Chapter 28
Psychiatric
Emergencies
National EMS Education
Standard Competencies
Medicine
Integrates assessment findings with principles
of epidemiology and pathophysiology to
formulate a field impression and implement a
comprehensive treatment/disposition plan for
a patient with a medical complaint.
National EMS Education
Standard Competencies
Psychiatric
• Recognition of
− Behaviors that pose a risk to the EMS provider,
patient, or others
• Assessment and management of
− Basic principles of the mental health system
− Suicidal/risk
National EMS Education
Standard Competencies
Anatomy, physiology, epidemiology,
pathophysiology, psychosocial impact,
presentations, prognosis, and management of
− Acute psychosis
− Agitated delirium
− Cognitive disorders
− Thought disorders
− Mood disorders
− Neurotic disorders
National EMS Education
Standard Competencies
Anatomy, physiology, epidemiology,
pathophysiology, psychosocial impact,
presentations, prognosis, and management of
(cont’d)
−
−
−
−
−
−
Substance-related disorders/addictive behavior
Somatoform disorders
Factitious disorders
Personality disorders
Patterns of violence/abuse/neglect
Organic psychoses
Introduction
• The mind and body are inseparable.
− Illness affects a person’s behavior.
− Changes in mental state affect physical health.
Definition of Behavioral
Emergency
• Most experts define behavior as the way
people act or perform.
− Overt behavior is generally understood by those
around the person.
− Covert behavior has hidden meanings or
intentions.
Definition of Behavioral
Emergency
• Behavioral
emergency
− Some disorder of
mood, thought, or
behavior that
interferes with
ADLs
• Psychiatric
emergency
− Behavior that
threatens a
person’s health or
safety and the
health and safety
of another person
Definition of Behavioral
Emergency
• A behavioral or psychiatric emergency is
defined by the person who dials 9-1-1.
• It can be difficult to understand the patient’s
confused and frayed feelings.
Prevalence
• Average number of mentally unhealthy days
for Americans has increased
− 1993: 2.9 days/month
− Today: 3.5 days/month
• 45.1 million US adults with any mental
illness in the past year
Medicolegal Considerations
• When behavior, speech, and thoughts are
erratic, it can be difficult to communicate.
− Spend time with the patient.
− Obtain consent when possible.
− Be clear in your explanations.
Causes of Abnormal Behavior
• Four broad categories
− Biologic or organic in nature
− Resulting from the environment
− Resulting from acute injury or illness
− Substance-related
Causes of Abnormal Behavior
• Biologic or organic
− Organic brain syndrome
− Conditions alter the functioning of the brain
Causes of Abnormal Behavior
• Environmental
− Psychosocial and sociocultural influences
• When consistently exposed to stressful events
patients develop abnormal reactions.
• Sociological factors affect biology, behavior, and
responses to the stress of emergencies.
Causes of Abnormal Behavior
• Injury and illness
− Illness results in
stress on coping
mechanisms.
− Acute trauma
creates stress.
• Post-traumatic
stress disorder
(PTSD)
Courtesy of Captain David Jackson, Saginaw Township Fire Department
Causes of Abnormal Behavior
• Substance-related
− Alcohol
− Cigarettes
− Illicit drugs
− Other substances
Psychiatric Signs and
Symptoms
• When mental health is challenged,
mechanisms or behaviors work to return
homeostasis.
− Present as psychiatric signs and symptoms
Psychiatric Signs and
Symptoms
Patient Assessment
• Assessment of the patient with a behavioral
emergency differs from other methods.
− You are the diagnostic instrument.
− The assessment is part of the treatment.
Scene Size-Up
• Situations with a strong behavioral
component may have a sudden and
unexpected turn of events.
− Determine whether it is dangerous to you and
your partner.
Scene Size-Up
Scene Size-Up
• The environment can give clues.
− Social history
− Living conditions
− Availability of support
−
−
−
−
Activity level
Medications
Overall appearance
Attitude/well-being
Primary Assessment
• Clearly identify yourself.
• Form a general impression.
− Assess appearance, posture, and pupils.
− Limit the number of people around the patient.
− Stay alert to potential danger.
Primary Assessment
• Airway and breathing
− Assess the airway and evaluate breathing.
− Provide interventions based on your findings.
Primary Assessment
• Circulation
− Assess the pulse rate, quality, and rhythm.
− Obtain systolic and diastolic blood pressures.
− Evaluate for shock and bleeding.
− Assess the patient’s perfusion level.
Primary Assessment
• Transport decision
− Disturbed patients should see a physician.
− If a patient withholds consent, they may be
taken against their will at the request of:
• Police
• County mental health physician
Primary Assessment
• Transport decision (cont’d)
− The same applies to the use of forcible restraint.
• Law enforcement officers should be summoned.
• Consult medical command as necessary.
History Taking
• Mental status
examination
− Key part of
assessment
− Check each
system using
COASTMAP.
COASTMAP
• Consciousness
− Level
− Concentration
• Orientation
− Year/month
− Location
• Activity
− Behavior
− Movement
• Speech
− Rate, volume,
flow, articulation,
and intonation
COASTMAP
• Thought
− Is the patient
making sense?
• Memory
− Recent
− Remote
− Immediate
• Affect and mood
− Do the inner
feelings seem
appropriate?
• Perception
− “Do you hear
things others
can’t?”
Secondary Assessment
• Obtain vital signs.
• Examine skin temperature and moisture.
• Inspect the head and pupils.
• Note unusual odors on the breath.
Secondary Assessment
• In examining the extremities, check for:
− Needle tracks
− Tremors
− Unilateral weakness or loss of sensation
Reassessment
• Routinely performed during transport
• Your radio report should include:
− Medical and mental health history
− Medications prescribed
− Assessment findings
− Information from the mental status examination
Reassessment
• Discuss with the hospital the need for
restraints or medications.
− If the patient is aggressive or violent, provide
advance notice to the emergency department.
Emergency Medical Care
• If the erratic behavior could be caused by a
medical disorder:
− Treat that before presuming the behavior is due
to an emotional or psychiatric cause.
Communication Techniques
• Begin with an
open-ended
question.
• Listen, and show
that you are
listening.
© Craig Jackson/IntheDarkPhotography.com
• Let the patient talk.
Communication Techniques
• Don’t be afraid of
silences.
• Facilitate
communication.
• Acknowledge and
label feelings.
• Direct the
patient’s attention.
• Don’t argue.
− Confrontation
Communication Techniques
• Ask questions.
− Avoid “yes-no” or leading questions.
− Use “how” and “what” questions.
• Adjust your approach as needed.
Crisis Intervention Skills
• Be as calm and
direct as possible.
• Exclude disruptive
people.
• Sit down.
− Preferably at a
45-degree angle
Crisis Intervention Skills
• Maintain a
nonjudgmental
attitude.
• Provide honest
reassurance.
• Develop a plan of
action.
− Once the plan is
set, allow the
patient to exercise
some control.
Crisis Intervention Skills
• Encourage some motor activity.
• Stay with the patient at all times.
• Bring all medications to the hospital.
• Never assume that it is impossible to talk
with any patient until you have tried.
Physical Restraint
• Improvised or commercially made devices
• Be familiar with restraints used by your
agency.
• Make sure you have sufficient personnel.
− Minimum of four trained, able-bodied people
Physical Restraint
• Discuss the plan of action before you begin.
− Include law enforcement.
− Use the minimum force necessary.
− Don’t immediately move toward the patient.
Physical Restraint
• If the show of force doesn’t calm the
patient, move quickly.
− Grasp at the elbows, knees, and head.
− Apply restraints to all four extremities.
− The best position is supine.
Physical Restraint
• Never:
− Tie ankles and
wrists together
− Hobble tie
− Place a patient
facedown in a
Reeves stretcher
• Once in place:
− Don’t remove
restraints.
− Don’t negotiate or
make deals.
− Place a mask over
the face of a
spitting patient.
Physical Restraint
• Continuously
monitor the patient.
• Never place your
patient face down.
• Check peripheral
circulation every
few minutes.
© Jones & Bartlett Learning. Courtesy of MIEMSS.
Physical Restraint
• Be careful if a combative patient suddenly
becomes calm.
• Document everything in the patient’s chart.
• You may defend yourself against an attack.
Chemical Restraint
• Use of medication to subdue a patient
− Only use with approval from medical control
− Follow local protocols and guidelines.
Chemical Restraint
• Haloperidol
− Administered either IM or IV
− Should not be administered to:
• Patients younger than 14 years
• Those with a suspected head injury
• Those who may be pregnant
Chemical Restraint
• Benzodiazepines
− Shorter-acting ones may be given intranasally.
− Only midazolam and lorazepam have reliable
intramuscular absorption.
− Side effects are usually mild and easily treated.
Chemical Restraint
• Closely monitor the patient’s:
− Pulse rate
− Blood pressure
− Respiratory rate
• Be prepared to support ventilation.
Pathophysiology, Assessment, and
Management of Specific Emergencies
• Many factors
contribute to
disturbances of
behavior.
Acute Psychosis
• Pathophysiology
− Person is out of touch with reality
− Occur for many reasons
− Episodes can be brief or last a lifetime.
Acute Psychosis
• Assessment
− Characteristic: profound thought disorder
− A thorough examination is rarely possible.
− Transport the patient in an atraumatic fashion.
− Use COASTMAP.
Acute Psychosis
• Consciousness
− Awake and alert
− Easily distracted
• Orientation
− Disturbances
more common in
organic disorders
• Activity
− Most commonly
accelerated
• Speech
− Neologisms
Acute Psychosis
• Thought
− Disturbed in
progression and
content
• Memory
− Relatively or
entirely intact
• Affect and mood
− Mood is likely to
be disturbed.
− Affect may reflect
mood or be flat.
• Perception
− Auditory
hallucinations
Acute Psychosis
• Management
− Reasoning doesn’t always work.
− Explain what is being done.
− Directions should be simple and consistent.
− Keep orienting the patient.
Acute Psychosis
• Management (cont’d)
− Before pharmacologic treatments, try:
• Maintaining an emotional distance
• Explaining each step of the assessment
• Involving people the patient trusts
Acute Psychosis
• Management (cont’d)
− When methods fail, it may be appropriate to:
• Safely restrain the patient.
• Administer a medication to help the behavior.
Agitated Delirium
• Pathophysiology
− Delirium: a state of global cognitive impairment
− Dementia: more chronic process
− Patients may become agitated and violent.
Agitated Delirium
• Assessment
− Try to reorient patients.
− Perform a thorough assessment.
• Management
− Identify the stressor or metabolic problem.
Suicidal Ideation
• Pathophysiology
− Suicide: any willful act designed to end one’s
life
Suicidal Ideation
• Assessment
− Every depressed
patient must be
evaluated for
suicide risk.
− Most patients are
relieved when the
topic is brought up.
Suicidal Ideation
• Assessment (cont’d)
− Broach the subject in a stepwise fashion.
− Higher-risk patients include patients who have:
• Made previous attempts
• Detailed, concrete plans
• A history of suicide among close relatives
Suicidal Ideation
• Management
− Don’t leave the patient alone.
− Collect implements of self-destruction.
− Acknowledge the patient’s feelings.
− Encourage transport.
Patterns of Violence, Abuse,
and Neglect
• Abuse and neglect
− Assess the following:
• The patient
• The environment
• Other persons involved
− Document your findings, and report your
concerns according to local protocols.
Patterns of Violence, Abuse,
and Neglect
• Violence
− Most angry patients can be calmed by a trained
person who conveys confidence.
− EMS personnel should prepare to deal with
hostile or violent behavior.
• Preventive action is best to ensure no harm.
Patterns of Violence, Abuse,
and Neglect
• Identify situations with the potential for
violence.
− Preventive action starts with being prepared for
a possible violent encounter.
− Develop “survival awareness.”
Patterns of Violence, Abuse,
and Neglect
• Risk factors
− Scenarios including:
− People who are:
• Alcohol or drug
consumption
• Crowd incidents
• Intoxicated
• Experiencing
withdrawal
• Violence has already
occurred
• Psychotic
• Delirious
Patterns of Violence, Abuse,
and Neglect
• Warning signs include:
− Posture: sitting tensely
− Speech: loud, critical, threatening
− Motor activity: unable to sit still, easily startled
− Clenched fists, avoidance of eye contact
− Your own feelings
Patterns of Violence, Abuse,
and Neglect
• Management of the violent patient
− Assess the whole situation.
− Observe your surroundings.
− Maintain a safe distance.
− Try verbal interventions first.
Mood Disorders
• Unipolar mood disorder: mood remains at
one pole of the continuum
• Bipolar mood disorder: mood alternates
between mania and depression
Mood Disorders
• Manic behavior
− Patients typically have abnormally exaggerated
happiness with hyperactivity and insomnia.
• Pressured and rapid speech
• “Tangential thinking”
• Grandiose and unrealistic ideas
Mood Disorders
• Manic behavior (cont’d)
− Be calm, firm, and patient.
− Minimize external stimulation.
− If the patient refuses transport, consult medical
control.
Mood Disorders
• Depression
− Leading cause of disability in people 15- to
44-year olds
− Can occur in episodes with sudden onset and
limited duration
− Onset can also be insidious and chronic.
Mood Disorders
• Depression (cont’d)
− Diagnostic features (GAS PIPES)
• Guilt
• Appetite
• Sleep disturbance
• Paying attention
• Interest
• Psychomotor abnormalities
• Energy
• Suicidal thoughts
Schizophrenia
• Typical onset occurs during early adulthood.
• Experience may include:
− Delusions
− Hallucinations
− A flat affect
− Erratic speech
Neurotic Disorders
• Collection of psychiatric disorders without
psychotic symptoms
− Includes anxiety disorders
• Mental disorders in which dominant moods are fear
and apprehension
Neurotic Disorders
• Generalized anxiety disorder (GAD)
− Patient worries for no particular reason or
worrying prevents decision-making abilities.
− Treated with pharmacologic agents and
counseling
Neurotic Disorders
• Generalized anxiety disorder (GAD)
(cont’d)
− When dealing with a patient with GAD:
• Identify yourself in a calm, confident manner.
• Listen attentively.
• Talk with the person about their feelings.
Neurotic Disorders
• Phobias
− Unreasonable fear, apprehension, or dread of a
specific situation or thing
• Simple phobias focus all anxieties on one class of
objects or situations.
Neurotic Disorders
• Phobias (cont’d)
− When managing a patient, explain each step of
treatment in detail.
Neurotic Disorders
• Panic disorder
− Sudden feelings of fear and dread
− If allowed to continue, panic attacks can cause
severe lifestyle restrictions.
• Agoraphobia: fear of going into public places
Neurotic Disorders
• Panic disorder
(cont’d)
− Signs and
symptoms usually
peak in
10 minutes.
Neurotic Disorders
• Panic disorder (cont’d)
− Separate from panicky bystanders.
− Provide a calm environment.
− Be tolerant of the disability.
− Reassure the patient.
− Give the symptoms a name.
− Help the patient regain control.
Substance-Related Disorders
• Regarded on four levels:
− Substance use
− Substance intoxication
− Substance abuse
− Substance dependence
• Determining the most effective treatment
requires an integrative approach.
Eating Disorders
• Persons may experience severe electrolyte
imbalances.
• Two thirds report anxiety, depression, and
substance abuse disorders.
Eating Disorders
• Bulimia nervosa
− Consumption of large amounts of food
− Compensated by purging techniques
Eating Disorders
• Anorexia nervosa
− Weight loss jeopardizes health and lives
− Typical patient:
• Decreased body weight based on age and height
• Intense fear of obesity
• Experience amenorrhea
Somatoform Disorders
• Preoccupation with physical health and
appearance
− Hypochondriasis: Anxiety or fear that the person
may have a serious disease
− Conversion disorders: a physical problem
results from faking a physical disorder
Factitious Disorders
• Patient produces or feigns physical or
psychological signs or symptoms.
− Symptoms are under voluntary control.
• Factitious disorder by proxy: a parent
makes a child sick for attention and pity
Impulse Control Disorders
• Lack of ability to resist a temptation
• Examples include:
− Intermittent explosive disorder
− Kleptomania
− Pyromania
− Pathologic gambling
Personality Disorders
• Maladaptive patterns of thinking about the
environment and one’s self
− Cause functional impairment or subjective
distress
• Be calm and professional.
Medications for Psychiatric Disorders
and Behavioral Emergencies
• Patients may be taking any of several types
of psychotropic drugs.
• During your assessment, determine:
− Which medications have been prescribed
− Whether they are being taken
Psychiatric Medication Types
• Antidepressants
− Combat the
symptoms of
depressive illness
− Alter levels of
neurotransmitters
in the autonomic
nervous system
Psychiatric Medication Types
• Antidepressants (cont’d)
− Fluoxetine: the most commonly prescribed
• Side effects are minimal.
− Heterocyclic: used for major depression
• Side effects are common.
Psychiatric Medication Types
• Antidepressants (cont’d)
− Monoamine oxidase inhibitors: recommended
for atypical major depressive episodes
• Potential side effects
Psychiatric Medication Types
• Benzodiazepines
− May be prescribed for severe emotional distress
− Contraindicated in patients with:
• Known hypersensitivity to benzodiazepines
• Acute, narrow-angle glaucoma
• First-trimester pregnancy
Psychiatric Medication Types
• Antipsychotics
− Newer medications have less risk of adverse
effects and are more effective.
• Known as atypical antipsychotic (AAP) drugs
− Relieve delusions and hallucinations.
− Improve symptoms of anxiety and depression.
Psychiatric Medication Types
• Antipsychotics (cont’d)
− May cause metabolic side effects
− Cardiovascular effects depend on medication.
− May cause an acute dystonic reaction
− May cause atropine-like effects
Psychiatric Medication Types
• Amphetamines
− CNS and PNS stimulants
− Help with ADHD.
− Raise systolic and diastolic blood pressure.
Psychiatric Medication Types
• Amphetamines
− Psychological
effects depend on:
• Dose
• Mental state
• Personality
− Results include:
• Alertness
• Elevated mood
• Increased motor
and speech
activities
Problems Associated with
Medication Noncompliance
• Increases the likelihood that a person with
mental illness will commit a violent act
• When obtaining medication history, include:
− Previously prescribed medications
− Missed doses
Emergency Use of Medications
• Emergency use of medications are often
required with violence.
− The potential danger is too great not to
intervene.
Emergency Use of Medications
• Before administering chemical restraint,
complete your assessment with:
− A thorough understanding of the chief complaint
− Attention to allergies
− Medical and medication history
Pediatric Behavioral Problems
• 50% of childhood
mental illnesses
will present by age
14 years.
− More likely to have
coexisting
problems
− Difficult to
diagnose
© Leah-Anne Thompson/ShutterStock, Inc.
Pediatric Behavioral Problems
• Mental status assessment is similar to that
of an adult.
− Exception: Consider developmental level.
• Abnormal findings are often related to
adjustment disorders and stress.
Geriatric Behavioral Problems
• Distress and pain
may be caused by:
− Exposure to new
experiences
− Alterations to
routines
© Leah-Anne Thompson/ShutterStock, Inc.
Geriatric Behavioral Problems
• Anxiety and depression are too often
considered a “normal part of aging.”
− Ageism: discrimination against older people
• Take stock of your own attitudes.
Summary
• Behavioral emergencies can present unique
challenges in patient management. Focus
on reducing the patient’s stress without
exposing yourself to unnecessary risks.
• A behavioral or psychiatric emergency is
any reaction to events that interferes with
activities of daily living.
Summary
• Behavioral emergencies can be a
temporary response to a traumatic event.
• Calls for behavioral emergencies have
special medical and legal considerations.
• You have limited legal authority to require a
patient to undergo care in the absence of a
life-threatening emergency. Always involve
law enforcement personnel when you are
called to assist a patient with a severe
behavior or psychiatric crisis.
Summary
• If a patient poses an immediate threat,
leave the area until law enforcement
personnel secure the scene.
• Underlying causes of behavioral
emergencies fall into four categories:
biologic (organic) causes, causes resulting
from the person’s environment, causes
resulting from acute injury or illness, and
causes that are substance related.
Summary
• Psychiatric signs and symptoms occur
when mental health is challenged and
psychological mechanisms or behaviors
mobilize to return the person’s mental state
to homeostasis.
• Assessment of a disturbed patient differs
from other assessment methods in that you
are the diagnostic instrument. Assessment
is also part of the treatment.
Summary
• When providing care, be direct, honest, and
calm; have a definitive plan of action; stay
with the patient at all times; and express
interest in the patient’s story.
• When sizing up the scene, pay special
attention to potential dangers and objects
that may be used as potential weapons,
hazardous chemicals, etc. Remove
potentially harmful objects.
Summary
• Primary assessment includes identifying
yourself, forming a general impression of
the patient’s condition and the nature of the
problem, assessing the ABCs, making a
decision about transport, and taking a
history via the mental status examination.
• Secondary assessment involves looking for
signs of an organic cause of the behavioral
emergency.
Summary
• Management is focused on ensuring scene
safety and maintaining awareness of lifethreatening conditions, while treating the
patient for any medical disorders.
• Effective communication techniques include
beginning with an open-ended question,
showing that you are listening, allowing
silence when appropriate, avoiding
argument, facilitating communication, and
asking questions.
Summary
• Crisis intervention skills include staying
calm and being direct, excluding disruptive
people from the scene, maintaining a
nonjudgmental attitude, developing a plan
of action, encouraging motor activity, and
assuming that the patient can hear and
understand everything you say.
• Use of chemical or physical restraints is
reserved for times when verbal intervention
fails to reduce severe agitation.
Summary
• Pathophysiologic factors that contribute to
behavioral disturbances include cognitive
impairment, thought disorders, mood
disorders, neurotic disorders, substancerelated disorders and addictive behavior,
somatoform disorders, factitious disorders,
impulse control disorders, and personality
disorders.
Summary
• You may encounter patients with psychosis,
a thought disorder characterized by a statue
of delusion in which the person is out of
touch with reality.
• You may encounter patients with agitated
delirium. This is impairment of cognitive
function that can present with disorientation,
hallucinations, or delusions, and is
characterized by restless and irregular
physical activity.
Summary
• The threat of suicide requires immediate
intervention. Depression is the most
significant risk factor for suicide.
• Situations involving violence, abuse, and
neglect can have the potential for escalation
and the possibility of evoking emotional
responses in you.
Summary
• Patients with psychiatric emergencies may
be taking any of several types of
psychotropic drugs. During assessment,
determine which medications have been
prescribed and whether the patient is
actually taking them.
Credits
• Chapter opener: © Mark C. Ide
• Backgrounds: Orange—© Keith Brofsky/
Photodisc/Getty Images; Blue—Jones & Bartlett
Learning. Courtesy of MIEMSS; Blue—Courtesy of
Rhonda Beck; Green—Courtesy of Rhonda Beck;
Purple—Courtesy of Rhonda Beck.
• Unless otherwise indicated, all photographs and
illustrations are under copyright of Jones & Bartlett
Learning, courtesy of Maryland Institute for
Emergency Medical Services Systems, or have
been provided by the American Academy of
Orthopaedic Surgeons.