Behavioral Emergencies

Chemical Restraints

 

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

 

 

 

 

 

OR

 

    Ketamine IM      (Online Order Required)

 

  • Age < 65 years old and > 12 years old

 

  • < 100 lbs
    • 200 mg IM - 4 mL
  • 100-200 lbs
    • 300 mg IM - 6 mL
  • > 200 lbs
    • 400 mg IM - 8 mL

 

  • Injections > 5 mL should be split over two separate syringes

 

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

 

 

 

 

See Cardiac Arrest protocol

 

  • Notify receiving facility

 

PEARLS:

 

  • Use this protocol for those patients with a psychosocial condition, including drug intoxication, exhibiting extreme anxiety and who are hemodynamically stable.
  • Be sure to consider all possible medical/trauma causes or behavior (hypoglycemia, overdose, substance abuse, hypoxia, head injury, etc.).
  • Withhold Ketamine in patients 65 or older. Administer Midazolam 5 mg IM; if further sedation is needed contact online medical control.
  • Ketamine dosing in this protocol will cause disassociation and unconsciousness even though patient will appear awake
  • Do not irritate the patient with a prolonged exam.
  • Do not overlook the possibility of associated domestic violence or child abuse.
  • 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 hogtie 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.

NREMR

National Registry Emergency Medical Responder

NREMT

National Registry Emergency Medical Technician

NRP

National Registry Paramedic

NREMT-I

National Registry EMT-Intermediate

NREMT

National Registry Emergency Medical Technician

NRP

National Registry Paramedic