Notes – Agitated or Violent Patient/Behavioral Emergency

Agitated or Violent Patient/Behavioral Emergency

Patient Safety Considerations

The management of violent patients requires a constant reevaluation of the risk/benefit balance for the patient and bystanders in order to provide the safest care for all involved. These are complex and high-risk encounters. There is no one size fits all solution for addressing these patients.

  1. Don PPE
  2. Do not attempt to enter or control a scene where physical violence or weapons are present
  3. Dispatch law enforcement immediately to secure and maintain scene safety
  4. Urgent de-escalation of patient agitation is imperative in the interest of patient safety as well as for EMS personnel and others on scene
  5. Uncontrolled or poorly controlled patient agitation and physical violence can place the patient at risk for sudden cardiopulmonary arrest due to the following etiologies:
    1. Excited delirium/exhaustive mania: A postmortem diagnosis of exclusion for sudden death thought to result from metabolic acidosis (most likely from lactate) stemming from physical agitation or physical control measures and potentially exacerbated by stimulant drugs (e.g. cocaine) or alcohol withdrawal
    2. Positional asphyxia: Sudden death from restriction of chest wall movement and/or obstruction of the airway secondary to restricted head or neck positioning resulting in hypercarbia and/or hypoxia
  6. Apply a cardiac monitor as soon as possible, particularly when pharmacologic management medications have been administered
  7. All patients who have received pharmacologic management medications must be monitored closely for the development of hypoventilation and oversedation
    1. Utilize capnography if available
  8. Patients who have received antipsychotic medication for pharmacologic management must be monitored closely for the potential development of:
    1. Dystonic reactions (this can easily be treated with diphenhydramine/benzodiazepines)
    2. Mydriasis (dilated pupils)
    3. Ataxia
    4. Cessation of perspiration
    5. Dry mucous membranes
    6. Cardiac arrhythmias (particularly QT prolongation)
  9. Placement of stretcher in sitting position prevents aspiration and reduces the patient’s physical strength by placing the abdominal muscles in the flexed position
  10. Patients who are more physically uncooperative should be physically secured with one arm above the head and the other arm below the waist, and both lower extremities individually secured
  11. The following techniques should be expressly prohibited by EMS providers:
    1. Secure or transport in a prone position with or without hands and feet behind the back (hobbling or “hog-tying”)
    2. “Sandwiching” patients between backboards
    3. Techniques that constrict the neck or compromise the airway
    4. EMS provider use of weapons as adjuncts in managing a patient
  12. Concurrent use of IM/IV benzodiazepines and olanzapine IM is not recommended as fatalities have been reported

Notes/Educational Pearls

Key considerations

  1. Direct medical oversight should be contacted at any time for advice, especially when patient’s level of agitation is such that transport may place all parties at risk
  2. Transport by air is not advised
  3. Stretchers with adequate foam padding, particularly around the head, facilitates patient’s ability to self-position the head and neck to maintain airway patency
  4. For patients with key-locking devices, applied by another agency, consider the following options:
    1. Remove device and replace it with a device that does not require a key
    2. Administer pharmacologic management medication then remove and replace device with another non-key-locking device after patient has become more cooperative
    3. Transport patient, accompanied in patient compartment by person who has device key
    4. Transport patient in vehicle of person with device key if medical condition of patient is deemed stable, direct medical oversight so authorizes, and law allows

Pertinent assessment findings

  1. Continuous monitoring of:
    1. Airway patency
    2. Respiratory status with pulse oximetry and/or capnography
    3. Circulatory status with frequent blood pressure measurements
    4. Mental status and trends in level of patient cooperation
    5. Cardiac status, especially if the patient has received pharmacologic management medication
    6. Extremity perfusion with capillary refill in patients in physical management device

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01)

  • 9914053 – General-Behavioral/Patient Restraint

Key Documentation Elements

  • Etiology of agitated or violent behavior if known
  • Patient’s medications, other medications or substances found on scene
  • Patient’s medical history or other historic factors reported by patient, family or bystanders
  • Physical evidence or history of trauma
  • Adequate oxygenation by pulse oximetry
  • Blood glucose measurement
  • Measures taken to establish patient rapport
  • Dose, route, and number of doses of pharmacologic management medications administered
  • Clinical response to pharmacologic management medications
  • Number and physical sites of placement of physical management devices
  • Duration of placement of physical management devices
  • Repeated assessment of airway patency
  • Repeated assessment of respiratory rate, effort, pulse oximetry/capnography
  • Repeated assessment of circulatory status with blood pressure, capillary refill, cardiac monitoring
  • Repeated assessment of mental status and trends in the level of patient cooperation
  • Repeated assessment of capillary refill in patient with extremity securing devices
  • Communications with EMS direct medical oversight
  • Initiation and duration of engagement with law enforcement

Performance Measures

  • Incidence of injuries to patient, EMS personnel, or others on scene
  • Incidence of injuries to patient, EMS personnel, or others during transport
  • Medical or physical complications (including sudden death) in patients
  • Advance informational communication of EMS protocols for the management of agitated and violent patients to others within the emergency care system and law enforcement
  • Initiation and engagement with EMS direct medical oversight
  • Initiation and duration of engagement with law enforcement
  • EMS Compass® Measure (for additional information, see http://www.emscompass.org)
    • PEDS-03: Documentation of estimated weight in kilograms. Frequency that weight or length-based estimate are documented in kilograms

References

  1. Adimando AJ, Poncin YB, Baum CR. Pharmacological management of the agitated pediatric patient. Pediatr Emerg Care. 2010;26(11):856-60.
  2. Drayna PC, Estrada C, Wang W, Saville BR, Arnold DH. Ketamine sedation is not associated with clinically meaningful elevation of intraocular pressure. Am J Emerg Med. 2012;30(7):1215-8.
  3. Ely EW, Truman B, Shintani A, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA. 2003;289(22):2983-91.
  4. Halstead SM, Deakyne SJ, Bajaj L, Enzenauer R, Roosevelt GE. The effect of ketamine on intraocular pressure in pediatric patients during procedural sedation. Acad Emerg Med. 2012;19(10):1145-50.
  5. Ho JD, Smith SW, Nystrom PC, et al. Successful management of excited delirium syndrome with prehospital ketamine: two case examples. Prehosp Emerg Care, 2013;17(2): 274-9.
  6. Kupas DF, Wydro GC. Patient restraint in emergency medical services systems. Prehosp Emerg Care. 2002;6(3):340-5.
  7. Sonnier L, Barzman D. Pharmacologic management of acutely agitated pediatric patients. Paediatr Drugs. 2011 1;13(1):1-10.
  8. Swift RH, Harrigan EP, Cappelleri JC, Kramer D, Chandler LP. Validation of the behavioural activity rating scale (BARS): a novel measure of activity in agitated patients. J Psychiatr Res. 2002;36(2):87-95.
  9. Tsze DS, Steele DW, Machan JT, Akhlaghi F, Linakis JG. Intranasal ketamine for procedural sedation in pediatric laceration repair: a preliminary report. Pediatr Emerg Care. 2012;28(8):767-70
  10. White Paper Report on Excited Delirium Syndrome. ACEP Excited Delirium Task Force, American College of Emergency Physicians; September 10, 2009.