Agitated/Behavioral Emergencies

Patient Care Goals

Provision of care while maintaining safety for the patient, EMS personnel, and others.

Assessment

Pediatric Pearls: Signs & Symptoms: Differential: 
□ Use approved reference document for medication dosing, electrical therapy, and equipment sizes. 

□ Parents may know what de-escalation techniques have worked in the past		□ Anxiety, agitation, confusion 
□ Affect change, hallucinations 
□ Delusional thoughts, bizarre behavior 
□ Expression of suicidal homicidal thoughts 
□ Tachycardia, diaphoresis, tachypnea 
□ Struggles violently despite appropriate restraints 
□ Combative / violent 
□ Very “hot” to touch		□ Refer to Altered Mental Status 
□ Hypoglycemia
□ Hypoxia 
□ Alcohol intoxication 
□ Medication effect / overdose 
□ Withdrawal syndromes 
□ Bipolar (manic-depressive) 
□ Schizophrenia, anxiety disorders, etc. 
□ Hypertensive emergency 
□ Seizure / Postictal 
□ Domestic Violence or Abuse 

Clinical Management Options

EMT-B
• Oxygen target SpO2 92% – 96%  
• Check a blood glucose
• Basic Airway Management as needed 
• Physical restraint if needed and use Restraint Checklist 
• Never transport a restrained patient in a prone position on a stretcher
• Cooling measures if needed 
Paramedic
• Vascular access as appropriate for patient condition 
• Fluid therapy as needed with Isotonic Isotonic Crystalloid, preferred cold if excited delirium 
• Cardiac monitor and 12 ECG 
• Consider sedation for agitated patients; document a pre-sedation RASS and a RASS after medications have been provided
• RASS +3/+4 Ketamine is preferred
• RASS +1/+2 Midazolam or Droperidol is preferred (droperidol is preferred in anyone has concern for airway compromise)
• Consider lower dosing in patients who are elderly (65yo+) or acutely intoxicated
• If the patient is suspected of excited delirium and suffers cardiac arrest, then consider a fluid bolus and Sodium Bicarbonate early
Consult Online Medical Control as Needed

Richmond Agitation Sedation Score (RASS) 

+4Combative Overly combative or violent and an immediate danger to provider 
+3Very Agitated Aggressive, non-combative or pulls on or removes tube(s) or catheter(s) 
+2Agitated Frequent, non-purposeful movement or patient/ventilation desynchrony
+1Restless Anxious or apprehensive, movements not aggressive or vigorous 
0Alert and Calm Spontaneously pays attention to provider 
-1Drowsy Not fully alert but sustains more than 10 seconds wake, with eye opening in response to verbal command 
-2Light Sedation Awakens briefly for less than 10 seconds with eye contact or verbal command
-3Moderate Sedation Any movement, except eye contact, in response to command 
-4Unarousable No response to voice or physical stimulation 

Restraints Checklist

 □ All other calming attempts have failed, which include at minimum verbal de-escalation and/or reduced stimulation. 
□ Adequate personnel to effect restraint, with consideration to include law enforcement. 
□ Place patient in supine position restrained with 1 arm up and 1 arm down, unless clinically contraindicated. 
□ Law enforcement must be immediately available if handcuffed. 
□ EMS personnel in constant attendance. 
□ Chemical sedation administered, if required. 
□ Continuous EtCO2, SpO2, ECG, and vital sign monitoring. 
□ Continuous assessment of neurovascular status every 15 minutes, which includes pulse, motion, sensation in all extremities. 
□ Adequate personnel for transport. 
□ Excited delirium is considered. 
□ Physical and/or chemical restraints reviewed on a periodic basis. 
□ Above documented fully in ePCR, including: Efforts prior to restraint, Time of restraint, Chemical sedation, Continuous monitoring, Neurovascular status evaluation 

Pearls

  • Consider your safety first. Physical restraint should be performed / assisted by Law Enforcement when available. 
  • Be sure to consider all possible medical and/or trauma causes for behavior. 
  • All patients who receive either physical or chemical restraint must be continuously observed by ALS personnel on scene or immediately upon their arrival. 
  • Any transported patient who is handcuffed or restrained by Law Enforcement should be accompanied by an officer whenever possible and if not, then law enforcement must be immediately available. 
  • Restrained patients must never be maintained or transported in a prone position. 
  • SAVE Mnemonic for De-Escalation: 
    • Support – “Let’s work together…” 
    • Acknowledge – “I see this has been hard for you…” 
    • Validate – “I would probably be reacting the same way if I was in your shoes…” 
    • Emotion naming – “You seem upset…” 
  • Excited Delirium (EXD) is interchangeable with Excited Delirium Syndrome (ExDS), both refer to a condition where the patient continues to struggle violently despite appropriate restraint that results from a combination of delirium, psychomotor agitation, anxiety, hallucinations, speech disturbances, disorientation, violent and bizarre behavior, insensitivity to pain, elevated body temperature, and superhuman strength. Therefore, underlying etiologies of EXD/ExDS must be considered: 
    • Metabolic / Endocrine – hypoxia, electrolyte abnormalities, hepatic encephalopathy, hypercarbia, hyper/hypoglycemia, thyrotoxicosis, uremia 
    • Neurologic – dementia, head injury, encephalitis, post-ictal state/seizure 
    • Psychiatric – acute psychosis, mania, medication stoppage, personality disorder, schizophrenia 
    • Infectious/Inflammatory – autoimmune encephalitis, herpes encephalitis, meningitis, sepsis 
    • Toxicologic – alcohol, amphetamines, cocaine, neuroleptic malignant syndrome, PCP, polypharmacy, serotonin syndrome, synthetic cannabinoids, synthetic cathinones 
  • Cold isotonic crystalloid boluses 30 ml/kg with temperature > 104 F up to 2 liters in adults. 
  • Blood samples for performing glucose analysis should be obtained through a finger-stick (heel for infants).
  • Droperidol can cause akisthesia (need to move) or torticollis. The treatment for both of these side effects is IV/IM Benadryl.