ATS - Behavioral Emergencies

Emergency Medical Technician
13 - Behavioral Emergencies
© 2014
• Complications in
people’s lives can cause
troubling behavioral
changes:
– Mild depression
– Aggression
– Violence
3

© 2014
• Factors that can cause
atypical behavior
include:
– Medical conditions
– Alcohol abuse
– Stress
– Failure to take
medication as
prescribed
– Illicit substance use
4

© 2014
• Behavior that rises to a
crisis level can:
– Result in a behavioral
emergency
– Put the patient,
bystanders and
responders at risk
• Your ability to
recognize, calm and
care for a person
experiencing a
behavioral emergency
can help minimize the
crisis
5

© 2014
1. Behavioral Emergency Causes
2. Assessment Techniques
3. Suicide Risks
4. Substance Abuse
5. Calming Methods & Emergency Care

13 - Behavioral Emergences
© 2014

© 2014
• You will encounter
patients who exhibit
emotional instability
• Patients may be
experiencing situational
stress:
– Traumatic incident
– Medical condition
– Psychiatric condition
8

© 2014
• It can be difficult to
determine if a patient’s
behavior is altered due
to a:
– Medical condition
– Psychiatric condition
• Erratic behavior is often
mistaken for alcohol or
drug abuse
9

© 2014
• When caring for
patients who are
exhibiting unusual
behavior:
– Maintain suspicion that
the patient may have
an underlying medical
emergency
– Do not assume it is
drug or alcohol related
10

© 2014
• Many things can mimic
signs & symptoms of
drug or alcohol abuse:
– Low blood sugar
– Head injuries
– Shock or hypoxia
• Symptoms range from:
– Confusion
– Anxiety
– Agitation
– Fear
– Violent acts
11

© 2014
• Withdrawal from drugs
or alcohol can cause
similar behaviors:
– Anxiety
– Irritability
– Confusion
• Poisoning and overdose
can create an altered
mental status
12

© 2014
• A psychiatric crisis can
cause extreme
depression, panic, and
episodes of mania
• Patients may
experience bizarre
thinking and behavior:
– Hallucinations and
paranoia:
 Can lead to
unpredictable and
often aggressive
actions
13

© 2014
• Use extreme caution when
approaching or treating
patients exhibiting a
behavioral crisis
• Regardless of the
underlying cause,
behavioral emergencies
can pose a danger to:
− Responders
− The patient
− Bystanders
14

© 2014
• When responding to a
behavioral emergency,
your first priority:
– Size-up the scene
– Ensure personal safety
• Never enter a scene if
you don’t feel safe
• Begin your patient
assessment by
maintaining a safe
distance:
– Survey the scene
– Gather information
16

© 2014
• Observing the general
appearance of patients
can offer clues about
their mental state:
– An unkempt
appearance may clue
you in to medical needs
• Note speech patterns:
– Impediments such as
slurring could indicate
intoxication but could
also indicate an
underlying medical
condition
17

© 2014
• Skin signs can also offer
clues regarding the
patient’s condition:
– A patient with hot, dry
and red skin who is
also exhibiting an
altered mental status
may be suffering from
hyperthermia or
intoxication from
medication or ingested
plants
18

© 2014
• Observe the patient’s
posture and gait:
– A patient with severe
depression may have a
slumped appearance
and a slow gait
– A patient exhibiting a
manic episode or
intoxication from
medication or drugs
such as amphetamines
may have an upright
posture and an excited
gait
19

© 2014
• Look for clues as to the
patient’s mental state
by examining:
– Alertness
– Verbal responsiveness
– Pain perception
– Their awareness of
your presence and the
environment
20

© 2014
• Assess the potential for
violence:
– Observe the patient
and the surroundings
for weapons or other
indications for the
potential for violence
• Ask about any past
history of violence
• Note whether the
patient is verbally
aggressive
21

© 2014
• A patient’s movements,
such as pacing or arm
waving as well as
posture, can indicate a
potential for violent
behavior
• Other threatening
behaviors include:
– Constant, direct staring
– An inability to
comprehend that you
are there to help
– Bizarre thinking
22

© 2014
• Keep in mind that
anything in your
possession is a
potential weapon in the
hands of a potentially
violent patient
23

© 2014
• Any patient can become
aggressive:
– Even elderly patients
can still pose a serious
threat under the right
circumstances
24

© 2014
• If the patient will allow
you:
– Perform a primary
assessment
– Treat any life-
threatening problems
• Minimize physical
touching and maintain
an “escape” route
• Perform a secondary
assessment if the
patient permits you to
proceed
25

© 2014
• Only perform a detailed
physical exam if:
– You suspect the patient
may have an injury
– You are confident that
it is safe
• When notifying the
receiving hospital:
– Report the patient’s
mental condition
26

© 2014
• Reassess for changes in
mental status
• Be calm and patient
throughout your care
– Continuously monitor
the situation for safety
27

© 2014
• Behavioral emergencies
can sometimes include
a suicidal patient
• Your assessment should
include a consideration
of suicide risk
Consider Suicide Risk:
29

© 2014
• Suicide risk is
particularly prevalent
for these age groups:
– Elderly
– Teenagers
• Look for factors
indicating depression:
– Withdrawal
– Sadness
– Inactivity
Suicide Risk Factors:
30

© 2014
Signs & Symptoms of Suicide Risk:
• Signs or symptoms of a
patient’s suicide risk
may include:
– Verbal cues
– Self-inflicted injuries
– Increased drug or
alcohol use
– Certain beliefs can
influence a person’s
mental state:
 Elderly person may feel
like a burden on others
31

© 2014
Gain Trust:
• If you suspect a patient
may be at risk for
suicide:
– Try to gain their trust
and confidence:
 Sometimes knowing
there is someone who
will listen or who
understands can help
diffuse the situation
 Ask how the patient
feels
32

© 2014
• Ask whether the patient
is thinking about
hurting or killing:
– Herself or himself
– Anyone else
• Investigate whether
there is an underlying
medical problem
• Perform a physical
assessment to
determine if there has
been any action toward
self-harm
33

© 2014
• Inquire about any
accessible weapons
• Try to determine if the
patient has a history of
similar behavior
34

© 2014
• The misuse of
alcohol and drugs,
whether by
intention or
mistake, can lead to
significant
behavioral changes
36

© 2014
• People who are
under the influence
of substances may
have a serious
medical problem
and could become
injured or cause
injury to others
37

© 2014
• When assessing
behavioral emergency
patients:
– Attempt to determine
whether one or more
substances are
involved
– You may have to
change methods of
communication and
examination in order to
perform an assessment
38

© 2014
• Look for:
– Unsteady,
uncoordinated
movements
– Swaying Slurred
speech
– Flushed skin
– Odor of alcohol on
breath:
 This alone does not
confirm intoxication
– Nausea
39

© 2014
• Obtain patient history
information from the
patient or bystanders:
– History information will
help determine the
existence of underlying
medical conditions:
• Diabetes
• Epilepsy
• Head injuries
• High fever
40

© 2014
• Remain alert for:
– Vomiting
– Signs of shock
– Changes in mental
status
• Patients who have
abused, are addicted to
or have overdosed on
prescription medications
or illicit drugs can
experience wide and
varied effects:
– The signs and symptoms
will depend on the drug
or substance involved
41

© 2014
• Commonly abused or
misused substances
are:
– Stimulants
– Depressants
42

© 2014
• Stimulants excite the central nervous
system:
– Cocaine
– Methamphetamines
• The use of stimulants can cause:
– Excitability
– Hyperactivity
– Apprehensiveness
43

© 2014
• Signs & Symptoms may include:
– Increase in pulse
– Increase blood pressure
– Increase in breathing rate
– Dry mouth
– Sweaty skin
– Dilated pupils
44

© 2014
• Excited delirium or
agitated delirium:
– Associated with central
nervous system
stimulants
– Some psychiatric
illnesses
45

© 2014
• Unusual strength and
endurance
• Tolerance of pain
• Agitation
• Hostility
• Frenzied, bizarre
behavior
• Hot, sweaty skin
• Unusual speech
• Patients are at risk of for
cardiac arrest:
– Prepare to perform CPR
46

© 2014
• Depressants:
– Slow down or depress
the central nervous
system
• Types of depressants
include:
– Sedatives
– Narcotics
– Hallucinogens
– Volatile inhalants
47

© 2014
• Sedatives have multiple medical uses for:
– Insomnia
– Anxiety
– Seizures
• Commonly abused sedatives include:
– Alcohol
– Marijuana
– Barbiturates
– Amphetamines
– Benzodiazepines
48

© 2014
• Signs & Symptoms of a
patient who has been
using sedatives may
appear:
– Drowsy
– Lack coordination in
physical movements
and speech
– Pulse, breathing rate
and volume, can be
dangerously low
– Pupils may respond
sluggishly to light
49

© 2014
• Narcotics are
depressants derived
from opioids:
– Heroin
– Codeine
– Hydrocodone
– Oxycodone
– Effects of narcotics
may cause the patient
to be:
 Sleepy
 Lethargic
50

© 2014
• Pulse will be slow
• Rate and depth of breathing reduced
• Skin may be cool and sweaty
• Pupils can constrict significantly
• Patients are at risk for respiratory and cardiac
arrest
51

© 2014
• Hallucinogens cause:
– Hallucinations
– Altered perceptions
• Some hallucinogens
have therapeutic uses
others are used for
recreational or
ritualistic purposes:
– LSD
– Mescaline
52

© 2014
• Patients under the
influence may:
– Have a distorted
experience of reality
– Be incoherent
– Paranoid
– Experience visual or
auditory hallucinations
• Pulse rate may be
elevated
• Pupils dilated
• Skin may be flushed
53

© 2014
• Many of these
substances do not have
a known or effective
antidote:
– Be prepared to support
cardiorespiratory
function until delivery
to an emergency
department
54

© 2014
• Volatile inhalants
typically act as
depressants on the
central nervous system
• Volatile inhalants
include substances such
as:
– Solvents
– Aerosols
– Nitrates
– Gases that produce
vapors
55

© 2014
• Inhalation of vapors
from containers or
bags:
– “Huffing”
• Adolescents engage in
huffing:
– Cheap
– Products are easily
accessible
56

© 2014
• Initially the vapors can
cause euphoria and
excitation, followed by
a dazed, drunk and
drowsy appearance
• Linings of the mouth
and nose can appear
swollen
• Eyes may look glazed
• Speech can be slurred
57

© 2014
• The patient may report:
– Headache
– Tingling sensation in
the head
– Feeling numb
• The pulse and blood
pressure can be erratic
• Seizures, coma and death
can result:
– Hydrocarbons can
cause cardiac rhythm
disturbances or sudden
death
58

© 2014
• Emergency care for
patients suffering from
substance abuse or
withdrawal remains
essentially the same,
regardless of the drug
involved
• Ensure your safety at all
times:
– Substance abuse can
cause sudden changes
in mood and behavior
59

© 2014
• Provide oxygen at 15
lpm by nonrebreather
mask or per protocol
• Perform a thorough
exam:
– Drugs can mask pain
and signs and
symptoms of other
conditions
– Look carefully for
injuries or illness
61

© 2014
• Obtain a patient history
if possible
• Try to determine the
substance involved
• Check blood glucose
level:
– Glucose emergencies
can cause AMS
62

© 2014
• Keep the patient alert
by talking
• If vomiting, provide
assistance to protect
airway
• Provide reassurance
while you transport
64

© 2014
• A behavioral emergency
can be a stressful
situation for both you
and the patient
• The sooner you can
calm the patient, the
safer the situation will
be
66

© 2014
• The presence of an
emergency responder
can make the patient
feel more agitated
• Maintaining a safe
distance during your
size-up:
– Increases your safety
– Helps the patient feel
less threatened
67

© 2014
• Identify yourself
• Let the patient know
you are there to help
• Acknowledge their
situation
• Restate that you’re
concerned and able to
help them
68

© 2014
• Assess the patient’s
mental status
• Avoid unnecessary
physical contact
• Let the patient know
what you are doing at
all times
• Keep your actions slow
69

© 2014
• Treat injuries and take
vital signs only if the
patient will cooperate
• Use a calm, reassuring
voice when asking
questions
70

© 2014
• Minimize distressing
stimuli and noise:
– Lights
– Sirens
• Move the patient away
if possible
• Use good eye contact
• Maintain a comfortable
distance
71

© 2014
• Encourage the patient to identify the
trouble
• Respond honestly to the patient’s
questions
• Avoid threatening actions, statements
or questions
• Do not threaten, challenge, or argue
with the patient
72

© 2014
• Determine whether the patient is
experiencing:
– Delusions
– Hallucinations
• Exaggerated worries or fears
• Never, “play along” with visual or auditory
disturbances
73

© 2014
• Involve friends and
family members
• Avoid pressuring or
attempting to control
the patient; this can
increase the incident’s:
– Stress level
– Safety risk
74

© 2014
• Always remain with the patient
• Be prepared to stay at the scene for a long
time
• If the patient creates a scene that is not safe,
retreat to a safe area until the arrival of law
enforcement
75

© 2014
• Behavioral Emergency Causes
• Assessment Techniques
• Suicide Risks
• Substance Abuse
• Calming Methods & Emergency Care

© 2014
• Behavioral emergencies can put you
and others at risk
• Whether caused by injury, mental
illness or chemical substances,
every behavioral emergency is a
medical emergency
• You must quickly identify these
situations and know what steps to
take to ensure your safety

ATS - Behavioral Emergencies

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