BEHAVIORAL EMERGENCIES

© 2011 National Safety Council 13-1

BEHAVIORAL EMERGENCIESLESSON 13


Behavioral Emergencies

• Process of giving emergency care may be complicated by patient’s behavior

• Many injuries and medical emergencies may cause altered mental status or emotional responses

• Patients may have emotional problems

• Patient may be a danger to self or others


Common Causes of Altered Behavior

• Situational stresses

• Illness or injury

• Psychiatric problems

• Not taking a prescribed psychiatric medication

• Low blood sugar

• Shock

• Inadequate blood flow to brain

• Head trauma


Common Causes of Altered Behavior (continued)

• Temperature extremes

• Poisoning or overdose

• Mind-altering substances, alcohol, drugs

• Seizure disorders

• Brain infection

• High fever


Assessing Behavioral Emergencies

• Perform standard assessment

• Assess mental status by observing:- Appearance

- Actions

- Speech

- Posture and gait

- Orientation for time, person and place

- Mood, thought processes


Signs Violent Behavior May Occur

• Person holding weapon or something that can be used as weapon

• Person in threatening posture

• Person is verbally abusive, threatening


• Person agitated, uncontrollably elated, uncontrollably angry or kicking or throwing things

• Person known to be violent• Hallucinations, paranoia

Signs Violent Behavior May Occur (continued)


Is Patient Dangerous?

• Self-destructive behavior or suicide attempts represent danger to the patient

• Threatening behavior, violence and the presence of weapons represent a danger to responders and others


Assessment for Suicide Risk

• How does the patient feel?

• Is the patient thinking about hurting or killing himself or herself or others?

• Does the patient have cultural or religious beliefs consistent with suicide or violence?

• Does the patient have a medical problem or trauma?

• Might the patient have a weapon?

• Is it safe to attempt an intervention?


Suicide Risk Factors

• Mental disorders (including depression)

• History of substance abuse

• Feelings of hopelessness

• Recent emotional crisis or painful illness

• Impulsive or aggressive tendencies

• Previous attempts

• More common in teenagers


Suicide Warning Signs

• Talking about suicide

• Comments about hopelessness or worthlessness

• Taking risks that could cause death

• Loss of interest in past activities

• Suddenly and unexpectedly seeming calm or happy after being sad


Emergency Care forBehavioral Emergencies

• Perform standard patient care

• Protect the patient and yourself

• Do not leave patient alone

• Consider need for law enforcement

• Be prepared to leave scene

• Give medications or drugs to arriving EMS

• Don’t assume patient is drug impaired


Emergency Care forBehavioral Emergencies (continued)

• Try to reduce any distressing stimuli at scene

• Always try to talk patient into cooperation

• Call for additional help if needed, including law enforcement if appropriate

• Avoid restraints unless necessary

• Calm and reassure patient


Calming a Behavioral Patient

• Approach slowly but purposefully

• Identify yourself

• Say you are there to help

• Ask patient for name, and use it

• Tell patient what you plan to do

• Treat patient with respect


Calming a Behavioral Patient (continued)

• Ask questions in calm, reassuring voice

• In cultures where acceptable, make eye contact

• Encourage patient to tell you what happened and what troubles him or her

• Show you care

• Rephrase or repeat what patient says



• Acknowledge patient’s feelings• Maintain a comfortable distance• Avoid unnecessary physical contact • Avoid any posture that may seem threatening• Do not make quick moves• Respond honestly to questions• Don’t belittle, threaten, challenge or argue• Don’t “play along” with hallucinations• Involve family members or friends



• Be patient, and be prepared to stay at scene for a long time

• Always remain with patient

• Call for additional help if needed


Victims of Abuse and Sexual Assault

• Child abuse, spouse abuse (domestic violence), elder abuse and sexual assault often cause injuries treated by EMRs

• These situations may also be behavioral emergencies

• Be sensitive to situation while providing medical care

• Report your observations to responding EMS personnel and in your run report

• Take special crime scene considerations


Domestic Violence

• Victim often does not report abuse to authorities

• Victim stays with abusing spouse or partner

• Signs of potential domestic violence:- Patient seems unusually fearful

- Patient’s account of injury seems inconsistent or unlikely

- Patient is uneasy in presence of spouse or partner

- Patient’s spouse or partner aggressively blames patient


Emergency Care for Domestic Violence

• Provide emergency care as usual for injuries

• Ensure privacy for patient

• Tell responding EMS personnel in private about your suspicions

• Do not directly confront patient with suspicions, especially if spouse or partner is present

• Do not confront patient’s spouse or partner

• Try to involve a friend or family member of patient in care giving


Emergency Care for Domestic Violence (continued)

• Follow local protocol to report suspected cases to appropriate authorities

• If patient communicates information to you suggesting abuse, report this to responding EMS personnel and document it

• If appropriate, call for law enforcement personnel

• If necessary, withdraw from scene to ensure your safety


Sexual Assault and Rape

• Victim of sexual assault or rape may have other injuries

• Patient may or may not say what happened

• Be aware of likely psychological trauma

• Do not push for answers when taking patient’s history


Emergency Care forSexual Assault and Rape

• Be sensitive to patient’s psychological trauma• Patient may be hysterical, crying, hyperventilating or in a

dazed, unresponsive state• Provide emotional support • Ensure appropriate responders have been summoned • Rape requires law enforcement personnel• Ensure privacy for patient• Try to involve a friend or family member of patient in care

giving or EMS responder of same sex


Emergency Care forSexual Assault and Rape (continued)

• Ensure patient is not left alone

• Provide medical care as needed for any injury

• Preserve evidence of rape – ask patient not to urinate (unless necessary), bathe or wash before EMS personnel arrive


Restraining Patients

• If patient is danger to self or others

• Most EMRs do not restrain patients

• Restrain only if you have been trained and it is part of local protocol

• Before using restraint, have police present and work with responding EMS


Restraining Patients (continued)

• Avoid unreasonable force- Use only as much force as needed to keep patient from

injuring him or herself or others

- Use reasonable force to defend yourself

• Avoid acts or physical force that may injure patient


Reasonable Force for Restraints Depends On

• Patient’s size, strength and gender

• Patient’s abnormal behavior

• Patient’s mental state

• Method of restraint


Guidelines for Restraining

• Act only as you have been trained, following local protocol• Ensure adequate personnel are present to help• Plan approach you will use – then act quickly • One responder should talk to patient throughout process• Four responders approach together, 1 assigned to

each extremity• Extremities restrained with equipment approved by

medical direction, avoiding unnecessary force


Guidelines for Restraining (continued)

• Do not restrain patient face down; maintain airway access at all times

• Assess patient’s breathing and circulation frequently

• Provide oxygen by non-rebreather mask if appropriate

• Once a patient is restrained, do not remove restraints

• Document indications and technique used


Legal Considerations in Behavioral Emergencies

• Patients may threaten or falsely accuse responders

• Document abnormal behavior factually

• Ensure others are present (witnesses)

• When possible, have same-sex responders provide care


Emotionally DisturbedPatients Resisting Treatment

• Get patient’s consent, witnessed by others

• If patient threatens self-harm or you believe this may occur, follow local protocol to provide care against patient's will if safe to do so

• Assistance of law enforcement usually required

BEHAVIORAL EMERGENCIES

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