Screen for acute medical conditions that may contribute to the patient's behavior.
Always obtain:
Blood glucose
Vitals, including pulse oximetry
Consider:
Metabolic panel: serum electrolytes, thyroid function
Toxicology screen and blood alcohol levels
Lumbar puncture (CNS infection)
Aspirin and acetaminophen levels (intentional ingestion)
Medication levels (sub- vs super-therapeutic)
Electrocardiogram (elders, intentional ingestion).
Cranial imaging
Electroencephalography
Unnecessary diagnostic testing prolongs ED stay and delays definitive psychiatric care.
Organic cause unlikely → may not require further workup
Younger than 40 years
Prior psychiatric history
Normal physical examination
Normal vital signs
Calm demeanor
Normal orientation
No physical complaints
Organic cause more likely → does require further workup
Acute onset of agitated behavior
Behavior that waxes and wanes over time
Older than 40 years with new psychiatric symptoms
Elders (higher risk for delirium)
History of substance abuse (intoxication or withdrawal)
Persistently abnormal vital signs
Clouding of consciousness
Focal neurologic findings
Always obtain:
Blood glucose
Vitals, including pulse oximetry
Consider:
Metabolic panel: serum electrolytes, thyroid function
Toxicology screen and blood alcohol levels
Lumbar puncture (CNS infection)
Aspirin and acetaminophen levels (intentional ingestion)
Medication levels (sub- vs super-therapeutic)
Electrocardiogram (elders, intentional ingestion).
Cranial imaging
Electroencephalography
Blood glucose
Vitals, including pulse oximetry
Metabolic panel: serum electrolytes, thyroid function
Toxicology screen and blood alcohol levels
Lumbar puncture (CNS infection)
Aspirin and acetaminophen levels (intentional ingestion)
Medication levels (sub- vs super-therapeutic)
Electrocardiogram (elders, intentional ingestion).
Cranial imaging
Electroencephalography
Organic cause unlikely → may not require further workup
Younger than 40 years
Prior psychiatric history
Normal physical examination
Normal vital signs
Calm demeanor
Normal orientation
No physical complaints
Organic cause more likely → does require further workup
Acute onset of agitated behavior
Behavior that waxes and wanes over time
Older than 40 years with new psychiatric symptoms
Elders (higher risk for delirium)
History of substance abuse (intoxication or withdrawal)
Persistently abnormal vital signs
Clouding of consciousness
Focal neurologic findings
Younger than 40 years
Prior psychiatric history
Normal physical examination
Normal vital signs
Calm demeanor
Normal orientation
No physical complaints
Normal vital signs
Calm demeanor
Normal orientation
No physical complaints
Acute onset of agitated behavior
Behavior that waxes and wanes over time
Older than 40 years with new psychiatric symptoms
Elders (higher risk for delirium)
History of substance abuse (intoxication or withdrawal)
Persistently abnormal vital signs
Clouding of consciousness
Focal neurologic findings
Combative patient
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Asplenic patient
Psychiatric
The obese patient
Schizophrenia, paranoid ideation, catatonic excitement
Second victim
Mania