Alexander ch31 lecture

Copyright © 2017, 2012 Pearson Education, Inc. All Rights Reserved.
Advanced EMT
A Clinical-Reasoning Approach, 2nd Edition
Chapter 31
Mental Illness
and Behavioral
Emergencies

• Applies fundamental knowledge to provide basic
and selected advanced emergency care and
transportation based on assessment findings for
an acutely ill patient.
Advanced EMT
Education Standard

1. Define key terms introduced in this chapter.
2. Explain the importance of being able to recognize
and respond to patients suffering from behavioral
emergencies.
3. Describe indications of danger associated with response
to behavioral emergencies.
4. Discuss the underlying physical and psychological
causes of behavioral emergencies.
5. Describe the focus of assessment and history taking for
patients experiencing behavioral emergencies.
Objectives (1 of 4)

6. Recognize behavioral characteristics of mental health
conditions.
7. Describe risk factors associated with violence toward
others and suicide.
8. Incorporate the basic principles presented in the text
into the assessment, communication, and management
of patients with behavioral emergencies.
9. Prioritize patient care needs in terms of managing
physical and behavioral problems.
Objectives (2 of 4)

10.Explain the importance of ongoing assessment of
patients with behavioral emergencies.
11.Evaluate the need for involving law enforcement on
behavioral emergency calls.
12.Recognize indications for physical restraint of a patient.
13.Follow principles of safe physical restraint of patients.
14.Comply with legal principles when responding to patients
with behavioral emergencies.
15.Document all information pertinent to calls involving
behavioral emergencies and patient restraint.
Objectives (3 of 4)

16.Given a number of patient scenarios, assess and
manage patients presenting with indications of a
psychiatric disorder or behavioral emergency.
17.Consider physiologic differential diagnoses for patients
presenting with indications of a psychiatric disorder.
18.Discuss substance abuse as a mental illness.
19.Describe the acute and long-term behavioral and
physiologic effects of alcohol abuse and alcohol
withdrawal.
Objectives (4 of 4)

• EMS providers are often uneasy managing
patients with mental illnesses and behavioral
emergencies.
• Use interpersonal skills and therapeutic
communication.
Introduction (1 of 2)

• Scene safety issues
– Critical patients are in need of immediate management
of airway, breathing, circulation.
– Distraught patients may feel hopeless.
– Medical–legal considerations about consent and
restraint
– Ethical considerations
Introduction (2 of 2)

Think About It
• What are some hypotheses that immediately
come to mind?
• What line of questioning could Courtney use to
determine the nature of the problem?
• What assessments could prove useful in
determining the nature of the problem?

An Overview (1 of 3)
• Mental illness
– Emotional or mental state of dysfunction that may or
may not be apparent
• Behaviors
– Facial expressions, posture, actions, words

• Mental illnesses
– Anxiety, depression, stress reactions, personality
disorders, psychotic disorders, addictive behaviors
• Behavioral emergency
– Behavior intolerable to patient or those around him,
elements of concern for patient’s safety and well-being
and that of others, unusual behavior, evidence of
unusual thoughts

• Patients with mental illness cannot be grouped
together.
• Mental illnesses are diverse, ranging from anxiety
to depression, stress reactions, personality
disorders, psychotic disorders, and addictive
behaviors.

Table 31-1
Indications of Impending Violence
• Increased fidgeting or restlessness
• Pacing
• Profanity
• Loudness, yelling
• Destructive behavior
• Clenched fists, increased muscle tension
• Threats
• Intoxication
• Signs of past violence (scars)

Assessment and Management (1 of 7)
• EMS requested often means element of violence
or impending violence.
• Law enforcement should secure scene before you
enter it.
• Patient may need to be restrained to keep him
from hurting himself or others.
• Scene safety is dynamic.

• Scene size-up and primary assessment
– Maintain confident but relaxed approach.
– Consider patient’s affect, posture, movements,
behaviors.
– Take note of living conditions.
– Look beyond obvious to determine if patient may have
attempted to harm himself.

• Scene size-up and primary assessment
(continued)
– Confirm unresponsiveness; check carotid pulse.
 If pulse is absent, begin CPR according to protocol. Look for
and control significant hemorrhage.
– For responsive patients, balance patient privacy with
need for safety and respect patient’s personal space.

• History and secondary assessment
– Empathetic, nonjudgmental approach is essential.
– Determine blood glucose level in patients with altered
mental status.
– List of medications is important.
– Interview family and friends separately.

Table 31-2
Selected Medications Used to Treat Mental Illness
Antidepressants Antipsychotics
Other Medications Used for Mental
Disorders
bupropion (Wellbutrin) aripiprazole (Abilify) alprazolam (Xanax)
citalopram (Celexa) chlorpromazine (Thorazine) buspirone (Buspar)
desvenlafaxine (Pristiq) clozapine (Clozaril) carbamazepine (Tegretol)
duloxetine (Cymbalta) haloperidol (Haldol) clonazepam (Klonopin)
escitalopram (Lexapro) olanzapine (Zyprexa) gabapentin (Neurontin)
fluoxetine (Prozac) quetiapine (Seroquel) lithium
paroxetine (Paxil) quetiapine (Seroquel) lorazepam (Ativan)
sertraline (Zoloft) ziprasidone (Geodon) modafinil/armodafinil (Provigil/Nuvigil)
St. John’s wort (herbal remedy) propranolol (Inderal)
trazodone (Desyrel) valproic acid (Depakote)
venlafaxine (Effexor) stimulants (amphetamine sulfate and
dextroamphetamine, such as Evekeo and
Adderall; methylphenidate, for example
Ritalin)
vortioxetine (Brintellix)

• Mental status exam (MSE)
– Level of responsiveness
– Orientation to person, place, and time
– Ability to sustain attention and concentrate
– Disorders of perception
– Disordered thinking
– Affect and mood
– Behavior

• Clinical reasoning
– Assess for medical and traumatic causes of behavior
change.
– Chief complaint may not be related to history of mental
illness.
– Diagnostic error: because history of mental illness,
current problem due to mental illness

Table 31-3
Problems That May Present as Behavioral
Emergencies
• Infection
• Tumor
• Neurologic damage from substance abuse
• Substance withdrawal
• Recent or past traumatic brain injury
• Stroke
• Seizure
• Endocrine emergencies (hypoglycemia, hyperglycemia, thyroid
• conditions, adrenal conditions)
• Hypoxia
• Metabolic disturbances (uremia)
• Drugs, toxins

• Treatment and reassessment
– Therapeutic communication is often the most effective
prehospital treatment.
– Treat injuries and medical conditions.
– Establish baseline for patient’s condition.
– If patient physically restrained, assess for injuries as
soon as restraint accomplished.

Anxiety Disorders (1 of 4)
• Excessive anxiety can interfere with social and
occupational functioning and can be harmful.
– Panic disorders
– Phobias
– Obsessive–compulsive disorder
– Acute stress reaction
– Post-traumatic stress disorder (PTSD)

• Signs and symptoms
– Tachycardia: chest pain or tightness
– Tachypnea: feeling of fear
– Diaphoresis: feeling of impending doom
– Sensation of choking or being suffocated

• Same symptoms as:
– Shock
– Myocardial infarction
– Hyperthyroidism
– Adrenal disorders
– Asthma
– Use of cocaine, caffeine, amphetamines
– Withdrawal syndromes

• A panic attack
– A brief period of intense fear, anxiety, and discomfort
• Patient might fear
– Dying, having a heart attack, or going crazy or losing
control, or may have a sensation of unreality
(depersonalization)

Cognitive Disorders
• Delirium
– Acute onset of confusional state with underlying
correctable cause
• Dementia
– Progressive deterioration of mental function, including
memory impairment
– Both can involve confusion, leading to fear and
combative behavior.

Eating Disorders
• Anorexia nervosa
– Very thin, but obsessed with weight loss
• Bulimia nervosa
– Normal weight, but obsessed with weight loss
• Binge eating
– Generally obese

Factitious Disorders and Somatoform
Disorders (1 of 2)
• Factitious disorders
– Intentional infliction of either physical or psychological
signs and symptoms, either in one’s self (Munchausen
syndrome) or others (Munchausen by proxy).
• Somatoform disorders
– Physical symptoms without apparent physiologic cause

Factitious Disorders and Somatoform
Disorders (2 of 2)
• Conversion disorder
– Sudden loss of specific neurologic function following
severe stressor
• Body dysmorphic disorder
– Preoccupied with physical defect not apparent to
others

Impulse Control Disorders
• Cannot control impulses to engage in certain
behaviors
– Kleptomania (stealing)
– Pyromania (fire setting)
– Pathologic gambling
– Intermittent explosive disorder (angry outbursts)

Mood Disorders (1 of 2)
• Major depressive episode
– Depressed mood; decreased interest in things once
found pleasurable
– Weight loss or gain
– Insomnia or excessive sleeping
– Increased or decreased psychomotor activity
– Feelings of worthlessness and guilt
– Inability to think, concentrate, make decisions
– Recurrent thoughts of death or suicide

Mood Disorders (2 of 2)
• Bipolar disorder
– Affects less than 1% of population.
– Periods of persistent, abnormally elevated mood
interspersed with periods of depression
– Medications: antipsychotics, antidepressants,
anticonvulsants, lithium (mood stabilizer)

Personality Disorders
• Cluster A disorders
– Emotionally distant and isolated, often with odd or
eccentric behavior
• Cluster B disorders
– Emotional instability, impulsiveness, intensity in
behavior or relationships
• Cluster C disorders
– Anxious or fearful personality disorders

Schizophrenia (1 of 2)
• Psychotic disorders: have lost contact with reality
– Delusions
– Disorganized thoughts and behavior
– Hallucinations (visual or auditory)
– Flat affect
– Impaired reasoning
– Catatonic behavior
– Most schizophrenics not violent
– Onset in early adulthood

Schizophrenia (2 of 2)
• While most schizophrenics are not violent, risk
increases in patients who
– Have hallucinations in which they are being persecuted
or commanded to do things
– Are not compliant with their medications
– Have substance abuse problems

Substance Abuse, Addiction,
and Withdrawal (1 of 2)
• Diagnostic and Statistical Manual (DSM-IV TR) of
the American Psychological Association (APA)
lists substance abuse as mental illness.
• Addiction
– Preoccupation with obtaining and using substance,
with or without physical dependence

Substance Abuse, Addiction,
and Withdrawal (2 of 2)
• Intoxication
– State of mental and behavioral changes
– Significant intoxication with CNS depressants (alcohol,
narcotics) can lead to respiratory depression and loss
of ability to protect airway.

Alcohol (1 of 3)
• Beverage alcohol absorbed quickly from stomach
and small intestine, metabolized in liver
• Effects of chronic alcohol abuse
– Cirrhosis of liver
– Pancreatitis
– Gastrointestinal bleeding

Alcohol (2 of 3)
• Effects of chronic alcohol abuse
– Cirrhosis of the liver
– Wernicke-Korsakoff syndrome
– Alcoholic dementia
– Malnutrition
• Alcohol withdrawal
– Delirium tremens (DTs)
– Begin 48–72 hours after abstaining from alcohol

Alcohol (3 of 3)
• Obtain IV access in patients with a decreased
level of responsiveness. Administer 50% dextrose
for hypoglycemia.
• Alcoholics may require the administration of
100 mg thiamine with 50% dextrose.

Suicide
• Tenth leading cause of death in the United States.
• 90% of all patients who commit suicide have
mental illness.
• Methods vary by gender and ethnicity.
• Treatment:
– Manage life threats.
– Care for behavioral aspect.

Think About It
• Treat suspected suicide deaths as a crime scene.
• Law enforcement and medical examiners office
must investigate to determine the cause and
manner (suicide, homicide, accident, or natural
causes) of death.

Violent Patients (1 of 2)
• Signs that patient may become violent
– Increasing fidgeting or restlessness
– Pacing
– Profanity
– Increasing voice volume
– Destructive behavior
• Restraint used in conjunction with law
enforcement; only done if person is threat to
himself or others

Violent Patients (2 of 2)
• Use of restraints
– Five people needed
 One on each extremity and one to apply restraint
– Explain plan to patient.
– Follow through with plan.
– Do not remove restraints.
– Use force only if necessary.
– Assess for injury.

Chapter Summary (1 of 2)
• Behavioral emergencies can have situational,
mental, physical causes.
• Your safety, patient’s safety, bystanders’ safety
can be at risk.
• Assess patient for indications of impending
violence.
• If necessary, request law enforcement.

Chapter Summary (2 of 2)
• Restrain patient only if necessary to protect from
harming themself and others.
• Identify medical or traumatic causes of behavior
and manage accordingly.
• Use therapeutic communication as essential
element of assessment and management.
• Be nonjudgmental and empathetic in your
approach.

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