Synopsis
Manage escalating behaviour in mania through medical assessment, trauma-informed de-escalation and proportionate least-restrictive intervention, while recognising delirium, intoxication and post-restraint physiological emergencies that require immediate treatment.
- First action is simultaneous safety and medical triage: acute agitation can arise from hypoxia, hypoglycaemia, delirium, intoxication, withdrawal, pain, head injury or mania.
- Use one calm lead communicator, personal space, simple choices, reduced noise and stimulation, access to food, fluid and toilet, and known preferences or advance statements.
- Verbal de-escalation and acceptable oral medication are preferred; as-needed medication alone is not a complete de-escalation strategy.
- Restrictive intervention is justified only after preventive strategies fail and harm is likely without action; continue communication and use the least restrictive proportionate option.
- For adult rapid tranquillisation, NICE recommends intramuscular lorazepam alone or intramuscular haloperidol with intramuscular promethazine after individual contraindication and exposure review.
- If information is insufficient, the person is antipsychotic-naive, cardiovascular disease or prolonged QT is present, or no ECG has been done, NICE favours intramuscular lorazepam.
- Prescribe the initial rapid-tranquillisation medicine as one dose and do not repeat until its clinical effect, observations, adverse effects and total daily exposure are reviewed.
- After rapid tranquillisation, monitor pulse, blood pressure, respiratory rate, temperature, hydration and consciousness at least hourly, or every fifteen minutes in specified high-risk circumstances.
- Debrief the patient and staff after containment, assess injury and emotional impact, document the legal and clinical rationale and revise the personalised prevention plan.
Key red flags
Stridor, respiratory depression, cyanosis, collapse, chest pain, severe hyperthermia, seizure or reduced consciousness requires immediate ABCDE management and resuscitation support.
Fluctuating attention, disorientation, fever, autonomic change, focal neurology or abrupt onset suggests delirium, intoxication, withdrawal or another acute medical cause.
Access to weapons, escalating threats, command hallucinations, persecutory fear or behaviour that creates imminent serious harm requires a coordinated emergency safety response.
Prolonged physical struggle, prone positioning, pressure on the neck or chest, obesity, intoxication and respiratory disease increase restraint-related physiological risk.
Pregnancy, frailty, older age, head injury, unknown medication exposure or absent ECG materially changes medicine and restrictive-intervention choices.
Investigation priorities
Detect airway, respiratory, circulatory, neurological, glucose, temperature and exposure emergencies during disturbance.
Management branches
A person with suspected mania becomes increasingly agitated but communication remains possible.
- Call appropriate support, remove hazards and bystanders, reduce stimulation and nominate one calm communicator with safe personal space.
- Offer simple choices, oral treatment and basic needs while checking ABCDE, cognition, injury, substances and the immediate harm scenario.
- Review the person's crisis plan and preferences and escalate only if preventive strategies fail and significant harm is otherwise likely.