QUICK STEP-UP

Mild anxiety / insomnia: Quetiapine PO
Moderate agitation: Olanzapine PO/IM
Severe dangerous agitation: Haloperidol IM/IV
Psychotic agitation: Ziprasidone IM
Withdrawal / catatonia: Lorazepam
ICU severe agitation: Precedex drip

1️⃣ COMMON FLOOR OPTIONS

Quetiapine (Seroquel) PO

  • 12.5–25 mg elderly | 25–50 mg adult q8–12 PRN/sched

  • 30–60 min | 6–12 hr | 800/day

  • Use: mild/mod agitation, delirium, sundowning, insomnia

  • Avoid: oversedation, QT, falls, orthostasis

✅ Great first-line floor med

Olanzapine PO / IM

  • 2.5–5 mg elderly | 5–10 mg adult

  • PO 30–60 min | IM ~15 min

  • 12–24 hr | 20/day

  • Use: mod/severe agitation, psychosis, delirium stronger control

  • Avoid: sedation, orthostasis, avoid IM + benzo close together

✅ Lower QT risk than haldol

Haloperidol PO / IV / IM

  • 0.5 frail elderly | 1–2 mg floor | 2–5 mg ICU

  • IV 5–20 min | IM ~20 min

  • 4–8 hr | goal <20/day

  • Use: severe agitation, dangerous delirium, pulling lines, ICU rapid control

  • Avoid: Parkinson disease, Lewy body dementia, QT prolongation, EPS/NMS

✅ Best-known medical delirium option

2️⃣ SITUATIONAL OPTIONS

Ziprasidone IM / PO

  • IM 10–20 mg

  • 15–30 min | 4–6 hr | IM max 40/day

  • Use: acute psychotic agitation, IM option when less EPS desired

  • Avoid: QT prolongation, low K/Mg, arrhythmia history

Lorazepam PO / IV / IM

  • 0.5–1 mg elderly | 1–2 mg adult

  • IV 5–10 min | PO ~20 min

  • 6–8 hr | often <8–10/day (non-withdrawal)

  • Use: alcohol withdrawal, benzo withdrawal, catatonia, seizure agitation

  • Avoid: respiratory depression, OSA, hypercapnia, delirium worsening

🚫 Not routine delirium med

3️⃣ ICU OPTION

Dexmedetomidine (Precedex) IV Drip

  • Titrated drip

  • Minutes onset | while infusion

  • Use: ICU agitation, ventilated pts, severe delirium needing titration

  • Avoid: bradycardia, hypotension, heart block

✅ Minimal respiratory depression

🔴 QUICK PICKS

Elderly delirium

Quetiapine low dose → Olanzapine low dose → tiny haldol if needed

Severe dangerous agitation

Haloperidol IM/IV

Psychotic agitation

Olanzapine IM or Ziprasidone IM

Alcohol withdrawal

Lorazepam

Parkinson / Lewy body dementia

Quetiapine preferred
🚫 Avoid haldol

Intubated ICU

Precedex