8000: Behavioral & Poisoning

A 25-year-old male with psychiatric disorder is threatening staff and attempting to flee. What criteria must be met to use this protocol?

- Patient is 16–65 years old
- Agitated with imminent risk to self/others
- May be psychiatric disorder or medical cause of agitation
- Exclude

What are key safety steps before managing an agitated patient?

- Ensure scene safety, involve law enforcement if needed
- Use soft physical restraints if required (4-point, supine, never prone)
- Apply spit mask if needed
- Monitor SpO₂, ETCO₂, ECG, and vitals every 5 min
Protocol: 8003 – Agitated Behavior

What IMCRASS score indicates mild agitation requiring only anxiolysis?

- IMCRASS score = 2
Protocol: 8003 – Agitated Behavior

What medication options exist for mild agitation (IMCRASS 2)?

- droPERidol 2.5 mg IM
- Midazolam 2 mg IM
- Lorazepam 1 mg IM
- Diazepam 5 mg IM
Protocol: 8003 – Agitated Behavior

What IMCRASS scores indicate severe agitation requiring chemical restraint?

- IMCRASS score = 3–4
Protocol: 8003 – Agitated Behavior

What are the chemical restraint options for severe agitation (16–65 years old)?

- Ketamine 4 mg/kg IM (max 500 mg)
- Ketamine 2 mg/kg IV (max 200 mg)
- droPERidol 5 mg IM + Midazolam 5 mg IM (combo)
- Midazolam 5 mg IM alone (if droPERidol unavailable)
Protocol: 8003 – Agitated Behavior

What precautions must be taken when giving ketamine for agitation?

- Monitor airway, SpO₂, ETCO₂, ECG
- Risk of respiratory depression, especially if benzos also given
Protocol: 8003 – Agitated Behavior

What are the risks of struggling patients who are physically restrained?

- May develop rhabdomyolysis, acidosis, sudden cardiac arrest
Protocol: 8003 – Agitated Behavior

What positioning and transport considerations are required for restrained patients?

- Supine position only
- Never transport prone
- Ensure adequate staffing/resources in back of ambulance
Protocol: 8003 – Agitated Behavior

When should Medical Command be contacted in an agitated behavior call?

- As soon as safe after restraint/sedation
- Orders for sedation or additional agents may be required
Protocol: 8003 – Agitated Behavior

A patient with suspected ingestion of unknown pills is lethargic. What are your first management steps?

- Scene safety and decontamination if needed
- Airway, O₂, monitor, ECG, IV/IO
- Check glucose
Protocol: 8031 – Poisoning/Toxin Exposure

What fluids are indicated for poisoning/toxin exposure?

- NSS boluses as needed for hypotension
Protocol: 8031 – Poisoning/Toxin Exposure

When should Poison Control be contacted in poisoning cases?

- As soon as possible after stabilization
Protocol: 8031 – Poisoning/Toxin Exposure

What is the transport consideration for poisoned patients?

- Transport to facility with antidote capability
Protocol: 8031 – Poisoning/Toxin Exposure

What optional treatments may Medical Command authorize for poisoning?

- Activated charcoal if ingestion within 1 hr and patient can protect airway
- Sodium bicarb for wide QRS (tricyclic OD)
- Calcium chloride and/or glucagon for CCB/beta-blocker OD
- Nitroglycerin for cyanide if stable
- Diphenhydramine for dystonic reaction
- Hyperbaric O₂ for CO/cyanide as appropriate
Protocol: 8031 – Poisoning/Toxin Exposure

A patient is pulled from a closed-space fire, confused, tachypneic. What is your first management?

- High-flow O₂ immediately
- Do not rely on SpO₂ readings
Protocol: 8081 – Cyanide Exposure

What is the antidote sodium thiosulfate dose for cyanide poisoning?

- Adult: 12.5 g IV over 10 min
- Pediatric: 1.6 mL/kg IV (max 12.5 g)
Protocol: 8081 – Cyanide Exposure

What is the antidote hydroxocobalamin dose for cyanide poisoning?

- 70 mg/kg IV/IO (max 5 g)
Protocol: 8081 – Cyanide Exposure

What additional treatments may Medical Command authorize in cyanide poisoning?

- Repeat sodium thiosulfate
- Sodium bicarb for acidosis
Protocol: 8081 – Cyanide Exposure

A patient exposed to organophosphate pesticide develops pinpoint pupils, tearing, and diarrhea. What is your initial management?

- Scene safety, PPE, decontaminate
- Airway/O₂, monitor, IV/IO
Protocol: 8083 – Nerve Agent/Pesticide Exposure

What antidotes are given for mild nerve agent/pesticide exposure?

- Atropine 2 mg IM (Adult)
- Pralidoxime (2-PAM) 600 mg IM
- For pediatric: Atropen 0.5–2 mg depending on age
Protocol: 8083 – Nerve Agent/Pesticide Exposure

What antidotes are given for moderate nerve agent/pesticide exposure?

- Atropine 2 mg IM
- Pralidoxime 600 mg IM
- Repeat every 5–10 min until symptoms improve
Protocol: 8083 – Nerve Agent/Pesticide Exposure

What is the treatment for severe nerve agent/pesticide exposure?

- Multiple doses of Atropine and Pralidoxime (NAAA kits)
- Add anticonvulsant: diazepam, lorazepam, or midazolam (CANA kit for military)
Protocol: 8083 – Nerve Agent/Pesticide Exposure

What special note applies to carbamate pesticide exposure?

- Do not give pralidoxime (2-PAM) for carbamate toxicity
Protocol: 8083 – Nerve Agent/Pesticide Exposure

Why must atropine be given before intubation in nerve agent exposure?

- Secretions and airway compromise must be controlled first
Protocol: 8083 – Nerve Agent/Pesticide Exposure

What pediatric-specific antidote guidance applies for nerve agent exposure?

- Atropen auto-injectors:
-

What resource may be requested for mass exposure events?

- CHEMPACK (federal antidote stockpile)
Protocol: 8083 – Nerve Agent/Pesticide Exposure