Severe Agitation / Hyperthermic Delirium (Stimulant Toxicity)
- Extreme psychomotor agitation; combativeness out of proportion to situation
- Marked insensitivity to pain; does not respond to verbal de-escalation
- Hyperthermia (elevated core temperature — often significantly above normal)
- Incoherent or unintelligible vocalizations
- Disrobing in public; bizarre behavior
- Tachycardia; diaphoresis; often associated with stimulant drug use
vs. Acute psychosis: Hyperthermic agitation / stimulant toxicity has prominent physical signs — hyperthermia, diaphoresis, tachycardia — and typically involves drug use (cocaine, methamphetamine). Acute psychosis may produce agitation but without the extreme physical findings. This is a medical emergency, not primarily a psychiatric one — treat the physiology, not just the behavior. Note: "excited delirium" as a formal diagnosis has been withdrawn by ACEP (2023) and is no longer endorsed by major medical organizations; describe the physiology (hyperthermia, stimulant toxicity, severe agitation), not the legacy label.
Sudden cardiac death can occur during or immediately after physical restraint, particularly prone restraint. Hyperthermia is the most dangerous physiological feature. Monitor continuously after restraint is achieved. Avoid positional asphyxia (weight on back while prone). Early chemical sedation (benzodiazepines) reduces risk.
Suicide Risk — Presentation and Assessment
- Stated suicidal ideation (with or without a specific plan)
- History of prior suicide attempts (strongest single predictor of future attempt)
- Giving away possessions, saying goodbye, putting affairs in order
- Sudden calmness after a period of severe depression (decision made)
- Access to means (firearms, medications, heights)
- Withdrawal from relationships; hopelessness; alcohol or drug use
Suicidal ideation with a plan + intent + access to means = imminent high-risk presentation requiring immediate intervention. Passive death wish ("I wouldn't mind if I didn't wake up") without plan or intent is lower acuity but still requires evaluation. Do not leave high-risk patients alone — remove access to means when safely possible.
Prior suicide attempt is the single strongest predictor of a future completed attempt. Always ask directly — "Are you thinking about killing yourself?" Asking does not increase risk; research consistently shows direct questioning is safe and often therapeutic. Document all findings and transport for evaluation.
Acute Psychosis
- Hallucinations — auditory most common in schizophrenia ("voices telling me to...")
- Delusions — fixed false beliefs (paranoid, grandiose, somatic)
- Disorganized or incoherent thinking; loose associations
- Paranoia; responding to internal stimuli
- Flat, blunted, or inappropriate affect
- Social withdrawal; self-neglect; decreased hygiene
vs. Organic (medical) psychosis: ALWAYS rule out medical causes before assuming primary psychiatric psychosis. Check: glucose, SpO2, temperature, pupils, vital signs, medication history. Causes include hypoglycemia, CO poisoning, encephalitis, intoxication, sodium abnormalities, and TBI. A patient who "acts crazy" may be critically ill.
Organic causes of apparent psychosis MUST be ruled out before attributing behavior to a psychiatric condition. A patient presenting as psychotic who has hypoglycemia or CO poisoning will die if treated as psychiatric. Medical assessment always precedes behavioral diagnosis in the field.
Severe Anxiety / Panic Attack vs. Cardiac
- Palpitations; chest tightness or chest pain
- Dyspnea; sensation of not getting enough air
- Paresthesias — tingling of hands, feet, or perioral area (hyperventilation-related)
- Diaphoresis; trembling or shaking
- Sense of impending doom; fear of dying or losing control
- Symptoms typically peak within 10 minutes and self-resolve — but ACS can too
vs. ACS: Panic attack typically occurs in younger patients with a normal 12-lead ECG, no radiation of pain, and no diaphoresis. ACS may show ST changes, radiation to jaw/arm, and profuse diaphoresis. The critical rule: a normal ECG does NOT rule out ACS (NSTEMI often has subtle or no ST changes). ALWAYS treat as cardiac until the ED says otherwise.
Never diagnose panic attack in the field. The chest pain and dyspnea of an acute MI can be indistinguishable from a panic attack based on presentation alone. Patients over 40, patients with cardiac risk factors, and patients with atypical presentations require a full cardiac workup. Transport and let the ED rule out ACS.
