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OverviewAetiologyPathophysiologyClinical features and red flagsInvestigationsDifferential diagnosisManagementComplicationsMonitoring and follow-upSpecial situationsCommon pitfallsQuestionsSources
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Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.

Agitation and rapid tranquillisation

Psychiatry · UK scope · Sources checked 7 Sept 2026 · Clinical review pending

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Agitation with physiological collapse

Extreme exertion, hyperthermia, hypoxia, collapse, reduced consciousness or abnormal breathing during agitation or restraint requires resuscitation assessment immediately.

Action: Call senior emergency and airway support, stop any restriction impairing ventilation, undertake ABCDE and glucose assessment, and move to a monitored resuscitation setting while treating the underlying cause.

Overview

Assess the cause and physiological danger of acute agitation, use proportionate calming measures, and administer and monitor emergency sedation without overlooking a medical emergency.

Acute agitation includes heightened motor activity, distress, irritability or loss of behavioural control. The intensity of shouting does not reliably measure the severity of the illness. A frightened person who can negotiate may need space and explanation; someone who is sweating, disoriented and struggling continuously may need immediate emergency treatment. Describe observed behaviour, onset, physiology and the suspected cause instead of using a label as a diagnosis.

Start assessment while the team makes the environment safer. Ask what has happened, what the person needs and what usually helps. Observe breathing, colour, attention, gait and obvious injury before attempting a full interview. Obtain a medication and substance history from the patient, records, ambulance staff and companions when possible. Pain, urinary retention, hypoglycaemia and hypoxia may produce resistance to care without a primary psychiatric illness.

Aetiology

01

Primary mental illness

Mania, persecutory psychosis and severe affective distress can increase activity or defensive behaviour, but their presence does not exclude concurrent infection, injury or intoxication.

02

Medical and toxicological triggers

Hypoxia, low glucose, delirium, pain, withdrawal and drug toxicity may impair judgement and produce agitation that improves only when the physiological cause is addressed.

Pathophysiology

  1. 1
    Threat response

    Perceived danger activates autonomic arousal and narrows attention, making complex instructions or a surrounding crowd harder to process and potentially escalating defensive responses.

  2. 2
    Disrupted cognition

    Acute brain dysfunction alters attention and interpretation of the environment, so ordinary procedures may be experienced as threatening or incomprehensible.

  3. 3
    Exertion and sedation

    Intense sustained muscular activity increases heat and metabolic demand, while sedatives can reduce airway tone and ventilation; both mechanisms require active physiological observation.

Clinical features and red flags

Threat and escalation

Pacing, clenched posture, increasing volume or statements of intent warrant early engagement and a realistic assessment of access to weapons or vulnerable people.

Delirious behaviour

Inattention, disorientation and rapid fluctuation suggest disturbed brain function; apparently psychotic statements may accompany infection, withdrawal or metabolic illness.

Medicine-induced restlessness

Akathisia can cause unbearable inner restlessness after dopamine-blocking treatment, and escalating the same antipsychotic may worsen the presentation.

Dangerous exhaustion

Persisting strenuous activity with fever, tachypnoea, collapse or abrupt loss of resistance requires immediate physiological assessment and resuscitation expertise.

Red flags requiring action

  • A suddenly quiet or unresponsive person after prolonged struggle may be deteriorating physiologically; release unsafe restraint, reassess breathing and circulation, and activate emergency help.
  • Fever, rigidity, clonus, focal neurological findings, head injury or a fluctuating attention deficit suggests a toxicological, neurological or medical cause requiring urgent investigation.

Investigations

  1. 01
    Immediate physiological assessmentFirst step
    Why
    Detect hypoxia, hypoglycaemia, hyperthermia and circulatory instability while arranging safe care.
    Interpretation and limitations
    Abnormal observations change the setting and urgency; inability to obtain measurements safely is itself a reason to obtain senior support, not reassurance.
  2. 02
    Medication reconciliation and exposure timeline
    Why
    Identify accumulated sedatives, recent dose changes and possible intoxication or withdrawal.
    Interpretation and limitations
    Include depot injections, antiemetics, non-prescribed drugs and alcohol; a negative routine urine screen cannot exclude many relevant intoxicants.
  3. 03
    ECG and electrolyte testing
    Why
    Assess rhythm, QT-related vulnerability and reversible arrhythmia risks before relevant antipsychotic use.
    Interpretation and limitations
    The absence of an ECG prevents safe selection of the NICE haloperidol-promethazine option; hypokalaemia and hypomagnesaemia increase concern.
  4. 04
    Targeted medical investigations
    Why
    Test suspected infection, injury, organ dysfunction or muscle injury after the initial assessment.
    Interpretation and limitations
    Choose blood count, renal profile, blood gas, creatine kinase, imaging or other investigations according to findings; tests must not delay treatment of immediate danger.

Differential diagnosis

01

Akathisia

An urge to move with distress after dopamine-blocking medication can mimic behavioural escalation, but may worsen when the same drug is repeatedly administered.

02

Withdrawal state

Abrupt reduction of alcohol or sedatives can produce tremor, autonomic activation, perceptual disturbance and seizures, requiring a cause-specific medical treatment pathway.

03

Delirium or encephalopathy

Fluctuating alertness and inattention favour an acute physiological process even when hallucinations or a previous psychiatric diagnosis make psychosis initially plausible.

Management

01Engage earlyCreate enough calm to assessFirst stepThe patient is distressed but there is time for verbal engagement and negotiation.+
  1. 1Introduce one staff member as the main speaker and ask what the person believes is happening and what would help immediately.
  2. 2Offer a quieter area with an exit route, communication support, analgesia or other practical relief, and voluntary oral treatment when clinically appropriate.
  3. 3Keep other staff available without surrounding the patient and reassess threats, attention and physiology as the interaction develops.
02Urgent injectionSelect and review a single doseImmediate risk persists and less restrictive measures or oral treatment are insufficient or unsuitable.+
  1. 1Check allergies, previous response, cardiac and respiratory disease, pregnancy, intoxication and all medication already given; identify a lawful basis for intervention.

Complications

01

Respiratory compromise

Sedation, intoxication and restrictive positioning may combine to cause obstruction or hypoventilation, particularly when staff focus only on whether movement has stopped.

02

Trauma and physiological injury

Falls, restraint injuries, dehydration, hyperthermia and rhabdomyolysis can follow severe agitation, with renal or circulatory consequences that continue after behavioural improvement.

03

Psychological harm

A frightening or humiliating intervention may damage trust and trigger future avoidance, making explanation, proportionate practice and a collaborative debrief clinically valuable.

Monitoring and follow-up

  • Observe respiratory effort as well as the numerical respiratory rate; snoring, obstruction, shallow breathing or reduced responsiveness demands immediate review even if the person looks peaceful. The Macure injection SmPC also advises observation for at least eight hours, preferably overnight; a stable early observation is not a discharge criterion.
  • Document drug, dose, route, time, reason, previous medication exposure, legal basis, response and the named person responsible for ongoing observations.
  • Look for dystonia, akathisia, hypotension, QT-related arrhythmia and delayed oversedation rather than attributing every new symptom to the initial agitation.
  • Review injuries, hydration, renal function and muscle injury when prolonged exertion, restraint or hyperthermia occurred; continue medical observation as the cause requires.
  • After recovery, agree an anticipatory plan and review whether regular treatment, the environment or staff communication contributed to the episode.

Special situations

Calmness is the endpoint

Loss of consciousness is an adverse outcome rather than proof that rapid tranquillisation worked, and requires a fresh airway and physiological assessment.

A quiet collapse matters

The transition from vigorous struggle to silence can signal exhaustion or cardiorespiratory failure, so teams must keep observing throughout restriction.

Schedules are not interchangeable

A medicine's licensed repeat interval does not authorise automatic repeated emergency injections without response review, cumulative dose calculation and adequate staffing.

Different setting, different pathway

Resuscitation sedation for severe physiological disturbance needs emergency and airway expertise; a psychiatric ward protocol cannot replace that capability.

Common pitfalls

  1. 01

    Giving repeated injections before the first dose has been assessed, especially when alcohol or other depressants may be present.

  2. 02

    Choosing haloperidol with promethazine despite a missing ECG because no cardiac disease has previously been recorded.

  3. 03

    Interpreting akathisia as worsening psychosis and repeatedly increasing the medicine that caused the restlessness.

  4. 04

    Stopping physical monitoring as soon as aggression decreases, although respiratory depression may emerge during apparent recovery.

  5. 05

    Recording restraint or medication as a response to non-compliance without describing imminent harm, alternatives and the legal basis.

Practice

Two practice questions

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Question 1 of 2
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PsychiatryOriginal SBA

Unknown cardiac information

A 35-year-old needs urgent intramuscular rapid tranquillisation after de-escalation fails. Previous antipsychotic exposure is unknown and an ECG cannot be obtained. There is no identified contraindication to lorazepam. Which regimen does NICE recommend in these circumstances?

Choose one answer, then submit
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Sources and review status7 sources · checked 7 Sept 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 7 Sept 2026; clinical approval remains outstanding.

  • NICE NG10 violence and aggression recommendationsSelection, single-dose review, restriction and observation requirements.
  • RCEM acute behavioural disturbance guideline May 2025Emergency assessment and distinction from routine psychiatric sedation.
  • Lorazepam Macure injection UK SmPCProduct-specific contraindications, preparation and monitoring; its licensed acute-anxiety dosing is distinct from the cited regional rapid-tranquillisation schedule.
  • Haloperidol injection Wockhardt UK SmPCProduct-specific adult agitation dose and contraindications.
  • NICE QS154 physical health after rapid tranquillisationMinimum physical monitoring responsibilities.
  • Phenergan 25mg per ml injection UK SmPCProduct-specific adult intramuscular dose, administration and safety precautions.
  • Leicestershire Partnership NHS Trust rapid tranquillisation policy August 2026Current regional adult intramuscular doses, repeat intervals and cumulative limits; NICE supplies the national choice and monitoring recommendations.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. ·

Escalation should follow a reasoned assessment of imminent harm and response to less restrictive measures. An injection is not justified merely because a person refuses a request or makes staff uncomfortable. If urgent sedation is required, allocate a clinical lead, an airway observer and staff able to monitor and manage adverse effects. Explain the intended action to the person even when their ability to participate is limited. Record the applicable consent or legal basis separately from the prescription.

Severe behavioural disturbance with abnormal physiology belongs in a resuscitation pathway. The RCEM emergency guideline addresses this setting, including clinician-led sedation with airway capability. It should not be confused with a routine psychiatric ward rapid-tranquillisation chart. Choice of drug, route and dose depends on the cause, physiological state, prior treatment and available monitoring. Pregnancy, older age, frailty, respiratory disease and combined intoxication materially alter the balance of risks.

Key points

  • Agitation is a presentation; distinguish fear and unmet needs from delirium, intoxication, withdrawal, psychosis, mania and medicine adverse effects.
  • Use one calm communicator, reduce noise and crowding, offer simple choices and voluntary oral medication when appropriate.
  • Rapid tranquillisation means urgent parenteral sedation when oral treatment is unsuitable; the clinical target is safe calmness with preserved respiratory function.
  • NICE adult options are intramuscular lorazepam alone or intramuscular haloperidol together with intramuscular promethazine, selected after checking individual risks.
  • Use lorazepam when antipsychotic exposure is unknown or there is insufficient history; avoid the haloperidol combination if no ECG is available or cardiovascular disease or prolonged QT is present.
  • Prescribe an initial single dose and review its effect before repeating; add scheduled, as-required and already administered medicines when calculating exposure.
  • Monitor physical observations and consciousness after injection, with greater frequency when sedation, intoxication, physical illness or restraint injury increases risk.
2
Use the NICE adult options according to risk and setting, prepare monitoring and resuscitation equipment, and prescribe one initial dose with a defined review.
  • 3Assess effect and adverse effects before any additional dose; seek senior review if initial treatment fails rather than stacking several sedatives rapidly.
    • 03After administrationObserve recovery and prevent recurrenceParenteral medication has been administered and the person appears calmer or has become sedated.+
    1. 1Monitor pulse, blood pressure, respiratory rate, temperature, hydration and consciousness at least hourly until physical concern has resolved, alongside locally required oxygen saturation monitoring.
    2. 2Use at least fifteen-minute observations when the person is asleep or sedated, has taken alcohol or illicit drugs within the previous twenty-four hours, has a relevant physical illness, has exceeded the BNF maximum or was harmed during restriction.
    3. 3PreferredEscalationEscalate airway, breathing or circulatory compromise immediately and conduct a debrief once recovery allows, revising the plan around identified triggers and preferred alternatives.
    Key medicines and prescribing safety2 treatments · regimens, roles and cautions+
    NICE supports intramuscular lorazepam alone for adult rapid tranquillisation, particularly with insufficient prior antipsychotic or cardiac information.

    Lorazepam injection

    An adult regimen in Leicestershire Partnership NHS Trust's August 2026 policy is lorazepam 1–2 mg intramuscularly once. After response and safety review, a further dose may be considered after two hours for a partial response, with a total maximum of 4 mg in 24 hours under that policy. Local protocols differ; count all prior benzodiazepine doses and prescribe each injection for the current episode.

    Use lower individualised doses in frail or older patients; the cited regional policy limits older or frail adults to 2 mg in 24 hours. Respiratory insufficiency, sleep apnoea, myasthenia gravis and severe hepatic insufficiency are important contraindications. Opioids and other depressants amplify respiratory risk; follow the actual product's dilution and administration requirements.

    A NICE alternative adult regimen when prior response and cardiac assessment support an antipsychotic-based rapid-tranquillisation approach.

    Haloperidol with promethazine

    The same regional adult protocol uses haloperidol 5 mg intramuscularly with promethazine 50 mg by a separate deep intramuscular injection. Review each initial dose before any repeat: haloperidol may be repeated after at least one hour, maximum 20 mg in 24 hours; promethazine after at least two hours, maximum 100 mg in 24 hours. Do not repeat both drugs automatically at the shorter interval.

    Avoid this combination without an ECG or with cardiovascular disease or prolonged QT; check interacting QT-prolonging drugs, electrolytes, Parkinson's disease and Lewy-body dementia. Product maximums are ceilings, not targets, and older patients need substantially lower doses. Promethazine's antimuscarinic effects can worsen delirium.

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