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Brooke Harbor Health System

PMHNP Clinical Learning Environment

TRAINING ENVIRONMENTFictional educational health system · No real patient data

Specialty Practice Area

Specialty Practice GuideGuidance for a population, acuity, or practice context.

Catatonia, Delirium, and Psychiatric Medical Emergencies

Some psychiatric-appearing presentations signal time-sensitive medical syndromes. Rapid recognition, stabilization, focused differential diagnosis, and coordinated transfer can prevent serious morbidity and death.

Clinical application

Using this resource

Apply these prompts within the simulated clinical context. They support—but do not replace—clinical judgment, supervision, consultation, current guidance, local policy, law, or emergency procedures.

Use this when

  • A psychiatric-appearing presentation includes an acute or fluctuating change, abnormal motor findings, altered attention or arousal, concerning exposure, or possible physiologic instability.

Clarify first

  • Establish the time course and baseline using examination, vital signs, available records, collateral, and recent medication, substance, or withdrawal history.
  • Identify which findings require immediate medical clarification and what remains uncertain about the syndrome or cause.

Act now

  • Prioritize medical stability and focused diagnostic clarification while coordinating the appropriate clinical team and level of evaluation.
  • Reassess changes in attention, arousal, motor behavior, cognition, and physiology as new information becomes available.

Document and communicate

  • Record the baseline and time course, observed findings, information sources, relevant exposures, current stability, differential, actions taken, pending information, and ownership of follow-up.

Escalate or consult when

  • Delirium, catatonia, toxicity, withdrawal, a severe adverse medication syndrome, or other physiologic instability is suspected or cannot be safely evaluated in the current setting.

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

  • Recognize respiratory compromise, circulatory or temperature instability, altered consciousness, dehydration, and acute safety concerns
  • Use a structured catatonia examination; a supervised lorazepam challenge may support diagnosis and guide treatment
  • Recognize features concerning for malignant catatonia and prioritize immediate medical evaluation and multidisciplinary coordination
  • Distinguish delirium from primary psychosis through attention, awareness, fluctuation, baseline, and medical findings
  • Recognize possible toxicity, withdrawal, or severe adverse medication syndromes and seek urgent medical and toxicology support as appropriate
  • Use assessment tools and treatment pathways only within appropriate clinical protocols and monitored settings
  • Recognize overdose, respiratory compromise, or other physiologic instability that may require immediate emergency and medical response; activate the appropriate local emergency, medical, and interdisciplinary pathway according to the clinical setting, institutional policy, local procedures, scope of practice, and available emergency resources

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.

NCBI Bookshelf: catatonia ↗SAMHSA overdose reversal medications ↗FDA antipsychotic safety labeling ↗
← Specialty Practice AreasEmergency levels of care →
Last updated July 29, 2026