Inclusion Criteria: Patients with an acute onset of altered mental status, manifesting as agitation, combativeness, and/or aggression.

SPECIAL NOTE: The cause of excited delirium is considered organic in nature until proven otherwise. Verbal de-escalation tactics, physical restraint, and chemical restraint are options to ensure the safety of patient and providers. For further information on physical restraints, please refer to RESTRAINT OF PATIENT Policy. The use of ketamine is restricted to paramedics in agencies carrying this scheduled drug, who have undergone required training on its use, and who have received medical direction authorization.

Basic Level

  1. Ensure scene safety.
  2. Assess and support ABCs.
  3. Attempt de-escalation methods.
  4. Transport the patient.

Advanced Level

  1. Perform POC glucose analysis.
  2. Consider establishing IV access at a TKO rate or use a saline lock.
  3. If necessary, restrain the patient. Refer to the RESTRAINT OF PATIENT Policy.
  4. DO NOT restrain the patient in the prone position or interfere with ventilation in any way.
  5. Continuously monitor ECG and SpO2.  Use continuous ETCO2 monitoring, if available.

    For acutely violent patients, for whom verbal re-direction and physical restraint are insufficient:


    • Midazolam 5 mg slow IV/IO push, IM, or IN.
    • May repeat once; OR
    • Ketamine 2 mg/kg slow IVP/IO, OR                 
      5 mg/kg IM.
    • Contact BioTel for authorization if additional dosing is required.


    • Contact BioTel.
    • BioTel may authorize midazolam 0.1 to 0.3 mg/kg IV/IO/IM/IN.
    • Do not administer ketamine to the pediatric patient with excited delirium.