History:

 

• Situational crisis
• Psychiatric illness
• Medications
• Injury to self or threat to others
• Medical alert tag
• Substance abuse/overdose
• Diabetes

 

Significant Findings:

 

• Anxiety/agitation/confusion
• Affect change/hallucinations
• Delusional thoughts/bizarre behavior
• Combative
• Expression of suicidal/homicidal thoughts

 

Differential:

 

• See AMS differential
• Alcohol Intoxication
• Toxin/substance abuse
• Medication effect/overdose
• Withdrawal syndromes
• Depression
• Bipolar (manic-depressive)
• Schizophrenia
• Anxiety disorders

 

Treatment:

 

• Remove patient from stressful environment
• Use verbal calming techniques (calm, reassure, establish rapport)
• GCS on all patients

• Obtain BGL

 

Medical Patient or glucose < 60 with signs of hypoglycemia?

 

• • • See appropriate Protocols:
    • AMS
    • Poisoning
    • Trauma

 

Patient remains combative and is unable to be calmed?

 

• Yes

 

• • Consider Midazolam (Versed) 5 mg / 1mL IM; may repeat once after 5 minutes

 

OR

 

• • Consider Ketamine 4 mg/kg IM, Max dose 400 mg

 

 

Suspected agitated delirium ?

 

(hyper aggression, hyperthermia, diaphoretic)

 

• Yes

 

• • Normal Saline up to 1,000 mL IV

 

• • Consider external cooling

 

• No

 

• • Notify receiving facility or contact Medical Control

 

Cardiac Arrest ?

 

• Yes

 

• • Sodium Bicarbonate 1 mEq/kg IV

 

• • See Cardiac Arrest protocol

 

• Notify receiving facility

 

PEARLS:

 

• Following medication administration the patient should be continuously monitored with waveform capnography and vitals Q 5.

• Use of this protocol is for the management of patients who are dangerously combative, posing an immediate threat to themselves or crew. The decision to administer this medication shall be made solely by the paramedics, acting in the patient's best interest. It is not for the management of anxiety, isolated psychosis, or redirectable behavioral issues.
• Higher doses of IM ketamine may result in respiratory depression and may require airway/breathing support. This is particularly the case in patients who have ingested alcohol, opiates, benzodiazepines, or recreational drugs.
• There is a possibility of larynogspasm with high dose Ketamine administration. Consider the Larson's maneuver for management.
• Be sure to consider all possible medical/trauma causes or behavior (hypoglycemia, overdose, substance abuse, hypoxia, head injury, etc.).
• Ketamine dosing in this protocol will cause disassociation and unconsciousness even though patient will appear awake. IM injections >5 mL should be split over two separate syringes.
• Any patient who is handcuffed or restrained by law enforcement and transported by EMS must be accompanied by law enforcement in the ambulance.
• Do not position or transport any restrained patient in such a way that could impact the patient's respiratory or circulatory status. Never hog-tie or restrain in a prone position with hands tied behind back. No restraint shall ever be tied around the head, neck or chest, nor shall pressure be applied to these areas in an attempt to restrain or control the patient.
• EMS providers may use physical and/or chemical restraints on patients who pose a danger to themselves or others. Use the minimum amount of restraint necessary.
• Physical restraints must be soft in nature and pose no threat to the patient's safety. Only the extremities shall be restrained and these restraints must be assessed every five minutes. Stretcher straps are not considered restraints.
• A surgical or oxygen mask may be placed loosely on the patient to prevent spitting.