illness
			*First-episode psychosis, age >40 onset, or atypical features should always prompt thorough medical workup
			*Causes: schizophrenia, bipolar disorder, substance intoxication/withdrawal, medical illness (infection, metabolic, neurologic, endocrine)

	==Clinical Features==		==Clinical Features==
			*[[Hallucinations]] (auditory most common in psychiatric; visual more suggestive of organic cause)
			*Delusions (paranoid, persecutory, grandiose)
			*Disorganized speech or behavior
	*[[Agitation]], restlessness, irritability		*[[Agitation]], restlessness, irritability
	*Decreased attention		*Decreased attention
	*Inappropriate or hostile behaviors		*Inappropriate or hostile behaviors
	*[[Hallucinations]], delusions, paranoia		*+/- additional features of underlying pathology (signs of intoxication/withdrawal, trauma, focal neurologic deficits)
	*+/- additional features of underlying pathology (~~e.g.~~ signs of intoxication/withdrawal, trauma)
			===Red Flags Suggesting Medical Cause===
			*Age >40 with no psychiatric history
			*Acute onset (hours to days)
			*Visual hallucinations predominant
			*[[Altered mental status]], clouding of consciousness (suggests [[delirium]])
			*Vital sign abnormalities (fever, tachycardia, hypertension)
			*Focal neurologic findings
			*Recent medication changes or new substances

	==Differential Diagnosis==		==Differential Diagnosis==
	{{AMS DDX}}		{{AMS DDX}}

	{{Psychiatric Disorders with Psychotic Symptoms DDX}}		{{Psychiatric Disorders with Psychotic Symptoms DDX}}

	==Evaluation==		==Evaluation==
	*Rule out ~~any~~ organic causes ~~or contributing factors~~		*Rule out organic causes before attributing to primary psychiatric illness

	{{General ED Psychiatric Workup}}		{{General ED Psychiatric Workup}}
			*Consider: glucose, BMP, CBC, [[urine toxicology screen]], TSH, urinalysis, [[ECG]]
			*CT head if: first episode, focal neuro findings, altered consciousness, age >40, head trauma
			*LP if meningitis/encephalitis suspected (fever + AMS)

	==Management==		==Management==
	*Treat underlying condition!		*'''Treat underlying condition''' first
			*Ensure scene safety — de-escalation techniques before pharmacologic intervention
	{{General ED Psychiatric Management}}		{{General ED Psychiatric Management}}
			*'''Pharmacologic management of acute agitation:'''
			**[[Haloperidol]] 5-10 mg IM + [[lorazepam]] 2 mg IM + [[diphenhydramine]] 50 mg IM (classic ''B52'' cocktail)
			**[[Olanzapine]] 10 mg IM (avoid with benzodiazepines — risk of respiratory depression)
			**[[Midazolam]] 5 mg IM (fastest onset for severe agitation)
			**[[Ketamine]] 4-5 mg/kg IM for severe undifferentiated agitation
			*Avoid restraints when possible; use least restrictive measures

	==Disposition==		==Disposition==
	*Depends on underlying cause ~~of psychosis~~		*Depends on underlying cause
	*~~Hospitalization for~~ first psychotic episode, suicidal or homicidal, unable to care for self or poor support system		*'''Admit/psychiatric hold:''' first psychotic episode, suicidal/homicidal ideation, unable to care for self, poor support system
			*'''Discharge:''' known psychiatric disorder with exacerbation, medically cleared, safe disposition plan, psychiatry follow-up

	==See Also==		==See Also==
Línea 33:		Línea 55:
	*[[Agitated delirium]]		*[[Agitated delirium]]
	*[[Hallucinations]]		*[[Hallucinations]]
			*[[Delirium]]
	~~==External Links==~~


	==References==		==References==

Rossdonaldson1: /* See Also */

2022-08-31T16:08:07Z

ClaireLewis at 16:05, 10 October 2019

2019-10-10T16:05:17Z

← Revisión anterior		Revisión del 16:05 10 oct 2019
Línea 1:		Línea 1:
	==Background==		==Background==
	*Caused by many psychiatric ~~and~~ medical conditions		*Caused by many psychiatric as well as medical conditions
	*Examples: schizophrenia, mania

	==Clinical Features==		==Clinical Features==
	*Agitation, restlessness, irritability		*[[Agitation]], restlessness, irritability
	*Decreased attention		*Decreased attention
	*Inappropriate or hostile behaviors		*Inappropriate or hostile behaviors
	*[[Hallucinations]], delusions, paranoia		*[[Hallucinations]], delusions, paranoia
			*+/- additional features of underlying pathology (e.g. signs of intoxication/withdrawal, trauma)

	==Differential Diagnosis==		==Differential Diagnosis==
Línea 15:		Línea 15:

	==Evaluation==		==Evaluation==
	*Signs or symptoms of intoxication or withdrawal
	*Signs of [[trauma]]
	*Rule out any organic causes or contributing factors		*Rule out any organic causes or contributing factors

Línea 22:		Línea 20:

	==Management==		==Management==
			*Treat underlying condition!

	{{General ED Psychiatric Management}}		{{General ED Psychiatric Management}}

Mholtz at 22:51, 21 October 2017

2017-10-21T22:51:08Z

← Revisión anterior		Revisión del 22:51 21 oct 2017
Línea 2:		Línea 2:
	*Caused by many psychiatric and medical conditions		*Caused by many psychiatric and medical conditions
	*Examples: schizophrenia, mania		*Examples: schizophrenia, mania

	==Clinical Features==		==Clinical Features==
	*Agitation, restlessness, irritability		*Agitation, restlessness, irritability
Línea 33:		Línea 34:

	==External Links==		==External Links==


	==References==		==References==
	<references/>		<references/>
	~~Brown, H. et al How to stabilize an acutely psychotic patient. Current Psychiatry. Dec 2012. Vol 11. No 12. p10-16 <br/>~~
	~~Rosen's Emergency Medicine 7th ed~~
	[[Category:Psychiatry]]		[[Category:Psychiatry]]

ClaireLewis at 00:46, 11 December 2016

2016-12-11T00:46:56Z

← Revisión anterior		Revisión del 00:46 11 dic 2016
Línea 3:		Línea 3:
	*Examples: schizophrenia, mania		*Examples: schizophrenia, mania
	==Clinical Features==		==Clinical Features==
	*Agitation		*Agitation, restlessness, irritability
	*Restlessness
	*Irritability
	*Decreased attention		*Decreased attention
	*~~innappropriate~~ or hostile behaviors		*Inappropriate or hostile behaviors
			*[[Hallucinations]], delusions, paranoia

	==Differential Diagnosis==		==Differential Diagnosis==
	{{AMS DDX}}		{{AMS DDX}}
Línea 14:		Línea 14:

	==Evaluation==		==Evaluation==
	*~~signs~~ or symptoms of intoxication or withdrawal		*Signs or symptoms of intoxication or withdrawal
	*~~signs~~ of trauma		*Signs of [[trauma]]
	*~~rule~~ out any organic causes or ~~contributors~~		*Rule out any organic causes or contributing factors

	{{General ED Psychiatric Workup}}		{{General ED Psychiatric Workup}}
Línea 29:		Línea 29:
	==See Also==		==See Also==
	*[[Altered mental status]]		*[[Altered mental status]]
			*[[Agitated delirium]]
			*[[Hallucinations]]

	==External Links==		==External Links==

Humanguy: Replaced with General ED Psychiatric Management template

2016-11-10T22:23:13Z

Replaced with General ED Psychiatric Management template

@@ Línea 21: / Línea 21: @@
 ==Management==
-*Non-pharmacologic
+{{General ED Psychiatric Management}}
 ==Disposition==

Humanguy: Added General ED Psych Workup To Evaluation

2016-11-10T19:43:37Z

Added General ED Psych Workup To Evaluation

← Revisión anterior		Revisión del 19:43 10 nov 2016
Línea 14:		Línea 14:

	==Evaluation==		==Evaluation==
	*Vital signs
	*Blood glucose
	*signs or symptoms of intoxication or withdrawal		*signs or symptoms of intoxication or withdrawal
	*signs of trauma		*signs of trauma
	*rule out any organic causes or contributors		*rule out any organic causes or contributors

			{{General ED Psychiatric Workup}}

	==Management==		==Management==

Rossdonaldson1: /* Differential Diagnosis */

2016-11-03T08:38:19Z

Differential Diagnosis

← Revisión anterior		Revisión del 08:38 3 nov 2016
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	==Differential Diagnosis==		==Differential Diagnosis==
	{{AMS DDX}}		{{AMS DDX}}

			{{Psychiatric Disorders with Psychotic Symptoms DDX}}

	==Evaluation==		==Evaluation==

ClaireLewis: /* Management */

2016-09-25T17:15:03Z

Management

← Revisión anterior		Revisión del 17:15 25 sep 2016
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	*Pharmacologic: Goal is to calm patient without oversedation		*Pharmacologic: Goal is to calm patient without oversedation
	**'''No history of psychosis'''		**'''No history of psychosis'''
	***Haloperidol 0.5mg-5mg + lorazepam 0.25-2mg (PO/IM/IV)		***[[Haloperidol]] 0.5mg-5mg + lorazepam 0.25-2mg (PO/IM/IV)
	***Consider adding benztropine 0.5-2mg '''or''' [[diphenhydramine]] 25-50mg (PO/IV/IM)		***Consider adding [[benztropine]] 0.5-2mg '''or''' [[diphenhydramine]] 25-50mg (PO/IV/IM)
	****reduces dystonia or ~~EPS~~		****reduces dystonia or [[extrapyramidal reaction]]
	***Consider risperidone 0.5-2mg PO '''or''' olanzapine 2.5-20mg (PO/IM/SL) '''or''' ziprasidone 10-20mg IM		***Consider [[risperidone]] 0.5-2mg PO '''or''' olanzapine 2.5-20mg (PO/IM/SL) '''or''' ziprasidone 10-20mg IM
	**'''Known or suspected underlying psychotic illness'''		**'''Known or suspected underlying psychotic illness'''
	***Continue treatment with previous antipsychotic '''or'''		***Continue treatment with previous antipsychotic '''or'''

Rossdonaldson1: Text replacement - " diphenhydramine" to " diphenhydramine"

2016-08-03T05:09:10Z

Text replacement - " diphenhydramine" to " diphenhydramine"

← Revisión anterior		Revisión del 05:09 3 ago 2016
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	**'''No history of psychosis'''		**'''No history of psychosis'''
	***Haloperidol 0.5mg-5mg + lorazepam 0.25-2mg (PO/IM/IV)		***Haloperidol 0.5mg-5mg + lorazepam 0.25-2mg (PO/IM/IV)
	***Consider adding benztropine 0.5-2mg '''or''' diphenhydramine 25-50mg (PO/IV/IM)		***Consider adding benztropine 0.5-2mg '''or''' [[diphenhydramine]] 25-50mg (PO/IV/IM)
	****reduces dystonia or EPS		****reduces dystonia or EPS
	***Consider risperidone 0.5-2mg PO '''or''' olanzapine 2.5-20mg (PO/IM/SL) '''or''' ziprasidone 10-20mg IM		***Consider risperidone 0.5-2mg PO '''or''' olanzapine 2.5-20mg (PO/IM/SL) '''or''' ziprasidone 10-20mg IM

← Revisión anterior		Revisión del 16:08 31 ago 2022
Línea 29:		Línea 29:

	==See Also==		==See Also==
			*[[Agitated or combative patient]]
	*[[Altered mental status]]		*[[Altered mental status]]
	*[[Agitated delirium]]		*[[Agitated delirium]]