Emergency, Critical Care, and Acute Hospital Psychiatry
Delirium first
The emergency psychiatric differential in the hospital is delirium, and the bedside tool is attention: digit span, months backward, and the CAM algorithm (acute onset, fluctuating course, inattention, plus disorganized thinking or altered awareness). Hypoactive delirium is missed when labeled depression or poor motivation. Nonpharmacologic prevention works: orientation, sleep hygiene, early mobility, glasses and hearing aids, hydration. Antipsychotics treat distress and dangerous behavior but do not shorten delirium and are not indicated for delirium itself. Benzodiazepines worsen delirium except in alcohol or benzodiazepine withdrawal.
Agitation and risk
De-escalate verbally first; offer oral medication before intramuscular. Choose by cause: antipsychotic for delirium or psychosis, benzodiazepine for withdrawal or catatonia (lorazepam challenge). In NMS, avoid antipsychotics and treat supportively with bromocriptine or dantrolene. Suicide and violence risk on the ward or in the ICU require means restriction, observation levels, sitter use and documented rationale. Restraints are a last resort, time-limited and monitored.
Catatonia and the ICU
Catatonia is underdiagnosed in intensive care: mutism, negativism, posturing, waxy flexibility and autonomic instability. Treat with lorazepam; use ECT for malignant or refractory cases. Distinguish it from NMS and delirium. After ICU discharge, screen for PTSD, depression and cognitive impairment, and engage families.
Capacity and transplant
Transplant evaluation addresses adherence, support, substance use and capacity to consent, not deservingness. Delirium invalidates a capacity assessment; reassess when lucid.
Trap
Giving a PRN benzodiazepine to an agitated delirious patient, or assuming a quiet patient is fine.
Rule of thumb
If the patient is agitated and confused, treat the cause; if the patient is mute and rigid, try lorazepam.