Your unit is dispatched to a nearby bus station for a psychiatric disturbance. Upon arrival, you encounter a 61-year-old homeless male, whom you’ve transported multiple times before for delusions and hallucinations, complaining he has “demons in his chest.” He’s alert and oriented, very anxious, slightly diaphoretic, breathing heavily and noted to have rapid speech. He yells, “Get them out of me! Get the demons out of me!”
Prehospital providers will routinely encounter patients with acute psychiatric disturbances and substance intoxication. Further, life-threatening medical conditions (such as acute coronary syndrome, pulmonary embolus, sepsis, hypoglycemia, shock, stroke, head trauma and seizure) may be mistaken for behavioral disturbances. A thorough understanding of the presentation and management of such patients is essential to provide safe and expedient transport to definitive care.
The Suicidal Patient
Suicide is the 11th leading cause of death in the U.S., and suicide attempts comprise more than 500,000 ED visits annually.1
Encountering a patient who’s attempted suicide or is threatening to attempt suicide can pose many challenges to prehospital providers. As always, scene safety is the first priority. It may be helpful to request law enforcement involvement early to assist in maintaining a safe environment. It’s particularly important to ensure the suicidal patient isn’t in possession of any potentially harmful items such as weapons, medications or toxic substances, and sharp objects.
If your patient is combative, attempt verbal de-escalation before using physical or chemical restraints and use PPE when possible. Photo Kevin Link
Once the scene is deemed safe, approach the patient in a nonthreatening manner and establish rapport. It’s important for the patient to understand you’re there to help them. Gather a brief history from the patient and ask if they’ve contemplated suicide or have a suicide plan in mind. If possible, also elicit any history of depression, anxiety, suicide attempts or other psychiatric illness. If the patient does report a history of psychiatric illness, it may be helpful to inquire about current medication compliance. As drugs and alcohol contribute to many cases of suicide, inspect the scene for evidence of alcohol, drug paraphernalia and pill bottles. Information from friends and family can also be helpful, as many patients will deny suicidality once confronted.
Patients who are contemplating or have attempted suicide shouldn’t be allowed to refuse transport. Each state has different legal statutes involving involuntary detention of patients with thoughts of harm to self or others. Involvement of law enforcement or medical control may be necessary. Be sure to document all information you gather, as this information may be necessary for the ED physician to involuntarily admit the suicidal patient.
The Anxious Patient
Anxiety disorders affect as many as 40 million American adults each year.2 Given their prevalence, prehospital providers are likely to encounter individuals with a history of an anxiety disorder. The most commonly encountered disorders include generalized anxiety disorder, panic disorder, acute stress disorder and posttraumatic stress disorder (PTSD).
PTSD is of particular importance for prehospital providers, as many patients suffering from PTSD may have experienced an inciting traumatic event that elicited a response from EMS and law enforcement agencies. In these cases, the very sound of sirens or the presence of emergency personnel may trigger flashbacks of the inciting event. Subsequently, these patients may develop acute anxiety and in some cases may even reenact the initial event.
A Binder Lift can be used as a safe way to physically constrain a combative patient. Photo Vandalay
Although PTSD has gained public attention from its prevalence in war veterans, it more commonly develops after traumatic events such as rape, torture, abduction, child abuse, car crashes, acts of terror or natural disasters.3 In addition, one survey suggests that up to 19% of urban EMS personnel may suffer from PTSD themselves secondary to work-related events.4
Despite the high prevalence of anxiety disorders, when an anxious patient is encountered in the prehospital setting, a primary anxiety disorder becomes a diagnosis of exclusion. Symptoms of anxiety may be a manifestation of a more life-threatening medical emergency. Common presenting signs and symptoms include tachypnea, tachycardia, diaphoresis, trembling, palpitations, shortness of breath and chest pain.5 Many high-acuity medical conditions can induce these very same symptoms, including acute coronary syndrome, pulmonary embolus, cardiac arrhythmias, asthma or chronic obstructive coronary disease exacerbation, acute heart failure, hypoglycemia, alcohol withdrawal and others. In the acute setting, these high-risk diagnoses should be ruled out prior to diagnosing a primary psychiatric disorder in order to avoid potentially grave errors.
Prehospital providers should never assume a patient’s complaints are completely attributable to an underlying anxiety disorder. These patients should be placed on a cardiac monitor, a blood glucose measurement should be obtained and the patient should be transported without delay. Alterations in mental status, anxiety and inappropriate affect have all been reported as the presenting signs of an ST elevation myocardial infarction (STEMI) in the elderly. When possible, gather collateral information at the scene regarding any past history of anxiety disorder, including any prescribed medications or substances the patient may use. This information will be helpful to ED staff in the event further diagnostic workup reveals an organic cause isn’t responsible for the patient’s anxiety.
Altered Mental Status or Agitation
Although psychiatric patients may present with altered sensorium, it’s important to remember there are five primary causes of altered mental status, as outlined in Table 1.6 Psychiatric causes are always a diagnosis of exclusion. There are several psychiatric disorders causing altered mental status EMS personnel should be particularly familiar with, including excited delirium, mood disorders
and psychosis.
Excited delirium syndrome is a dangerous disease entity characterized by extreme agitation, combativeness, bizarre behavior and a hyperadrenergic state. Specifically, these patients are known to exhibit unusual strength, an extreme tolerance to pain, a propensity to remove their clothing, noncompliance with law enforcement, hyperthermia and an apparent attraction to mirrors or glass objects. This constellation of symptoms has been described in the literature for over 150 years, although the name “excited delirium” was not coined until the 1980s.7
Although the exact cause and pathophysiology of this entity is not completely understood, the general consensus attributes the syndrome to an alteration in dopamine levels in the brain.8 In most cases, patients are intoxicated with a sympathomimetic drug such as cocaine or methamphetamine. However, the condition has also been attributed to other recreational drugs, the abrupt cessation of antipsychotic agents, and primary psychiatric illnesses such as acute mania
or psychosis.7
Excited delirium has gained significant attention in the media due to a number of these patients suffering from sudden cardiac death while in the custody of law enforcement personnel. Because of the erratic and unrelenting behavior of these patients, they often struggle with law enforcement for an extended period of time before they’re subdued. As a result, these patients are at risk of developing severe metabolic acidosis, rhabdomyolysis, hyperthermia and hyperkalemia, which may increase the risk of cardiac dysrhythmias and sudden cardiac death.7 Failure of prehospital providers to quickly recognize this entity may be a fatal error.
In 2009, the American College of Emergency Physicians released a white paper on excited delirium, citing that patients exhibiting the aforementioned symptoms should raise suspicion for excited delirium syndrome, and immediate medical evaluation and treatment should ensue once the patient is physically subdued.9
It’s a good idea to request law enforcement involvement in order to maintain scene safety. Photo Kevin Link
Mood disorders and psychosis may also cause altered mental status. Depression in its most severe state may lead to suicidal ideation or suicide attempt as discussed earlier, and this subset of patients must be handled with care. Acute mania in patients with bipolar disorder is a medical emergency, as these patients may engage in high-risk behaviors that place themselves and others in danger. Symptoms of acute mania include pressured speech, disorganized or racing thoughts, insomnia, increased motor activity, aggression, and poor decision making.10 Many of these features may also be seen in acute psychosis, often accompanied by delusions and auditory or visual hallucinations.
Management
Whether your patient is combative due to intoxication or an underlying medical or psychiatric condition, protecting yourself and the patient from further harm is paramount. Verbal de-escalation methods should always be attempted first. When doing so, keep a safe distance from the patient. If you’re indoors, position yourself close to the exit of the room. Never let the patient get between you and your potential exit. Inform the patient in a calm voice you’re there to help. Closely inspect the patient’s surroundings and take note of any weapons or potentially hazardous objects within their reach. If appropriate, involve a friend or family member of the patient to help them calm down.11
Physical restraints: When verbal attempts to gain a patient’s cooperation fail, physical and/or chemical restraints may be required to maintain the safety of the patient and providers in transport. Physical restraints can be difficult to deploy safely, and the assistance of law enforcement personnel may minimize the risk of injury. Remember, physical restraints may exacerbate the patient’s agitation, and as the patient continues to struggle against restraints, they may be more likely to experience sequela such as metabolic acidosis, hyperthermia, rhabdomyolysis and, in extreme cases, sudden cardiac death.12
Four extremity leather restraints are generally very effective. The patient should be positioned on their side if possible and never in a prone position, as this may place the patient at risk of asphyxiation.13 Restraints should never restrict movement of the patient’s chest, as doing so may prevent the patient from hyperventilating in the setting of a metabolic acidosis.
The need for physical restraints should be constantly reassessed, and they should be loosened or removed when appropriate. In many cases, physical restraints may only be needed temporarily while chemical restraints are delivered. Always appropriately document the indications for physical restraints for legal purposes.
Review local protocols and talk with your medical director to ensure you have adequate training in handling these potentially dangerous patients. Photo Kevin Link
Chemical restraints: Chemical restraints may be used as an alternative or adjunct to physical restraints. Traditionally, benzodiazepines and antipsychotics have been the most commonly used drug classes in the prehospital and ED settings. A frequently used in-hospital combination is lorazepam 1—2 mg intramucosal (IM)/IV and haloperidol 5 mg IM, which produces a sedative effect within 30 minutes. Diphenhydramine 25 mg oral/IV or benztropine 1 mg oral/IV is often administered concurrently to treat or prevent the dystonic reactions and akathisias occasionally associated with haloperidol and other antipsychotics.14
Benzodiazepines: Lorazepam is heat labile, and thus almost all EMS personnel carry midazolam or diazepam as their benzodiazepine of choice in the field. A reasonable starting dosage for midazolam is 2 mg IV or 5 mg IM. If the 5 mg/mL midazolam solution is available, it may be given intranasally via a mucosal atomizer.14 Diazepam 5 mg IV is also acceptable. All three of these medications can also be given intraosseously. All benzodiazepines may cause respiratory depression, particularly when combined with alcohol, so use caution when administering to intoxicated patients. In the relatively rare event of benzodiazepine-induced respiratory depression, supportive measures such as supplemental oxygenation, placement of a nasal trumpet, ventilatory assistance with bag-valve mask, or definitive airway management may be necessary. Flumazenil, a benzodiazepine reversal agent, is rarely indicated and has the potential to trigger refractory seizures.15
Antipsychotics: Haloperidol is a conventional antipsychotic agent, which works by blocking dopamine receptors in the brain to create a sedative effect. Other antipsychotic agents such as droperidol (5 mg IM) and newer agents such as ziprasidone (10—20 mg IM) and olanzapine (10 mg IM) have a similar mechanism of action.
As mentioned previously, these medications occasionally cause acute psychomotor agitation that can usually be treated (or prevented) with diphenhydramine or benztropine.14 In addition, these medications are known to cause QT interval prolongation. Droperidol carries an FDA black box warning for QT prolongation and an increased risk of torsades de pointes. A baseline ECG should be obtained prior to administration if possible, and all patients receiving antipsychotics should be placed on a cardiac monitor in transport. Neuroleptic malignant syndrome, a rare but potentially fatal side effect of these medications, is usually associated with chronic use.
Ketamine: In addition to benzodiazepines and antipsychotics, ketamine, a dissociative anesthetic and analgesic agent, has recently been explored as a second line agent for agitation, particularly in patients with excited delirium.16,17 Ketamine is commonly used for procedural sedation in the ED, as well as for rapid sequence induction, although current literature regarding the use of ketamine as an alternative agent for acute agitation in the prehospital setting is inconclusive, it does appear to hold promise. However, case reports have described oversedation requiring intubation and laryngospasm as potential caveats to its use in this setting.16,17
A special note on management of excited delirium: Initial action by EMS personnel should involve the administration of medications to prevent the patient from continuing to struggle against physical restraints. Benzodiazepines should be the first line agents, and patients with excited delirium often require multiple doses to provide adequate chemical restraint. Use caution with antipsychotic agents in this patient population, as the potential for QT prolongation may increase the risk of cardiac dysrhythmias. Once the patient is less agitated, place the patient on a cardiac monitor, obtain vital signs and serum glucose measurement, and administer supplemental oxygen. Assess for early signs of hyperkalemia on the cardiac monitor such as peaked T waves or QRS widening. Administer cooled IV fluids, and loosen any constricting restraints when appropriate to avoid further hyperthermia.18
All patients with presumed excited delirium should be transported to an ED for further evaluation and treatment. Beware of the agitated patient suddenly becoming calm, as this has been reported just prior to precipitous cardiopulmonary arrest. A review of the presenting signs and symptoms of excited delirium and the initial management is outlined in Table 2.
Final Thoughts
Encountering patients with acute behavioral disturbances can present unusual challenges to prehospital providers. Review your local protocols and discuss these topics with your medical director to ensure you have adequate training in handling these potentially dangerous scenarios. Knowledge of safe and appropriate use of both physical and chemical restraints is essential to maintain scene safety when verbal de-escalation techniques have been exhausted.
The 61-year-old gentleman with “demons in his chest” was placed on a stretcher and loaded into the truck for non-emergent transport to the ED. Initial vitals revealed blood pressure of 196/111, pulse 121, pulse oximetry of 99% on room air, respiration rate of 30 and a blood glucose of 130. The patient was restrained with four leather straps before being placed on a cardiac monitor and a 12-lead ECG was obtained, which revealed ST elevations in V1—V3. In accordance with STEMI protocol, aspirin, nitroglycerine and supplemental oxygen were administered, and the patient was transported with lights and siren.
The patient was taken directly from the ED to the cath lab, where he was found to have a 100% occlusion of the left anterior descending artery. A stent was placed and he was successfully reperfused, just 40 minutes after EMS dispatch. History obtained later revealed the patient had a history of paranoid schizophrenia, hypertension and high cholesterol, and had been off of his medications for approximately three weeks. The patient had an uneventful recovery from his STEMI, much accredited to the expertise of the EMS personnel.
References
1. Wilson AG. Be wary of the suicidal patient. In BJ Lawner, CM Slovis, R Fowler, et al. (Eds.), Avoiding common prehospital errors. Lippincott, Williams, and Wilkins: Philadelphia, pp. 377—379, 2013.
2. Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617—627.
3. Anxiety disorders. (n.d.) National Institute of Mental Health. Retrieved May 12, 2014, from www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml.
4. Blumenfield M, Byrne BW. Development of posttraumatic stress disorder in urban emergency medical service workers. Medscape Psychiatry and Mental Health e-Journal. 1997;2(5).
5. Persse D. Do not overdiagnose anxiety. In BJ Lawner, CM Slovis, R Fowler, et al. (Eds.), Avoiding common prehospital errors. Lippincott, Williams, and Wilkins: Philadelphia, pp. 358—360, 2013.
6. Slovis CM. Don’t assume the intoxicated patient is just drunk. In BJ Lawner, CM Slovis, R Fowler, et al. (Eds.), Avoiding common prehospital errors. Lippincott, Williams, and Wilkins: Philadelphia, pp. 361—363, 2013.
7. Vilke GM, DeBard ML, Chan TC, et al. Excited delirium syndrome (ExDS): Defining based on a review of the literature. J Emerg Med. 2012;43(5):897—905.
8. Staley JK, Ruttenber AJ, Hearn WL, et al. Altered dopaminergic synaptic markers in cocaine psychosis and sudden death. In: Harris LS (Ed.), Problems of drug dependence, 1994: Proceedings of the 56th annual scientific meeting, vol. 2. National Institute on Drug Abuse: Palm Beach, Fla., p. 491, 1995.
9. Excited Delirium Task Force. White paper report on excited delirium syndrome [white paper]. American College of Emergency Physicians: Maryland, 2009.
10. Belmaker RH. Bipolar disorder. N Engl J Med. 2004;351(5):476—486.
11. Wilson AG: Keep yourself safe on the scene. In BJ Lawner, CM Slovis, R Fowler, et al. (Eds.), Avoiding common prehospital errors. Lippincott, Williams, and Wilkins: Philadelphia, pp. 370—372, 2013.
12. Coburn VA, Mycyk MB. Physical and chemical restraints. Emerg Med Clin North Am. 2009;27(4):655—667.
13. Hick JL, Smith SW, Lynch MT. Metabolic acidosis in restraint-associated cardiac arrest: A case series. Acad Emerg Med. 1999;6(3):239—243.
14. Mechem CC. Know the pros and cons of chemical restraint. In BJ Lawner, CM Slovis, R Fowler, et al. (Eds.), Avoiding common prehospital errors. Lippincott, Williams, and Wilkins: Philadelphia, pp. 352—354, 2013.
15. Haverkos GP, DiSalvo RP, Imhoff TE. Fatal seizures after flumazenil administration in a patient with mixed overdose. Ann Pharmacother. 1994;28(12):1347—1349.
16. Burnett AM, Watters BJ, Barringer KW, et al. Laryngospasm and hypoxia after intramuscular administration of ketamine to a patient in excited delirium. Prehosp Emerg Care. 2012;16(3):412—414.
17. Ho JD, Smith SW, Nystrom PC, et al. Successful management of excited delirium syndrome with prehospital ketamine: Two case examples. Prehosp Emerg Care. 2013;17(2):274—279.
