Scope of Application
This guideline is intended for physicians working in emergency departments.

Inclusion Criteria
This guideline applies to adult patients presenting to the emergency department with psychiatric symptoms. Critical question 4 includes patients with delirium.

Exclusion Criteria
This guideline is not intended to be used for pediatric patients. It is also not intended for patients with delirium in regard to critical questions 1, 2, and 3.

Critical Questions

1. In the alert adult patient presenting to the emergency department with acute psychiatric symptoms, should routine laboratory tests be used to identify contributory medical conditions (nonpsychiatric disorders)?
   
   Level C Recommendation:
   
   Do not routinely order laboratory testing on patients with acute psychiatric symptoms. Use medical history, previous psychiatric diagnoses, and physician examination to guide testing.
   
   
   
2. In the adult patient with new-onset psychosis without focal neurologic deficit, should brain imaging be obtained acutely?
   
   Level C Recommendation:
   
   Use individual assessment of risk factors to guide brain imaging in the emergency department for patients with new-onset psychosis without focal neurologic deficit. (Consensus recommendation)
   
   
   
3. In the adult patient presenting to the emergency department with suicidal ideation, can risk-assessment tools in the emergency department identify those who are safe for discharge?
   
   Level C Recommendation:
   
   In patients presenting to the emergency department with suicidal ideation, physicians should not use currently available risk-assessment tools in isolation to identify low-risk patients who are safe for discharge. The best approach to determine risk is an appropriate psychiatric assessment and good clinical judgment, taking patient, family, and community factors into account.
   
   
   
4. In the adult patient presenting to the emergency department with acute agitation, can ketamine be used safely and effectively?
   
   Level C Recommendation:
   
   Ketamine is one option for immediate sedation of the severely agitated patient who may be violent or aggressive. (Consensus recommendation)
   
   
   

Disclaimer
Recommendations offered in this policy are not intended to represent the only diagnostic and management options that the emergency physician should consider. ACEP recognizes the importance of the individual physician's judgment and patient preferences.