Prehospital and transport

Agitated or Violent Patient Algorithm

Safety, words first, medical causes, then sedation that is monitored

Reviewed by Alex G, BSN, RN, CEN, CCRN, CMC, NREMT-P · From the Reference tab of the app

Each step lists what to do, then the choices that lead on. In the app the algorithm is tapped through one decision at a time.

1 Is the scene safe?

Do not enter or try to control a scene with violence or weapons (NASEMSO V3)
Law enforcement should be involved whenever the patient threatens self, the public or responders (NAEMSP 2021)
Gloves and PPE; keep an exit behind you

Weapons or active violence → step 2 Safe to approach → step 3

2 Retreat and wait for law enforcement

If you are in danger, retreat to a safe place and wait (NAEMSP 2021)
If you cannot retreat and are attacked, you may defend yourself as local law permits (NAEMSP 2021)
EMS must not give sedatives to help an arrest or custody (NAEMSP 2021)

Scene secured → step 3

3 Verbal de-escalation first

De-escalation takes precedence over physical or chemical restraint whenever possible (NAEMSP 2021)
One calm speaker; build rapport; reassure; involve family if they calm the patient (NASEMSO V3)
Score agitation with RASS, AMSS or BARS and repeat it (NASEMSO V3; NAEMSP 2021)

Calming and cooperating → step 4 Danger to self or others despite de-escalation → step 5

4 Look for a medical cause

Hypoxia, hypoglycemia, stroke, seizure, head injury, delirium, alcohol or drug intoxication (NAEMSP 2021); also consider withdrawal
Glucose, SpO₂, temperature, vital signs, signs of trauma; note drugs on scene (NASEMSO V3)
High-flow oxygen by mask treats hypoxia in a patient too agitated for oximetry (NAEMSP 2021)

A medical cause found → step 6 Cooperative: transport and keep talking → step 7 Escalating danger → step 5

5 Sedation needed: how high is the risk?

Delirium with agitated behavior can lead to hyperthermia, hyperkalemia, rhabdomyolysis and cardiac arrest; rapid sedation may prevent them (NAEMSP 2021)
Use the term delirium with agitated behavior (NAEMSP, NASEMSO) or hyperactive delirium with severe agitation (ACEP); in October 2023 ACEP withdrew approval of its 2009 excited delirium paper and said the term should not be used
Choose by condition, medications, allergies and protocol (NASEMSO V3)

Adult, high violence risk or delirium with agitation → step 8 Adult, less severe or partly cooperative → step 9 Child → step 10

6 Treat the cause

Hypoglycemia: dextrose per protocol; hypoxia: oxygen and ventilation
Hyperthermia over 40 °C: cool at once with standard care; ice water immersion at 1–5 °C (2a), at least 0.15 °C/min, stop at 38.6 °C (AHA 2025)
Severe agitation from stimulants: sedation is recommended (AHA 2025, class 1)
Agitation after naloxone is often withdrawal: support the airway, no more naloxone

Still dangerous → step 5 Settled: transport → step 7

7 Monitor and reassess continuously

Airway, SpO₂ and capnography, cardiac monitor as soon as possible, frequent blood pressure, mental status (NASEMSO V3)
Check circulation and capillary refill in every restrained limb, and repeat (NAEMSP 2021; NASEMSO V3)
After antipsychotics: watch for dystonia (treat with diphenhydramine or a benzodiazepine) and arrhythmias, especially a long QT (NASEMSO V3)
Ground transport; air is not advised (NASEMSO V3). Document behavior, the reason for restraint, drugs, doses and every reassessment

Breathing slows or SpO₂ or ETCO₂ worsens → step 11 Hot, rigid or still struggling → step 6

8 Rapid sedation: high violence risk

Ketamine 4 mg/kg IM (onset 3–5 min) or 2 mg/kg IV (onset about 1 min) (NASEMSO V3)
Or droperidol 5–10 mg IM (onset about 20 min) or 2.5 mg IV (NASEMSO V3)
Or midazolam 5 mg IM, IV or IN (NASEMSO V3, which does not mark it as a high-violence-risk option)
A rapid-onset drug is preferred for delirium with agitation or serious self-injury risk (NAEMSP 2021)

Physical restraint still needed → step 12 Sedated: monitor → step 7

9 Sedation: other options

Midazolam 5 mg IV, IM or IN; lorazepam 2 mg IV or 4 mg IM; diazepam 5 mg IV or 10 mg IM (NASEMSO V3)
Haloperidol 5 mg IV or 5–10 mg IM; ziprasidone 10 mg IM; olanzapine 10 mg IM, or 10 mg ODT if the patient will take it (NASEMSO V3)
Diphenhydramine 25–50 mg IM, IV or PO (NASEMSO V3)

Physical restraint still needed → step 12 Sedated: monitor → step 7 Escalating despite this → step 8

10 Child: weight-based doses

Midazolam 0.05–0.1 mg/kg IV, 0.1–0.15 mg/kg IM or 0.3 mg/kg IN, max 5 mg (NASEMSO V3)
Ketamine 1 mg/kg IV or 3 mg/kg IM (NASEMSO V3)
Ages 6–12: haloperidol 1–3 mg IM (max 0.15 mg/kg); droperidol not routinely recommended (NASEMSO V3)
Diphenhydramine 1 mg/kg, max 25 mg (NASEMSO V3); document the weight in kg

Physical restraint still needed → step 12 Sedated: monitor → step 7

11 Oversedation or hypoventilation

Open the airway (jaw thrust), sit up or turn to the side, oxygen
Ventilate with a bag-mask if breathing is inadequate: 1 breath every 6 seconds (AHA 2025 BLS)
Loosen any restraint near the chest or neck; check for vomiting
No pulse: CPR and ALS; tell the receiving hospital early

End of this path.

12 Physical restraint: least restrictive, never prone

Soft devices that release without a key; secure all four limbs to the stretcher frame, one arm up and one down for the most combative (NASEMSO V3)
Stretcher sitting up; nothing may restrict the chest wall (NASEMSO V3)
Physically restrained patients should also be sedated (NASEMSO V3); prolonged restraint without sedation is harmful (AHA 2025, 3: Harm)
EMS does not use handcuffs; a police device that must stay means an officer rides along, or it is swapped for an EMS device (NAEMSP 2021)

Restrained: monitor → step 7

Drugs in this algorithm

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