Emergency Care
Fourteenth Edition
Chapter 27
Behavioral and Psychiatric
Emergencies and Suicide
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Topics
• Behavioral and Psychiatric Emergencies
• Emergency Care for Behavioral and Psychiatric Emergenci
es
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Behavioral and Psychiatric
Emergencies
Back to Topics
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What Is a Behavioral Emergency? (1 of 2)
• Behavior
– Manner in which a person acts or performs
• Behavioral emergency
– Behavior within a given situation that is unacceptable
or intolerable to patient, patient’s family, or community
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What Is a Behavioral Emergency? (2 of 2)
• Recognize cultural behavior.
• Behavioral conditions require full patient assessment.
• Remain objective.
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Behavior and Brain Chemistry (1 of 2)
• Observable behavior largely controlled by
neurotransmitters
– Inside the brain
– Neurotransmitters travel from neuron to neuron.
– Impulses move across nervous system by this
mechanism.
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Behavior and Brain Chemistry (2 of 2)
• Neurotransmitters—or the lack of neurotransmitters—have
been implicated in depression and other behavioral and
psychiatric disorders.
– Medications prescribed for these conditions are
designed to affect the relevant neurotransmitters.
– Newer medications offer reuptake inhibition of more
than one neurotransmitter.
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Psychiatric Conditions
• Some behavioral emergencies are caused by psychiatric
conditions (mental disorders).
• Almost one in five adults in the United States have some
sort of mental illness.
• Mental health services declining or overcrowded
– More patients with mental illness are in the community
with minimal treatment.
– This makes it more likely they will be seen as a patient
by EMS systems.
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Physical Causes of Altered Mental
Status
• Medical and traumatic conditions that can alter a patient’s
behavior
– Low blood sugar
– Lack of oxygen
– Stroke or inadequate blood to brain
– Head trauma
– Seizures
– Mind-altering substances
– Environmental temperature extremes
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Situational Stress Reactions (1 of 2)
• Normal reactions to stressful situations produce emotions
– Fear
– Grief
– Anger
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Situational Stress Reactions (2 of 2)
• Caring for patients with situational stress reactions
– Do not rush.
– Tell patient you are there to help.
– Remain calm.
– Keep emotions under control.
– Listen to patient.
– Be honest.
– Stay alert for changes in behavior.
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Acute Psychosis (1 of 2)
• Involves a severe break in patient’s abilities to process
information and interact with their environments
• Often associated with a psychiatric disorder such as
schizophrenia
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Acute Psychosis (2 of 2)
• Symptoms
– Hallucinations
– Delusions
– Catatonia
– Thought disorder
• Ensure safety of patient and responders.
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Emergency Care for Behavioral and
Psychiatric Emergencies
Back to Topics
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Assessment and Care for Behavioral
and Psychiatric Emergencies (1 of 3)
• Range of presentations
– Withdrawn, not communicating
– Talkative, agitated
– Bizarre or threatening behavior
– Wish to harm selves or others
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Assessment and Care for Behavioral
and Psychiatric Emergencies (2 of 3)
• Key techniques
– Identify yourself and your role.
– Speak slowly and clearly.
– Make eye contact.
– Listen to the patient.
– Do not be judgmental.
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Assessment and Care for Behavioral
and Psychiatric Emergencies (3 of 3)
• Key techniques
– Use positive body language.
– Acknowledge patient’s feelings.
– Do not enter patient’s personal space.
▪ Stay at least 3 feet from patient.
– Be alert for changes in emotional status.
– Use restraint to prevent harm if necessary.
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General Rules for Interactions
1. Plan your approach to the patient in advance and remain outside the range of
the patient’s arms and legs until you are ready to act. Note: A fifth rescuer, if
available, can control the patient’s head–taking special care, however, not
to be bitten.
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Patient Assessment (1 of 2)
• Perform careful scene size-up.
• Identify yourself and your role.
• Complete primary assessment.
• Perform as much of detailed examination as possible.
• Gather thorough history.
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Patient Assessment (2 of 2)
• Common signs and symptoms
– Panic or anxiety
– Unusual appearance, disordered clothing, or poor
hygiene
– Agitated or unusual activity
– Unusual speech patterns
– Bizarre behavior or thought patterns
– Suicidal or self-destructive behavior
– Violence or aggressive behavior
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Patient Care
• Be alert for personal or scene safety problems.
• Treat any life-threatening problems.
• Consider medical or traumatic causes.
• Spend time talking to patient.
• Encourage patient to discuss feelings.
• Never play along with hallucinations.
• Consider involving family or friends.
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Suicide (1 of 4)
• Tenth-leading cause of death in United States
– Depression coupled with successful suicide has
reached alarming levels in combat veteran and senior
citizen populations.
– Many more people suffer both physical and emotional
injuries in unsuccessful suicide attempts.
– Anyone may become suicidal if emotional distress is
severe.
– People attempt suicide for many reasons.
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Suicide (2 of 4)
• Potential or attempted suicide
– Explore the following possibilities
▪ Depression
▪ High stress levels (current or recent)
▪ Recent emotional trauma
▪ Age (15 to 25 and 40+ highest risk)
▪ Drug or alcohol abuse
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Suicide (3 of 4)
• Potential or attempted suicide
– Explore the following possibilities
▪ Threats of suicide
▪ Suicide plan
▪ Previous attempts or threats
▪ Sudden improvement from depression
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Suicide (4 of 4)
• Your first concern must be your own safety.
• Emergency care
– Scene size-up
– Identify and treat life-threatening problems.
– Reassure patient.
– Perform secondary assessment.
▪ Detailed exam only if safe
– Reassess frequently.
– Notify receiving facility.
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Think About It (1 of 2)
• Patient is 23-year-old male. His girlfriend called 911 after a
domestic dispute. He is uncooperative and refusing
treatment. The girlfriend reports patient is depressed and
suicidal. He owns a gun and has threatened to shoot
himself.
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Think About It (2 of 2)
• Can you treat the patient if he did not call?
• Should you believe the girlfriend?
• Does the patient need treatment or transport?
• Can you treat and transport the patient against his will?
• What should you do?
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Aggressive or Hostile Patients (1 of 3)
• Consider clues.
– Dispatch information
– Clues from the scene
– Information from neighbors, family, or bystanders
– Patient’s stance or position in room
• Ensure escape route.
• Do not threaten patient.
• Stay alert for weapons of any type.
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Aggressive or Hostile Patients (2 of 3)
• Patient assessment
– May not proceed beyond primary assessment until
patient is calmed or restrained
– May spend most of time calming patient and ensuring
everyone’s safety
– Hostility or aggression never an excuse for not
assessing patient as thoroughly as possible
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Aggressive or Hostile Patients (3 of 3)
• Emergency care
– Perform a scene size-up.
– Request additional help if necessary.
– Seek advice from medical control if necessary.
– Watch for sudden changes in behavior.
– Reassess frequently.
– Consider restraint.
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Reasonable Force and Restraint (1 of 6)
• Reasonable force
– Force necessary to keep patient from injuring self or
others
• “Reasonable” determined by:
– Patient’s size and strength
– Type of behavior
– Mental status
– Available methods of restraint
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Reasonable Force and Restraint (2 of 6)
• In most localities, restraint is within jurisdiction of law
enforcement.
• Never attempt restraint without proper legal authority and
sufficient assistance.
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Reasonable Force and Restraint (3 of 6)
• Excited delirium
– Extremely agitated or psychotic behavior
– Triggers for this condition can include uncontrolled
psychiatric illness and/or drug intoxication.
– These patients frequently develop significant and even
life-threatening cardiovascular and metabolic stress.
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Reasonable Force and Restraint (4 of 6)
• Positional asphyxia
– Inadequate breathing or respiratory arrest caused by a
body position that restricts breathing
– Carefully monitor all restrained patients.
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Reasonable Force and Restraint (5 of 6)
• Restraining a patient
– Have adequate help.
– Plan actions.
– Stay beyond patient’s reach until prepared.
– Act quickly.
– One EMT talks to and calms patient.
– Requires four persons, one at each limb.
– Restrain all limbs with approved leather restraints in
supine position, always.
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Reasonable Force and Restraint (6 of 6)
– EMT is responsible for restrained patient’s airway.
– Ensure patient is adequately secured throughout
transport.
– Apply a surgical mask to spitting patients if local
protocols permit.
– Reassess frequently.
– Document thoroughly.
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Transport to an Appropriate Facility
• Not all hospitals are prepared to treat behavioral
emergencies.
• Choose correct facility based on capabilities and local
protocol.
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Medical/Legal Considerations (1 of 2)
• Consent
– Refusals and restraints cause significant medical/legal
risk.
– Laws typically allow providers to treat and transport
patients against their will if a danger to themselves or
others.
– Know your state laws on treating patients without
consent.
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Medical/Legal Considerations (2 of 2)
• Sexual misconduct
– Behavioral patients sometimes accuse EMS providers
of sexual misconduct.
– Have same-sex provider attend to patient.
– For the aggressive or violent patient, make sure law
enforcement officers accompany you to the hospital.
▪ Protect you and the patient.
▪ In the event of a legal problem, they can serve as
third-party witnesses.
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Chapter Review
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Chapter Review (1 of 4)
• As an EMT, you will respond to many behavioral
emergencies. Be sure to ensure your own safety before
entering a scene or caring for a violent or potentially violent
patient.
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Chapter Review (2 of 4)
• A considerable portion of the population has a
diagnosable psychiatric condition. However, not all
patients are violent. It is important to remember that
patients in crisis are patients–and people–who need your
compassion as well as your care.
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Chapter Review (3 of 4)
• Always consider patients acting in an unusual or bizarre
fashion to be experiencing an altered mental status; this
will help you to avoid overlooking a medical or traumatic
cause for the patient’s problem.
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Chapter Review (4 of 4)
• Because treatment of these patients usually requires
long-term management, little medical intervention can be
done in the acute psychiatric situation. However, the way
you interact with the patient during the emergency and
assess your patient throughout the call is crucial for the
patient’s continued well-being.
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Remember (1 of 3)
• Safety is the first priority when approaching a patient with
altered mental status.
• Psychiatric and behavioral emergencies are prevalent in
our society. EMTs should treat them as they would any
other potentially life-threatening disorder.
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Remember (2 of 3)
• Assessment of altered mental status should rule out
physical causes first.
• Psychiatric and behavioral emergencies can present
differently, depending upon the disorder. There are best
practices EMTs employ in approaching, assessing, and
treating such patients.
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Remember (3 of 3)
• Follow local protocols and use appropriate procedures to
restrain patients when necessary.
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Questions to Consider
• What methods help calm the patient suffering a behavioral
or psychiatric emergency?
• What can you do when scene size-up reveals it is too
dangerous to approach the patient?
• What factors help assess the patient’s risk for suicide?
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Critical Thinking
• You respond to an intoxicated minor who is physically
aggressive, threatens suicide, and whose parents permit
you to treat but not transport the patient. How would you
manage this patient?
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