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  • Consider transportation to an Alternative Destination if the patient is a) not intoxicated and b) voluntary and willing to go

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

Richmond Agitation Sedation Score (RASS) 

+4	Combative	Overly combative or violent and an immediate danger to provider
+3	Very Agitated	Aggressive, non-combative or pulls on or removes tube(s) or catheter(s)
+2	Agitated	Frequent, non-purposeful movement or patient/ventilation desynchrony
+1	Restless	Anxious or apprehensive, movements not aggressive or vigorous
0	Alert and Calm	Spontaneously pays attention to provider
-1	Drowsy	Not fully alert but sustains more than 10 seconds wake, with eye opening in response to verbal command
-2	Light Sedation	Awakens briefly for less than 10 seconds with eye contact or verbal command
-3	Moderate Sedation	Any movement, except eye contact, in response to command
-4	Unarousable	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

Alternative Destination

Alternative Destination to SSM (DePaul or SLUH) may be considered in patient who are 18 years or old with:

• Symptoms of anxiety, depression, grief reaction, hallucinations 
• Self-injurious behavior without need for medical evaluation
• Need for medication adjustment
• Request for psych or counselling therapy
• Patients who feel they are in crisis and seeking counseling/intervention
• They consent to transport to SSM Behavior Health Urgent Care

Alternative Destination to SSM (DePaul or SLUH) should not be considered in patient who are 18 years or old with:

• SI or HI with intent, plan, and means
• Affidavit or 96-hour old order
• Aggressive patients or patients who require sedation
• Anyone under the influence of drugs or alcohol
• Anyone in withdrawal from alcohol or other substance
• Overdose in the last 48 hours
• Anyone who has medical needs that need to be addressed
• *Pediatric patients need a parent to transport to with the patient, parents must be ok taking the patient back home

SSM Process Monday – Saturday, 0900 – 1800

1. EMS crew calls BHUC to give report of patient 
   • a. DePaul Phone number: 314-344-7200
   • b. SLUH Phone number: 314-257-7430
   • c. If needed, caller can request to speak with a nurse
   • d. Gives report of patient presentation
2. EMS arrives at Behavioral Health Urgent Care
3. EMS takes patient to the main entrance of the BHUC without a stretcher
   • a. EMS should not enter through the ambulance doors
     • i. Patient needs to go through metal detector and the registration process before being brought into the treatment area.
4. Patient is escorted to the registration kiosks to begin registration process.
5. EMS Crew will be badged into the treatment area so that report can be given.
6. Nurse or Nurse Practitioner will receive report and sign required EMS documents.
7. EMS will exchange dirty linen for clean linen if needed.
8. EMS exits and process ends.

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.