3.3. AGITATED OR AGGRESSIVE PATIENT/BEHAVIORAL HEALTH EMERGENCY

Related terms

Acute psychosis, physical fixation of the patient.

Objective of care

1. Providing assistance to a patient who is agitated and aggressive, as well as non-contact patients.
2. Maximum support for the safety of the patient, EMS workers and others.

Patient description

Inclusion criteria

Patients of all age groups with manifestations of agitation, aggression or conflict behavior or who pose a threat to themselves and others.

Exclusion criteria

Patient exhibits aggression or agitation due to, but not limited to, a medical condition:

1. Head injury.
2. Metabolic disorders (e.g., hypoglycemia, hypoxia).

Patient management

Assessment

1. Check for medications/medications at the scene that could contribute to the patient’s agitation or that treat medical conditions.

2. Monitor and maintain respiratory function.

3. Assess respiratory rate and pattern – use a pulse oximeter and/or capnograph if possible.

4. Assess circulatory status:

a) blood pressure (if possible);
б) HEART RATE
c) capillary filling.

5. Assess the state of consciousness.
Check glucose levels (if possible).

6. Check body temperature (if possible).

7. Assess for signs of traumatic injury.

8. Use validated risk assessment tools such as the Richmond Arousal Sedation Scale (RASS), Altered Mental State Scale (AMSS), Behavioral Activity Rating Scale (BARS) to stratify the risk of patients with psychomotor agitation to guide interventions.

Treatment and interventions

1. Establish full contact with the patient.

1.1. Try to verbally reassure and calm the patient before administering medications and/or physical control aids.

1.2. Involve family members or significant others to motivate the patient to cooperate, unless their presence will worsen the patient’s behavior.

1.3. Continue to verbally reassure the patient of the need for cooperation and reassure the patient after chemical/physical controls have been applied.

2. Administration of medications.

2.1. Important:

a) the choice of medications should be based on the patient’s general condition, medications currently being used, possible allergies to medications included in the EMS resource and medical supervision by management;
b) the medications should be commented on to indicate when they are preferred for patients at high risk of violence on an approved scale – note that the dosage can be adjusted to achieve different levels of sedation;
c) the list of drugs below is not organized in a priority/more desirable order.

2.2. Benzodiazepines:

a) diazepam

Adults:

– 5 mg IV; 2-5 minutes before onset of action

OR

– 10 mg i.p.; 15-30 minutes before the onset of action

Children:

– 0.05-0.1 mg/kg IV (maximum dose – 5 mg)

OR

– 0.1-0.2 mg/kg IM (maximum dose: 10 mg)

b) lorazepam

Adults:

– 2 mg IV; 2-5 minutes before onset of action

OR

– 4 mg in/m; 15-30 minutes before the onset of action

Children:

– 0.05 mg/kg IV (maximum dose – 2 mg)

OR

– 0.05 mg/kg IM (maximum dose – 4 mg)

c) midazolam

Adults:

– 5 mg IV; 3-5 minutes before the onset of action

OR

– 5 mg IM; 10-15 minutes before the onset of action

OR

– 5 mg nasally; 3-5 minutes before the onset of action

Children:

– 0.05-0.1 mg/kg IV (maximum dose – 5 mg)

OR

– 0.1-0.15 mg/kg IM (maximum dose: 5 mg)

OR

– 0.3 mg/kg nasally (maximum dose – 5 mg).

2.3. Antipsychotic drugs (antipsychotics):

a) droperidol (option for high risk of violence)

Adults:

– 2.5 mg IV; 10 minutes before the start of the action

OR

– 5 mg w/m; 20 minutes before the start of the action

Children: usually not recommended;

b) haloperidol (little evidence, optimal dose not determined)

Adults:

– 5 mg IV; 5-10 minutes before the start of the action

OR

– 10 mg w/m; 10-20 minutes before the start of the action

Children: aged 6-12 years: 1-3 mg w/m (maximum dose 0.15 mg/kg);

c) olanzapine

(Important: It is not recommended to use IV benzodiazepines and olanzapine IV at the same time due to reported deaths)

Adults: 10 mg w/w; 15-30 minutes before the start of the action

Children:

– aged 6-11 years: 5 mg IV (insufficient evidence base for use in children)

– aged 12-18 years: 10 mg w/w;

d) ziprasidone

Adults: 10 mg w/w; 10 minutes before the start of the action

Children:

– aged 6-11 years: 5 mg IV (insufficient evidence base for use in children)

– aged 12-18 years: 10 mg w/w.

2.4. Dissociatives (provide sedation and anesthesia).

Ketamine (an option for high risk of violence).

Adults:

– 2 mg/kg IV; 1 minute before the start of the action

OR

– 4 mg/kg w/m; 3-5 minutes before the start of the action

Children:

– 1 mg/kg IV

OR

– 3 mg/kg w/m

2.5. Antihistamines.

Diphenhydramine

Children: 1 mg/kg IV/IV/oral (maximum dose – 25 mg)

3. Means of physical control of the patient.

3.1. Body:

a) fixing belts should be used as a standard procedure for all patients during transportation;
b) physical controls, including fixing belts, should not interfere with the movement of the patient’s chest walls;
c) if necessary, sheets can be used as an improvised auxiliary in addition to fixing belts, other improvised fixing methods are not allowed for use;
d) auxiliary belts and sheets may be required to prevent bending/extension of the torso, hips, legs due to their location in the lower lumbar region, below the buttocks, above the hips, knees and shins.

3.2. Endings:

a) soft or leather tools should not contain locks, for unlocking of which a key is required;
b) fix all the limbs of the patient for the sake of his safety, as well as the safety of others;
c) fix all the limbs on the spinal board;
d) it is not allowed to use a large number of units to fix the device.

Patient safety

Management of aggressive patients requires constant reassessment of the balance of risk/benefit for the patient and others, this is necessary in order to provide the safest care to all who need it. Such situations are complex and contain serious risks, there is no single standard rule for working with such patients.

1. Wear personal protective equipment.

2. Do not attempt to approach or control the scene where weapons or violence are present.

3. Call law enforcement immediately to ensure control and safety at the scene.

4. Immediate reduction of patient agitation is essential both in the interests of the patient himself and for the safety of EMF workers and others at the scene.

5. Uncontrolled or poorly controlled excitation or aggression of the patient puts him at risk of sudden cardiac arrest due to the following etiology:

a) delirium/manic arousal – the cause of sudden death is metabolic acidosis (most likely from lactate), which in turn is caused by physical arousal or physical controls and potentially worsened by stimulating narcotic substances (for example, cocaine) or treatment for alcoholism;
b) positional asphyxia – sudden death due to restriction of movement of the walls of the chest and/or obstruction of the respiratory tract, which are secondary to restriction of movement of the head or abnormal in the position of the neck, which in turn lead to hypercarbia and/or hypoxia.

6. Connect the patient as soon as possible to a heart rate monitor, especially after administration of drugs.

7. All patients who have been administered drugs to control their behavior need close supervision to prevent problems of hypoventilation and excessive sedation.
Apply capnograph (if any).

8. All patients who have been administered antipsychotic drugs to control their behavior need close supervision to prevent the following problems:

a) dystonic reactions (such cases are easily controlled with diphenhydramine/benzodiazepine);
b) mydriasis (dilated pupils);
c) ataxia;
d) stop sweating;
d) dryness of mucous membranes;
e) cardiac arrhythmia (especially with prolonged QT interval).

9. Using a stretcher in a sitting position prevents the risk of aspiration and reduces the patient’s physical strength due to the location of the abdominal muscles in a bent state.

10. Patients who strongly show physical disobedience should be fixed on a stretcher with one hand above their head and the other at waist level, both lower limbs should be fixed separately.

11. The following techniques are strictly prohibited for use by EMF employees:

a) fixing the patient in the prone position with fixing the arms and legs behind his back (the so-called “pig binding”);
b) fixing the patient between two boards;
c) any fixation methods that restrict the movement of the neck and interfere with the patency of the respiratory tract;
d) use of weapons by EMF employees as a tool for patient monitoring.

12. It is not recommended to use IV benzodiazepines and olanzapine IV at the same time, as they can lead to deaths.

Key points

1. For direct medical supervision, advice should be sought at all times, especially if the patient’s level of arousal is such that transporting it could endanger the EMF team.
2. It is not recommended to use air vehicles.
3. Stretcher with a special foam pillow, especially around the head, which allows the patient to independently position the head in a comfortable position to maintain airway patency.
4. In patients with devices that are key locked by another agency that is key locked, consider the following options:

a) replace devices with others without locks;
b) use drugs to control behavior, only then replace the devices with alternative ones that do not have locks if the patient does not resist and cooperates with the EMF;
c) transport the patient together with the person who has the key;
d) transport the patient together with the person holding the key, if the patient’s medical condition is stable and there is permission from the medical management and the law allows.

Relevant evaluation results

Continuous monitoring:

a) airway patency;
b) respiration using pulse oximetry and/or capnography;
c) circulation conditions with frequent measurement of blood pressure;
d) states of consciousness and changes in the level of cooperation;
d) heart function, especially in the case of pharmacological treatment of the patient;
e) perfusion of limbs by capillary filling in the case of physical control devices.

Key elements of documentation

1.  
2. Etiology of agitation and aggression (if known).
3. Drugs used by the patient or any drugs or substances found at the scene near the patient.
4. History or relevant facts from the past that were provided by the patient, loved ones or strangers.
5. Physical evidence or history of injury.
6. Adequate level of oxygenation in terms of pulse oximetry.
7. Glucose level indicator.
8. Applied methods of establishing contact with the patient.
9. Doses, routes of administration, and number of doses administered.
10. Clinical response to administered drugs.
11. Number and locations of physical devices for patient monitoring.
12. Reassessment of airway patency.
13. Repeated assessment of breathing – frequency, nature, pulse oximetry/capnography indicators.
14. Re-assessment of circulation – pressure, capillary filling, heart rate monitoring.
15. Re-assessment of the state of consciousness and changes in the patient’s cooperation.
16. Re-evaluation of capillary filling on limbs after application of physical patient monitoring devices.
17. Communication with EMF medical management.
18. Call time and arrival of law enforcement services.

Criteria for the effectiveness of care

1. Injury to the patient, EMF workers or others at the scene.
2. Injury to the patient, EMF workers or other persons during transportation.
3. Medical or physical complications (including sudden death) in the patient.
4. Detailed description of EMF protocols for dealing with agitated or aggressive patients with other emergency services and law enforcement agencies.
5. Call and contact with EMF medical management.
6. Challenge and time of communication with law enforcement agencies.