Agitated or Violent Patient/Behavioral Emergency

Table of Contents

Aliases

Acute psychosis, patient restraint

Patient Care Goals

  1. Provision of emergency medical care to the agitated, violent, or uncooperative patient
  2. Maximizing and maintaining safety for the patient, EMS personnel, and others

Patient Presentation

Inclusion Criteria

Patients of all ages who are exhibiting agitated, violent, or uncooperative behavior or who are a danger to self or others

 Exclusion Criteria

  1. Patients exhibiting agitated or violent behavior due to medical conditions including, but not limited to:
    1. Head trauma
    2. Metabolic disorders (e.g. hypoglycemia, hypoxia)

Patient Management

Assessment

  1. Note medications/substances on scene that may contribute to the agitation, or may be relevant to the treatment of a contributing medical condition
  2. Maintain and support airway
  3. Note respiratory rate and effort – If possible, monitor pulse oximetry and/or capnography
  4. Assess circulatory status:
    1. Blood pressure (if possible)
    2. Pulse rate
    3. Capillary refill
  5. Assess mental status
    1. Check blood glucose (if possible)
  6. Obtain temperature (if possible)
  7. Assess for evidence of traumatic injuries
  8. Use RASS (Richmond Agitation Sedation Score) to risk stratify violent patients to help guide interventions

Treatment and Interventions

Notes – Agitated or Violent Patient/Behavioral Emergency

  1. Ensure scene safety with law enforcement presence if needed
  2. Establish patient rapport
    1. Attempt verbal reassurance and calm patient prior to use of pharmacologic and/or physical management devices
    2. Engage family members/loved ones to encourage patient cooperation if their presence does not exacerbate the patient’s agitation
    3. Continued verbal reassurance and calming of patient following use of chemical/physical management devices
  3. Pharmacologic management
    1. Notes:
      1. Selection of medications for pharmacologic management should be based upon the patient’s clinical condition, current medications, and allergies in addition to EMS resources and medical oversight
    2. Determine 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 dyssynchrony
      • +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 awake, with eye opening in response to verbal command.
      • -2 – Light sedation: Awakens briefly (less than 10 seconds) with eye contact to verbal command.
      • -3 – Moderate sedation: Any movement, except eye contact, in response to command.
      • -4 – Deep sedation: No response to voice, but any movement to physical stimulation.
      • -5 – Unarousable: No response to voice or physical stimulation.
    3. For RASS +3 or + 4: Dissociative Agents
      1. Ketamine
        1. 4 mg/kg IM, max of 500 mg per dose; 3-5 minute onset of action
          1. Age > 60: 2 mg/kg IM, max of 250 mg per dose
        2. 1 mg/kg IV, max of 250 mg per dose; 1 minute onset of action,
    4. For RASS +1 or + 2: Benzodiazepines
      1. Midazolam
        1. Adults:
          1. 5 mg IV/IM/IN per dose
        2. Pediatrics:
          1. 0.1 mg/kg IV
          2. 0.2 mg/kg IM
          3. 0.3 mg/kg IN
          4. Max of 5 mg per dose
    5. Check RASS score every 5 minutes and redose as above.
  4. Physical Management Devices
    1. Body
      1. Stretcher straps should be applied as the standard procedure for all patients during transport
      2. Physical management devices, including stretcher straps, should never restrict the patient’s chest wall motion
      3. If necessary, sheets may be used as improvised supplemental stretcher straps. Other forms of improvised physical management devices should be discouraged
      4. Supplemental straps or sheets may be necessary to prevent flexion/extension of torso, hips, legs by being placed around the lower lumbar region, below the buttocks, and over the thighs, knees, and legs
    2.  Extremities
      1. Soft or leather devices should not require a key to release them
      2. Secure all four extremities to maximize safety for patient, staff, and others
      3. Secure all extremities to the stationary frame of the stretcher
      4. Multiple knots should not be used to secure the restraint device
      5. Document distal neuro-vasculature status in all restrained limbs every 15 minutes
  5. After sedation, patient must be monitored with cardiac monitor, pulse oximetry, and continuous waveform capnography.
  6. Administer Normal Saline 20 cc/kg IV/IO bolus, max of 1 L, repeat as necessary
  7. Document RASS presedation and every 5 minutes after sedation
  8. Patient Destination
    1. For patients requiring chemical/physical restraints
      1. Transport to closest emergency department with an ICU
    2. For patients with suspected mental health pathology but not requiring chemical/physical restraints
      1. Transport to most appropriate emergency department taking in to consideration: available capabilities and/or established care with a medical facility.
      2. Coordinate with operations supervisor, assistant chief, or chief to ensure system needs are being considered
      3. Discuss with medical oversight if questions remain