Recognize, stabilize, escalate
Physiology and safety determine the first steps
Begin with airway, breathing, circulation, vital signs, level of consciousness, glucose when indicated, medication and substance exposure, withdrawal risk, and an urgent search for the underlying cause. Reassessment continues throughout transfer and treatment.
- Practice context
- Emergency, inpatient, consultation-liaison, detoxification, outpatient, residential, and community settings with rapid transfer pathways
- Typical pace
- Minutes to hours for recognition, stabilization, consultation, and disposition; frequent reassessment as physiology and mental status change
- Who's involved
- People with acute motor, cognitive, autonomic, toxicologic, withdrawal, overdose, or medication-related syndromes
Common presentations
- Catatonia, including immobility, mutism, posturing, negativism, agitation, or echophenomena
- Malignant catatonia with fever, autonomic instability, rigidity, or rapid deterioration
- Delirium with acute onset, fluctuating attention, altered awareness, or disorganized thinking
- Neuroleptic malignant syndrome and serotonin toxicity
- Lithium, valproate, or anticholinergic toxicity
- Severe alcohol, benzodiazepine, or other sedative withdrawal
- Opioid overdose with respiratory depression and impaired consciousness
PMHNP priorities
- Identify immediate threats to airway, breathing, circulation, temperature regulation, hydration, and safety
- Use a structured catatonia examination; a supervised lorazepam challenge may support diagnosis and guide treatment
- Treat malignant catatonia as a medical emergency and obtain urgent specialty support, including consideration of ECT
- Distinguish delirium from primary psychosis through attention, awareness, fluctuation, baseline, and medical findings
- Stop suspected offending agents and activate emergency toxicology or medical protocols
- Use withdrawal scales and medication pathways only within appropriate clinical protocols and monitoring environments
- Administer an opioid-overdose reversal medication when indicated, support ventilation, call emergency services, and continue observation
Care team
PMHNPs, psychiatrists, emergency and hospital medicine clinicians, critical care teams, toxicologists and poison control, pharmacists, neurologists, addiction specialists, ECT services, nurses, respiratory therapists, laboratory services, emergency medical services, and patient-identified supports.