Clinical Policy: Critical Issues in the Diagnosis and
Management of the Adult Psychiatric Patient
in the Emergency Department
September 23, 2005

1. What testing is necessary in order to determine medical
stability in alert, cooperative patients with normal vital
signs, a noncontributory history and physical examination,
and psychiatric symptoms?

Level B recommendations. In adult ED patients with
primary psychiatric complaints, diagnostic evaluation should be
directed by the history and physical examination. Routine
laboratory testing of all patients is of very low yield and need
not be performed as part of the ED assessment.

2. Do the results of a urine drug screen for drugs of abuse
affect management in alert, cooperative patients with normal
vital signs, a noncontributory history and physical examination,
and a psychiatric complaint?

Level C recommendations.
1. Routine urine toxicologic screens for drugs of abuse in
alert, awake, cooperative patients do not affect ED
management and need not be performed as part of the
ED assessment.
2. Urine toxicologic screens for drugs of abuse obtained
in theEDfor the use of the receiving psychiatric facility or
service should not delay patient evaluation or transfer.

3. Does an elevated alcohol level preclude the initiation of a
psychiatric evaluation in alert, cooperative patients with
normal vital signs and a noncontributory history and
physical examination?

Level C recommendations.
1. The patient’s cognitive abilities, rather than a specific
blood alcohol level, should be the basis on which
clinicians begin the psychiatric assessment.
2. Consider using a period of observation to determine if
psychiatric symptoms resolve as the episode of
intoxication resolves.

4. What is the most effective pharmacologic treatment for
the acutely agitated patient in the ED?

Level B recommendations.
1. Use a benzodiazepine (lorazepam or midazolam) or a
conventional antipsychotic (droperidol* or haloperidol)
as effective monotherapy for the initial drug treatment
of the acutely agitated undifferentiated patient in the
ED.
2. If rapid sedation is required, consider droperidol*
instead of haloperidol.
3. Use an antipsychotic (typical or atypical) as effective
monotherapy for both management of agitation and
initial drug therapy for the patient with known
psychiatric illness for which antipsychotics are indicated.
4. Use a combination of an oral benzodiazepine
(lorazepam) and an oral antipsychotic (risperidone) for
agitated but cooperative patients.

Level C recommendations. The combination of a parenteral
benzodiazepine and haloperidol may produce more rapid
sedation than monotherapy in the acutely agitated psychiatric
patient in the ED.