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Behavioral Emergencies
PARAMEDIC PROGRAM
P. Andrews
Summer 07
Strange But True
A 28-year old male was brought into the ER
after an attempted suicide. The man had
swallowed several nitroglycerin pills and a
fifth of vodka.
When asked about the bruises about his
head and chest, he said that they were from
him ramming himself into the wall in an
attempt to make the nitroglycerin explode.
What’s this all about?
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Is it normal or abnormal?
Prevalence?
Pathophysiology of behavioral and
psychiatric disorders
Factors that alter behavior or emotional
status
Medical legal considerations
Overt behaviors associated with behavioral
and psychiatric disorders
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Verbal techniques useful in mgmt of the
emotionally disturbed pt.
Appropriate safety measures
When should family, etc be removed from
premises?
Techniques for physical assessment
When are you expected to transport a
patient against his/her will?
To restrain or not?
Terms
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Affect
Anger
Anxiety
Confusion
Depression
Fear
Mental status
Open-ended questions
Posture
Post-traumatic stress
syndrome
Psychogenic amnesia
Schizophrenia
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Bereavement
Biological/organic
Bipolar disorder
Catatonia
Delirium
Delusions
Dementia
Flat affect
Manic
Multiple personality
disorder
Phobia
Positional asphyxia
Behavioral and Psychiatric
Emergencies
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Not clear cut
They require a complete history, exam,
and careful/skilled approach
Most of what you do will depend on your
people skills
Behavioral emergency
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Behavior is so unusual, bizarre, threatening or
dangerous – possibly life-threatening to self
or others
What is normal, anyway???
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Determined by
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Does it
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Culture
Ethnic groups
Socioeconomic class
Personal interpretation, opinion
Interfere with core life functions?
Pose a threat to the life or well-being of the patient or
others?
Significantly deviate from society’s expectations?
Normal ? Behavior that is readily acceptable in
a society!
Pathophysiology
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~ 20% of population has some type of
mental health problem
1 in 7 will require treatment
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Anxiety
Depression
Eating disorders
Mild personality disorders
Behavioral and psychiatric disorders
incapacitate more people than all other
health problems combined!
True/not true?
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All mental patients are unstable and
dangerous
Their conditions are incurable
Biological causes
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Alcohol
Drugs (including OTC, Rx)
Infection
Tumors
Potential Organic Causes
Frontal atrophy from
Alzheimer’s disease
Brain neoplasm
Psychosocial
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Personality style
Dynamics of unresolved conflict
Crisis management methods
Environment
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Traumatic childhood incidents
Sociocultural
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Situational
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Relationships
Support systems
Social isolation
Rape/assault
Witnessing acts of violence
Loss of a job
Ongoing prejudice or discrimination
Assessment of behavioral patients
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The same as for all other
patients
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Scene size-up – look for
hazards
Initial assessment – watch
posture & body language
Focused history
Physical examination
You begin your care at the
same time – good
interpersonal skills,
remember?
More about the H & E
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Listen – open-ended questions
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Pay attention
Spend time
Be assured
Do not threaten
Let there be silence
Place yourself at their level
Keep a safe & proper distance
Appear comfortable
Don’t judge
Never lie
Mental status examination
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General appearance
Behavioral observations – verbal and non-verbal
behavior
Orientation
Memory
Sensorium – is pt. Focused, paying attention?
Perceptual processes – thought patterns ordered?
Mood and affect
Intelligence
Thought processes
Insight
Judgment
psychomotor
Form a general impression
Dementia
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25 – 50% over 85 y/o have dementia
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Affected person sometimes recognizes first
signs
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Alzheimer’s most common
Mini-strokes
Keys?
Lost while driving, etc
Common tasks
Difficulty with words
Time between first symptoms & death – 7
– 10 years
Dementia
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Gradual impairment of
memory and cognitive
functions
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Forgetfulness
Failure to recognize objects
or stimuli
Orientation
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Excellent recall of past
history
May not remember current
events
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Affect
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Aphasia
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Impaired motor activities
Agnosia
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Impaired communication
Apraxia
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Normal or flat, depending
on stage of condition
Failure to recognize objects
Disturbance in executive
functioning
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Impaired ability to plan,
organize or sequence
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Causes:
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Alzheimer’s disease
AIDS
Parkinson’s disease
Vascular disease
Head trauma
Substance abuse
Dementia and Delirium
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Delirium may occur in dementia patients
Delirium Presentation
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Rapid onset (hours or days)
Inattention, disorientation, memory
impairment and visual hallucinations
Causes of delirium are usually reversible
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Rule out acute medical problems, medication
changes
Treatment
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Supportive
Meds
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Aricept
Cognex
Schizophrenia
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Gross distortions of reality
Preoccupation with inner
fantasies
Withdrawal from social
interaction
Disorganization of thoughts,
perceptions, and emotions
Behavior linked with
medication noncompliance
Chronic substance abuse in
teenage years linked to
development of the disease
Schizophrenia Symptoms
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Disorganized behavior/dress
Flat affect
Disorganized speech
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Delusions
Hallucinations
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Incoherent or frequently veers off track
Often auditory; sometimes visual
Motor Movements
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May act upon hallucinations
Profiles of
Schizophrenic Behavior
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Delusional:
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A man who wraps his house in tin foil
to divert the rays from FBI satellites.
Paranoid:
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The man introduces himself as Jesus
Christ and tells you that the city
council is out to crucify him.
Profiles of Schizophrenic
Behavior
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Disorganized (interview with a physician):
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“S____t on you all who rip into my internals!
The grudgerometer will take care of you all! I
am the Queen, see my magic, I shall turn you
all into sidgelings forever!”
Profiles of Schizophrenic
Behavior
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Undifferentiated:
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Magical thinking
Creates new words or cryptic language
Cannot reason abstractly
Diagnosis of Schizophrenia
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Two or more symptoms must each be
present for a significant portion of each
month over the course of 6 months.
Sx must cause a social or occupational
dysfunction
Most schizophrenics are diagnosed in early
adulthood
Approach to a schizophrenic
pt.
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Be supportive
Be nonjudgmental
Don’t reinforce the patient’s hallucinations
– but know that he considers them real
Speak openly and honestly
Be encouraging and realistic
Be alert for aggressive behavior
Restrain pt if necessary
Anxiety Disorders
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Panic Attacks
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Acute, unprovoked episodes
Last approximately 1 hour
Symptoms:
Cardiac chest pain, nausea
 Dyspnea or a sense of feeling “smothered”
 Fear of going crazy
 Paresthesia, dizziness
 Trembling, shaking
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Mood Disorders: Mania
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Sudden onset with rapid progression of
symptoms (days)
Presentation:
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Progressive inflation of self-esteem
Distracted, racing thoughts
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Delusions may occur
Very talkative with rapid speech
Excessive involvement in high pleasure/high
risk activities
Management for anxiety
disorder
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Simple, supportive
Be empathetic
Assess medical complaints & tx prn
Consider sedative
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Valium
Versed
Ativan
Benadryl
Bipolar disorder
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One or more manic episodes with or
without depression, lasting at least one
week
Not common
Episodes often begin suddenly and
escalate rapidly
Disorder usually develops in adolescence
or early adulthood
The Stages of Mania
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Mild
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“On top of the world”
Egocentric
Decreased need for sleep
Severe elation
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Rapid speech
Illogical associations
Delusions of grandeur
Excessive
involvement in
pleasurable activities
with high potential
for consequences
Mood Disorders: Depression
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Situational v. persistent
Lack of interest in daily activities
Altered mood impairs daily functioning
May be present with other disorders
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Bipolar disease
Substance abuse
Presentation of Depression
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Bizarre behavior usually not seen in
depression
Inability to see beyond the person’s
immediate situation
Lethargy, slow thought process and
speech
Stooped posture
Poor appearance
General Management
Considerations
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Behavioral crisis development and
management are viewed as a “spectrum”
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Patients do not suddenly develop anger or
passivity
Use the scene dynamics wisely to effect
patient cooperation
Never leave depressed or suicidal patient
alone
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Assess situation
Protect self and others
Summon law enforcement if necessary
If no evidence of immediate danger, then
one EMT responsible for assessing,
treating and communicating with patient
Transport with consent (when possible)
without sirens
The Spectrum
When is it time for patient
restraint?
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Use only when necessary
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Patient is a danger to themselves
or others
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Look for all possible causes for the
behavior
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Restraints must allow for adequate
monitoring of vital signs
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Restraints applied by law
enforcement must allow sufficient “slack”
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Patient must be able to straighten the
abdomen and chest and take full breaths
The officer must accompany the patient in
the ambulance
Approved equipment for prehospital
personnel
Padded leather
Soft restraints (posey, velcro, seatbelts)
Unapproved methods of restraint
for prehospital personnel
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Hard plastic ties or device that requires a key to
remove
Backboard, scoop, or flat used to sandwich the
patient
“Hog - tied” (hands and feet behind the patient)
Methods or material that could cause
neurovascular compromise
Evaluate and document the condition of the
restrained extremity (neurovascular check) every
15 minutes.
Documentation of Restraint
Application
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Reason the restraints were needed·
Which agency applied the restraints·
Information and data regarding the
monitoring of circulation to the restrained
extremity·
Information and data regarding the
monitoring of respiratory status while
restrained
Somatoform disorders
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Somatization disorder
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Conversion disorder
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Pt is preoccupied with physical symptoms
Loss of function (blindness, paralysis)
Hypochondriasis
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Exaggerated interpretation of physical
symptoms
Neurotransmitters
and Behavior
Neurotransmitters: Norepi
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Promotes awakening and enhances
dreams
Elevates mood
CNS locations: cortex, medulla,
hypothalamus, limbic system, cerebellum
NE locations outside the CNS
Mania and delusions with overstimulation
Depression with low levels
Neurotransmitters: Dopamine
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Stimulates emotional responses
Controls subconscious skeletal movement
CNS locations: cerebral cortex,
hypothalamus and limbic system
Schizophrenia and schizoid symptoms
from amphetamines
Neurotransmitters: Serotonin
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Controls sleep, sensory perception, mood
control
Thermal regulation
CNS locations: hypothalamus, limbic
system and cerebellum
Hallucinations with LSD and
overstimulation
Depression and anxiety with low levels
Neurotransmitters: GABA
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Gamma aminobutyric acid
Depresses mood and emotion
CNS locations: everywhere!
Enhanced by benzodiazepines
Anxiety from low levels of GABA
Neurotransmitters and Drug
Therapy
Top prescribed Rx for 2004
#6 – Zoloft (SSRI)
#9 – Zyprexa
(Antipsychotic)
#13 – Effexor XR (SSRI)
#18 – Risperdal
(Antipsychotic)
#19 – Seroquel
(Antipsychotic)
#23 – Ambien
#47 – Welbutrin (SSRI)
#53 – Ablify
(Antipsychotic)
#58 – Paxil (SSRI)
#69 – Adderall
(Amphetamine)
Additional Top Rx - 2003
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Alprazolam
Lorazepam
Clonazepam
Wellbutrin
Amitryptiline
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Trazadone
Diazepam
Temazepam
Remeron (Serotonin
stimulant)
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Concerta
(amphetamine)
Drug Therapies: Antipsychotics
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Phenothiazines and their derivatives
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Mellaril, Navane, risperidone, thorazine,
stelazine, Prolixin
Dopamine blockade
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Will produce a flatter affect
Suppress hallucinations and delusions
Side effects: hypotension, dystonic reactions
Drug Therapies: Lithium
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Metallic compound
Slows the elevated use of serotonin, NE
and dopamine in the synapse
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Slows sodium transport into the cell and
reduces nerve transmission
Effective for chronic control of mania
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In mania, sodium transport occurs 200%
more than normal!
Drug Therapies: TCA, MAOI
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Both work to keep norepinephrine in the
synapse longer
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Elevates activity and mood in depression
Anticholinergic effects
Overdose
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Initially, massive amounts of NE released
Lack of reabsorption drops functional NE levels
dramatically
Systemic effects!
Drug Therapies: SSRI
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Keeps serotonin in the synapse
Prozac, Paxil, Zoloft
Overdose symptoms typically limited
Serotonin Syndrome
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Medications that work in similar areas as
SSRIs
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TCAs and MAOIs
Tramadol (narcotic)
Meprobamate (Sedative-hypnotic)
Promethazine
Intense potentiation of SSRI effects
Medical causes of
behavioral crises
Clues suggestive of a potential
medical cause of the behavior
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Abnormal vital signs
Depressed level of consciousness
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Obtunded
Evidence of drug or toxin ingestion
Very sudden onset of symptoms
Focal neurological signs
No previous psychiatric history
Presence of specific physical symptoms
A 24 year-old female was seen for manictype symptoms. She had irritability, rapid
speech and distracted conversation. These
symptoms had progressed over a 1-week
period.
She had no history of mental illness or drug
intoxication.
Lab tests revealed a markedly high T4 level
and she was diagnosed with thyrotoxicosis.
A 28 year-old female with a history of
bipolar disorder was experiencing
significant withdrawal and depression.
She was apathetic with a flat affect and
did not seem to interact with things
around her. An hour after admission, she
was lethargic, nonresponsive and
hypotensive.
Lab tests revealed lithium toxicity.
A 20 year-old was talking incoherently,
picking at her clothes and staring into
space. After she was admitted to the
hospital, her level of consciousness
rapidly deteriorated, becoming
disoriented and less responsive. She had
no history of psychiatric disease or drug
use. Her only history was that of herpes
zoster.
After an EEG and lumbar puncture, she
was diagnosed with encephalopathy.
Suicide
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9th leading cause of death overall
3rd leading cause of death in 15-24 age
group
Women attempt suicide more often, but –
men are more often successful
Assessing potentially suicidal
patients
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Perform appropriate H & E
Provide appropriate psychological care
Document observations, especially any
detailed plans
Risk factors for suicide
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Previous attempts
Depression
Age (15-24, & >40)
Alcohol or drug abuse
Divorced or widowed
Giving away personal belongings
Living alone/increased isolation
Psychosis with depression
Major separation trauma
Major physical stresses
Risk factors, cont.
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Loss of independence
Lack of goals & plans for future
Suicide of same-sexed parent
Expression of a plan for suicide
Possession of mechanism for suicide (gun,
rope, pills)
Age-related conditions
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Geriatrics
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You may mistake depression for dementia
Assess their ability to communicate
Provide reassurance
Compensate for vision, hearing loss
Treat with respect
Avoid administering medication if possible
Take your time
Allow family & friends to be with patient
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Pediatrics
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Avoid separating young child from parent
Make all explanations brief and simple; repeat
often
Be calm, speak slowly
ID yourself
Be truthful
Encourage child to help with his care
Don’t discourage child from crying, showing
emotion
Allow child to keep favorite blanket or toy
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Peds, cont.
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Don’t leave child alone, even for short period
If you must be separated from child,
introduce care giver who will take over
Management of Sudden Death
Situations
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Resuscitate patient unless obviously dead
Keep family informed
Be truthful
Avoid trite phrases
Do not offer false hope
Empathize/sympathize
Allow emotional response
Maintain professionalism
Management of terminally ill
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Do not isolate the family
Allow feelings to be expressed
Provide for patients physical comfort
Allow for patients dignity in dying process
Resuscitate according to local protocol
regardless of a living will
Grief
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Many different reactions
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Cultural differences
Denial
Anger
Bargaining
Depression
Acceptance
How you doin’?
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Helplessness/Guilt
Anger/Frustration
Avoidance
Nightmares
Gallows humor
Physiological response
Can you cope?
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Rest
Exercise
Humor
Hobbies
Have a life outside of EMS
Talk!
Others?