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Chapter 28 Objectives

1.)  Discuss the potential causes of behavioral emergencies, including organic and environmental causes.

Potential causes for behavioral emergencies

Organic - Biologic or organic influences that interfere with normal cerebral function.  Such patients are usually classified as Organic Brain Syndrome.  Examples would be chronic hypoxia, seizure, traumatic brain injury, chronic alcohol and drug abuse, and brain tumors.  These conditions alter the normal functioning of the brain and may cause derangements in behavior.  The most common offenders are alcohol and drugs, but consider dementia and delirium.

Environmental - When people are consistently exposed to stressful psychosocial events, or developmental influences, they may develop abnormal reactions.  When a person’s basic needs are threatened, that person faces a crisis.  a person in crisis has two alternatives for dealing with this threat:  (1) cope with it, finding ways to alter the situation or his or her perception of it so that it is no longer so stressful, or (2) attempt to alleviate the discomfort by escaping from the stress.  Escape may take many forms, including alcohol, drugs, psychiatric symptoms, even suicide. Humans are social, preferring to live in groups.  Not surprisingly, then, sociocultural factors directly affect biology, behavior, and responses to stress of emergencies.  For example, the effects of assault, rape, and racial attacks or the death of a loved one may produce significant changes in a person’s behavior.

2.)  Define normal, abnormal, overt, and covert behavior.

Normal behavior is defined as the way people act or perform, for example, how they respond to a situation.  Behavior includes all the things people do and the reasons why they do those things.

Abnormal behavior is hard to define.  Who decides what is abnormal.  Usually society as a whole, or a group of people, or a community  define what is normal or abnormal.  A general way of thinking and doing.  When one opposes this general way, it is thought to be abnormal, against the normal.

Overt behavior is open and generally understood by those around the person.

Covert behavior has hidden meanings or intentions that only the person understands.

3.Discuss medicolegal considerations and their relevance in psychiatric emergencies.

Medics are especially at risk for the potential to have legal problems, on calls involving behavioral emergencies.  When a patient's behavior, speech, and thoughts are erratic and disorganized, it can be difficult for you to communicate clearly and understand the situation.  Be prepared to spend extra time with disturbed patients.  Do not be in a hurry, show  you have time to talk and show concern about what is bothering the patient.  Obtain consent from the patient just like any other patient.  If they refuse, continue to talk, explain your responsibilities to the patient.  Be clear in your explanations about treatment, and medications if used.  Do not assume the patient cannot understand.  Include the patient in his or her own care.  Good communication, following standards and protocols, having patience, and good documentation will be your best protection against legal action.

4.Describe the assessment process for patients with psychiatric emergencies, including safety guidelines and specific questions to ask.

Your approach to assessing a psychiatric patient must differ from those of trauma.  These assessment techniques are not in using equipment, or diagnostic tools, rather your brain.  You must use your thinking process to evaluate someone else's thought process.  Use your feelings to gauge others feelings, use you perception to see if someone else’s perception is valid. 

Observe the situation to determine whether it is dangerous to you and your partner.  If so, call law enforcement.  Observe carefully for weapons, remember almost anything can be used as a weapon.  If you need help call for assistance.  Behavioral emergencies can look safe and easy, but they can change rapidly.  You never know for sure what someone is thinking. 


            1.  Assess the scene

            2.  Be prepared to spend extra time

            3.  Have a definite plan of action

            4.  Identify yourself clearly

            5.  Be direct

            6.  Stay with the patient

            7.  Encourage purposeful movement

            8.  Express interest in the patient

            9.  Keep a safe distance from the patient

            10.  Avoid fighting with the patient

            11.  Be honest and reassuring

            12.  Do not judge



5.)  Discuss the importance of history taking when assessing a patient with a psychiatric emergency.

There is great importance in taking a history with psychiatric patients.  The use of the mnemonic COASTMAP is a helpful way to remember what to be looking for.  You can assess nearly all of these by watching and listening. Memory, Orientation, and Perception may need questions asked to determine.


            C - Consciousness

            O - Orientation

            A - Activity

            S - Speech

            T - Thought

            M - Memory

            A - Affect and mood

            P - Perception


            Ask open ended questions to get an idea of what the patient is thinking.  Ask questions like, “Tell me about the problems you’ve been having”, or “Tell me what you feel like?”.

            Use of closed questions may help obtain more specific answers like, “How many pills did you take?” or “What medication did you take?”  



6.)  Discuss general management of a patient with a psychiatric emergency.


            1.  Begin with an open ended question

            2.  Let the patient talk

            3.  Listen, and show that you are listening

            4.  Do not be afraid of silences

            5.  Acknowledge and label the patient’s feelings

            6.  Do not argue

            7.  Facilitate communication


            8.  Direct the patient’s attention

            9.  Ask Questions

            10.  Adjust your approach as needed

            11.  Be calm and direct as possible

            12.  Exclude disruptive people

            13.  Sit down

            14.  Maintain a nonjudgmental attitude

            15.  Provide honest reassurance

            16.  Develop a plan of action

            17.  Encourage some motor activity

            18.  Stay with the patient at all times

            19.  Bring all patient’s medication to hospital

            20.  Never assume that it is impossible to talk with any patient until you try


7.Describe situations where restraint may be justified.

Any time the patient is going to harm someone, or themselves, restraining the patient must be considered.  Notify medical control, and law enforcement. 

8.Describe methods used to restrain patients.

Physical restraint such as leather or nylon straps, that are padded for comfort and safety, are placed around wrists and ankles of the patient.  Then they are secured to the stretcher or long spine board.  The goal is to immobilize the patient from movement  so they do not hurt themselves or others

Chemical restraints such as benzodiazepines, haloperidol, or droperidol are used to sedate the patient, so the patient does no harm to self or others. 

Law enforcement use Tasers to restrain violent or aggressive behavior.  The taser use of electricity in small, short bursts delivered to a person through several different devices.

9.)  Compare physical restraint with chemical restraint.

Chemical restraint may be much better for the patient to avoid trauma to patient, as long as there are no contraindications to the medications used.  Physical restraint may be dictated if those having contraindications need restraining.

10.)  Describe care for a psychotic patient.

A patient with a psychotic behavior needs structure.  Explain in plain language what is being done and what the patients role will be.  The patient may have a completely different set of logical rules than you are used to dealing with.  Directions should be simple, consistent, and firm.  Keep orienting the patient to time, place, and the people around them.

11.)  Define agitated delirium and describe the care for patient with agitated delirium.

Agitated Delirium is a state of global cognitive impairment that is acute in onset and associated with fluctuations in mental status and behavior, inattention, disorganized thinking, and altered level of consciousness.  It is usually caused by toxic and metabolic problems or infections.  Dementia is a more chronic process that produces severe deficits in memory, abstract thinking, and judgement. 

Identifying the stressor or metabolic problem may help identify possible  treatments (for example, reducing fevers, administering glucose for hypoglycemia, treating dysrhythmias to improve hypoperfusion).  Be cautious when administering morphine or antipsychotics to patients with a known history of dementia because complication may be common.

12.)  Explain how to recognize the behavior of a patient at risk of suicide, and discuss management of such patient.


            Risk factors for suicide include:         depression

sudden improvement in depression

male gender age 55 and older

single, widowed, or divorced

                                                                        Alcohol or other drug abuse

                                                                        Recent loss of spouse or significant relationship

                                                                        Chronic, debilitating illness


                                                                        Expresses suicidal thoughts and plans to carry out


                                                                        Social isolation

                                                                        Previous suicide attempts

                                                                        Financial setback or job loss

                                                                        Family history of suicide


Do not leave the patient alone.  Look around scene for any implements, such as pill bottles, meds, or weapons, and bring to hospital.  Acknowledge the patient’s feelings, and encourage the patient to be transported to the hospital.  If the patient refuses, try to get close ones to talk to him and encourage transport.  If patient still refuses, call for law enforcement.



13.)  Discuss risk factors that help indicate whether a patient may become violent.


            Risk factors for a potentially aggressive or violent patient include:

Posture - the patient who sits tensely at the edge of the chair or grips the armrest.

Speech - loud, critical, threatening, full of profanity

Motor activity - unable to sit still; pacing back and forth or in circles

Body language - clenched fists, avoiding eye contact, turning away when spoken to

Your own feelings - your own “gut” feeling or response, pay attention



14.Explain the safe management of a potentially violent patient.


            Assess the whole situation.   Observe your surroundings.  Maintain a safe distance.  When speaking to the patient, try to convey an impression of calmness and self control.  Identify yourself as medical personnel who are there to help.  Keep your voice low, making the patient pay attention to hear you.  Acknowledge the patients behavior, and restate you are there to help.  Encourage the patient to talk.  Listen to what they say.  Ask the patient if they feel like they are gonna lose control or carry any weapons.  Define your expectations of the patients behavior.  If you have problems and cannot  handle the patient, get help.


15.List specific psychiatric disorders that can play a role when a patient experiences acute psychosis or agitated delirium.


            1.  Manic-depressive illness

            2.  Depression

            3.  Bipolar mood disorder

            4.  Schizophrenia

            5.  Generalized anxiety disorder

            6.  Phobic disorders

            7.  Panic disorders

            8.  Substance related disorders

            9.  Eating disorders

            10.  Somatoform

            11.  Factitious Disorder

            12.  Impulse Control Disorder

            13.  Personality Disorders


16.Discuss assessment and management of specific psychiatric emergencies.


            EMS providers have difficulty influencing these patients.  Paramedics will not diagnose these disorders, but it is helpful to be familiar with these as potential causes for  acute psychosis or agitated delirium.


1.  Begin with an open ended question

            2.  Let the patient talk

            3.  Listen, and show that you are listening

            4.  Do not be afraid of silences

            5.  Acknowledge and label the patient’s feelings

            6.  Do not argue

            7.  Facilitate communication  

            8.  Direct the patient’s attention

            9.  Ask Questions

            10.  Adjust your approach as needed

            11.  Be calm and direct as possible

            12.  Exclude disruptive people

            13.  Sit down

            14.  Maintain a nonjudgmental attitude

            15.  Provide honest reassurance

            16.  Develop a plan of action

            17.  Encourage some motor activity

            18.  Stay with the patient at all times

            19.  Bring all patient’s medication to hospital

            20.  Never assume that it is impossible to talk with any patient until you try




17.)  Discuss medications used in the treatment of psychiatric emergencies.


                        1.  Antidepressants - used primarily for major depression, also effective for panic disorders, agoraphobia, obsessive-compulsive disorder, enuresis, and school phobia.

2.  Benzodiazepines - used in treatment of severe emotional distress, even if a patient is not psychotic or an imminent threat to himself or others.  Other uses include muscle relaxation, controlling seizure, and treating alcohol, sedative, or hypnotic withdrawal.

3.  Antipsychotics - these relieve symptoms such as hallucinations and delusions but also enhance the quality of life by improving the affective symptoms of anxiety and depression and decreasing suicidal tendencies.

4.  Amphetamines - used to help with attention deficit disorders with hyperactivity, in adults and children, also used for narcolepsy.