Routine Patient Care, followed by:
- One EMT should manage the patient while the other handles scene control, but no EMT or First Responder should be left alone with the patient.
- Avoid areas/patients with potential weapons (e.g., kitchen, workshop), and avoid areas with only a single exit; do not allow patient to block exit.
- Keep environment calm by reducing stimuli (may need to ask family/friends to leave room, ask patient to turn off music/TV). Transport in a non-emergent mode unless the patient’s condition requires lights and sirens.
- Respect the dignity and privacy of the patient.
- Make eye contact when speaking to the patient.
- Speak calmly and in a non-judgmental manner; do not make sudden movements.
- Maintain non-threatening body language (hands in front of your body, below your chest, palms out and slightly to the sides).
- Establish expectations for acceptable behavior, if necessary.
- Ask permission to touch the patient before taking vital signs, and explain what you are doing.
- Assess the patient to the extent that they allow without increasing agitation, maintain a safe distance from a violent patient.
- Stop talking with patient if they demonstrate increased agitation; allow time for them to calm down before attempting to discuss options again.
- Provide reassurance by acknowledging the crisis and validating the patient’s feelings and concerns; use positive feedback, not minimization.
- Determine risk to self and others (“Are you thinking about hurting/killing yourself or others?”).
- Encourage patient to cooperatively accept transport to the hospital for a psychiatric evaluation and treatment.
- Consider asking friends/relatives on scene to encourage patient to accept transport, if needed; but only if they are not a source of agitation.
- Ask law enforcement or Online Medical Control to complete a MDMH Section 12 application for uncooperative patients who acknowledge intent to self-harm or harm others, but do not delay transport in the absence of this document.
- Use restraints in accordance with 2.5 Behavioral Emergencies: Restraint if de-escalation strategy fails and the patient is a danger to him/herself or others.
Acute risk factors for violence include:
- Male gender
- Homicidal or violent intent or plans
- Intoxication or recent substance use
- Actions taken on plans/threats
- Unconcerned with consequences
- No alternatives to violence seen
- Intense fear, anger, or aggressive speech/behavior
- Specified victim (consider proximity, likelihood of provocation)
Red Flag: Haloperidol should be administered by INTRAMUSCULAR injection ONLY.
PARAMEDIC STANDING ORDERS
- Initiate an IV of Normal Saline at a KVO rate.
- Apply cardiac monitor if clinically feasible, obtain 12 lead ECG-manage dysrhythmias per protocol.
- Position patient to ensure breathing is not impaired.
- If providing medication to patients >70 years of age, limit dose.
ADULT STANDING ORDERS
- Haloperidol 5 mg IM; and/or
- Lorazepam 2mg IV/IO/IM; or
- Midazolam 2-6 mg IV/IO/IM/IN
- Ketamine 4mg/kg IM only, to a maximum dose of 400mg IM only, as a single dose.
- NOTE: In patients >70 years of age, limit medication to half these doses.
PEDIATRIC STANDING ORDERS
- Midazolam1mg/kg IV/IO/IM/IN
NOTE: MEDICAL CONTROL MAY ORDER ADDITIONAL DOSES OF ABOVE MEDICATIONS
Red Flag: NOTE:
Haloperidol is preferable for psychotic patients; but do not administer to patients with a history of seizures or prolonged QT intervals.
Lorazepam is preferable for patients experiencing alcohol withdrawal or the toxic effects from sympathomimetic drugs, e.g. cocaine (or pcp).
Diazepam should NOT be administered to patients experiencing behavioral emergencies.