Behavioral Emergencies

Chemical Restraints




  • 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




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






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




  • Obtain BGL






Reassess after 10 minutes


Patient remains combative and is unable to be restrained?


  • Yes


    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




  • 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.
  • Continuously monitor EKG and O2 sat once the level of patient agitation allows.


National Registry Emergency Medical Responder


National Registry Emergency Medical Technician


National Registry Paramedic