Severely agitated adult in the ED with unclear intoxication or medical cause: how should I choose medications, avoid respiratory/QT complications, and teach the resident the safety priorities?

Severe agitation with unclear intoxication or medical etiology requires simultaneous safety control, medical assessment, and de-escalation. Initial priorities are scene safety, rapid identification of red flags for organic disease, point-of-care glucose, and early calming interventions.¹² Medication choice depends on agitation severity, route feasibility, speed needed, comorbidities, and adverse-effect profile.²³⁴ Benzodiazepines act rapidly but increase risk of respiratory depression and oversedation, particularly in older adults.²⁴ Antipsychotics are commonly used for psychotic or undifferentiated agitation; haloperidol and droperidol carry QT concerns, while second-generation agents generally have lower EPS and less QT risk.¹²⁴ Ketamine provides the fastest reliable sedation for violent patients but may increase complications and can worsen psychotic symptoms.¹²⁴ Physical restraints are a last resort and require team-based application, close monitoring, and continued verbal de-escalation.²³