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Agitation & Suicidal Ideation

Medical first — then safety, then psychiatry.

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Your objective: explain the approach, recognize important warning signs, then test your recall.

Abbreviations explained
ACS
Acute coronary syndrome
OMI
Occlusion myocardial infarction
ECG
Electrocardiogram
PE
Pulmonary embolism
POCUS
Point-of-care ultrasound
QTc
QT interval corrected for heart rate
LBBB
Left bundle branch block
RBBB
Right bundle branch block
hs-cTn
High-sensitivity cardiac troponin
CTA
Computed tomography angiography
ICU
Intensive care unit
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The jobMedical first — then safety, then psychiatry.

  1. Glucose, SpO₂, temperature, and a toxidrome exam first — agitation is medical until those are done.
  2. Then safety: means, environment, 1:1 observation — no gaps for imaging or the toilet.
  3. Ask directly about suicide. Asking does not plant the idea.
  4. Paracetamol and salicylate in every intentional overdose. Disposition is a written safety plan or admission — document who they leave with.

Acute agitation is a medical presentation until glucose, oxygen, temperature, trauma, and toxidrome are addressed — hypoxia, hypoglycemia, encephalitis, serotonin syndrome, sympathomimetics, and withdrawal kill before a psychiatric label is safe.

Self-harm thought still deserves a direct, non-judgmental ask (asking does not plant the idea). Safety (means, environment, observation) and then disposition against local mental-health law.

Active suicidal intent with a plan and access to means Critical

Key: Constant observation now; remove means; do not leave alone for imaging, the toilet, or a smoke break.

Recent attempt Critical

Key: Medical stabilization first (paracetamol/salicylate levels in every intentional overdose). The repeat-attempt window is highest in the following weeks to months, and after psychiatric discharge.

Agitation from a medical cause Critical

Key: Hypoxia, hypoglycemia, encephalitis, serotonin syndrome, sympathomimetics, DTs, head injury, thyrotoxicosis — treat these before a psychiatric label. Verbal de-escalation, then medication; restraint only per protocol with monitoring.

Agitation with violence risk Critical

Key: Safety of staff and patient; medical workup proceeds in parallel, not after the patient is “medically cleared” as a checkbox.

Adolescent disclosure Emergent

Key: Screen every young person (ASQ); explain confidentiality limits before the interview.

Depression / anxiety / psychosis without acute intent Common

Key: Treat, ask about suicidality in every psychiatric presentation, and arrange close follow-up.

Tick what your patient has — the banner updates as you go.

Ideation

passive (wish to be dead) vs active (plan, intent, preparation, rehearsal)

Plan specificity and access to means (firearms, medications, heights, ligatures)

Prior attempts — the strongest single clinical predictor

Substances, recent losses, recent discharge from psychiatric care (high-risk window)

Protective factors

reasons for living, dependents, engaged care, future orientation

Epidemiologic amplifiers (older age, male sex, isolation, access to firearms) inform risk but are not a substitute for the interview

Medical clearance

vitals, glucose, targeted tox, trauma from attempts — clearance is not a psych screen

Mental status

orientation, psychosis, mood, hopelessness, command hallucinations

Signs of intoxication/withdrawal that alter risk and capacity

Agitation level and environmental safety scan

Bedside

  • Glucose, SpO₂; breath alcohol when relevant
  • Environment: remove ligatures/sharps; 1:1 observation for high risk

Labs

  • Paracetamol and salicylate in all intentional overdoses and when history is incomplete
  • Targeted toxicology; TSH, electrolytes when a medical cause is possible

Screening tools

  • C-SSRS or ASQ (youth) to structure the interview — tools inform, they do not replace judgment or a safety plan
Medication safety reminder

Use this as a first-pass prompt; verify all medications, doses, concentrations, contraindications, weight, pregnancy status, and local protocols before administration.

Check indication, allergy, route, renal/hepatic risk, interactions, monitoring, and local formulary.

Discharge

  • Low acute risk: no plan/intent, strong protective factors, means-restriction counselling, written safety plan, reliable follow-up within days, and crisis-line numbers. Document who they leave with.

Admit (psychiatric, after medical clearance)

  • Active ideation with plan, attempt survivors, high risk with insufficient supports — per local mental-health law (voluntary/involuntary).

Emergency psychiatric hold + security

  • Imminent danger to self/others, agitation requiring restraint protocols, refusal of care with impaired capacity.

Use objective reassessment and the local pathway.

Before the next decision · reassess and hand over

Use these learning prompts with the presentation’s pathway. They are not discharge criteria.

  1. Reassess: compare symptoms, observations and examination with the initial assessment and response to treatment.
  2. Warning signs for Agitation & Suicidal Ideation:
    • Stated intent with available means
    • Attempt within the last days to week
    • Psychotic symptoms or command hallucinations
    • Intoxication with ongoing access to means
    • Discharge from psychiatric care in the past month
    • Inability to engage in a safety plan, or no safe person to go home with
  3. Reconsider: check unresolved findings and alternative explanations, including the pitfalls below.
  4. Escalate: communicate deterioration, uncertainty or needs beyond the current setting.
  5. Plan the transition: identify outstanding results, responsibility for follow-up, patient understanding and specific return advice.
Review this presentation’s disposition pathway →Practice a handover →

Clinical Pearls

  • Agitation is medical first: glucose, oxygen, temperature, toxidrome — then psychiatry.
  • Ask directly. Asking does not plant the idea.
  • Paracetamol and salicylate in every intentional overdose.
  • The highest-risk window is the days after an attempt and the month after psychiatric discharge.

Pitfalls

  • Asking about suicide does not increase risk — it opens the door.
  • Apparent calm after an attempt can signal a decision, not relief.
  • Medical clearance is not a psych-screen substitute — delirium and toxins masquerade as psychiatric illness.
  • Observation gaps (imaging, toilets, smoking areas) are when patients elope or harm themselves.
  • Document risk, protective factors, means restriction, capacity, and who the patient goes home with.
  • Do not use sex or age as a checkbox that replaces the interview — they are epidemiologic context, not disposition rules.
PRACTICE REFRESHER

Rapid recall

Test your first action and the dangerous diagnoses before revealing the answer.

01 · First move

Before you scroll, what needs to happen first?

02 · Immediate threats

Name at least two diagnoses that cannot wait.

PRIVATE TO THIS DEVICE

Your learning note

Capture a weak point, a teaching pearl, or a question to take to your next shift.

Review schedule starts when marked reviewed
Poisoning & OverdoseAltered Mental StatusHeat Stroke & Hypothermia

Foundational references below. No separate topic-specific guideline check is recorded here.

Assessment and safety planning

A numeric risk category must not determine discharge after self-harm. Use an individual psychosocial assessment and a collaborative plan, alongside local legal and safeguarding requirements.

Source and scope

Supporting teaching points checked 2026-09-10. This is an educational synthesis, not an independently peer-reviewed protocol.

NICE NG225: self-harm assessment and care

Confirm patient context, full recommendations and local policy. External sources need an internet connection.

  • Rosen’s Emergency Medicine, 10th ed. (2023) — behavioral & psychiatric emergencies
  • Columbia Suicide Severity Rating Scale; ASQ Toolkit (NIMH)
  • Joint Commission NPSG 15.01.01; Zero Suicide framework
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