Chapter 23: Behavioral Health Emergencies

What is behavior?

A person's observable response to the environment—the actions you can see.

What is a behavioral crisis?

A reaction to events that interferes with activities of daily living or has become unacceptable to the patient, family, or community.

Can a behavioral crisis be caused by a medical condition?

Yes. Acute medical illness can cause or contribute to abnormal behavior.

What broad causes can produce a behavioral health emergency?

Acute medical problems, mental illness, mind-altering substances, stress, and other causes.

Does experiencing an emotional crisis automatically mean a person has a mental illness?

No. Otherwise healthy people can have acute or temporary emotional crises.

Are all patients with mental health disorders dangerous or violent?

No. Only a small percentage are violent or unmanageable.

Why might EMTs encounter a higher proportion of violent behavioral patients than the general population?

EMS is often called specifically when behavior has escalated into a crisis.

What is a psychiatric disorder?

An illness with psychological or behavioral symptoms that may result in impaired functioning.

Name anxiety disorders listed in the chapter.

Generalized anxiety disorder, panic disorder, social/other phobias, PTSD, and obsessive-compulsive disorder.

What are the two broad diagnostic categories discussed in the chapter?

Organic (physical) disorders and functional (psychological) disorders.

What is an organic brain syndrome?

Temporary or permanent brain dysfunction caused by a disturbance in the physical or physiologic functioning of brain tissue.

What can cause an organic brain syndrome?

Sudden illness, traumatic brain injury, seizure disorders, drug/alcohol abuse or withdrawal, overdose, and brain diseases such as Alzheimer disease or meningitis.

What medical causes of altered mental status are emphasized in this chapter?

Hypoglycemia, hypoxia, impaired cerebral blood flow, and hyperthermia or hypothermia.

What is a functional disorder in the chapter's framework?

A disorder that impairs function when the body appears structurally normal.

What examples of functional disorders are given?

Schizophrenia, anxiety conditions, and depression.

Is the EMT expected to diagnose the exact psychiatric disorder?

No. The EMT should recognize threats, consider medical causes, assess the patient, provide appropriate care, and transport.

Why must bizarre behavior be treated as potentially medical until assessed?

Medical illness, trauma, hypoxia, hypoglycemia, drugs, and other physiologic problems can produce abnormal behavior.

What can medication noncompliance do in a behavioral health disorder?

It can worsen or compound the patient's condition.

What is a major NREMT principle for behavioral emergencies?

Do not assume the problem is purely psychiatric; assess for medical and traumatic causes.

Why is identifying a geriatric patient's baseline mental status important?

Dementia, delirium, depression, or acute illness can alter behavior, so baseline helps identify an acute change.

What behavioral conditions should be considered in geriatric patients?

Dementia, depression, and delirium, while also evaluating for medical causes.

Can aggressive behavior in a child reflect an underlying condition?

Yes. It may reflect an underlying medical or psychological condition.

What is the EMT's overall goal in a behavioral emergency?

Maintain safety, identify and treat medical/traumatic life threats, de-escalate when possible, and arrange appropriate transport.

What is the role of communication in a behavioral crisis?

Calm, reassuring communication can build trust and help de-escalate the situation.

What should the EMT remember about a patient's behavior?

Behavior is a sign or presentation; it does not by itself establish the underlying cause.

What is the FIRST concern when approaching a behavioral emergency?

Scene safety, including the safety of you, your partner, the patient, and others.

When should EMTs stage for law enforcement?

When the scene may be violent or unsafe and has not yet been secured.

When should additional resources be requested during a behavioral call?

Early, when law enforcement, additional personnel, or ALS may be needed.

Where should the general impression begin in a behavioral emergency?

From the doorway or from a safe distance.

What should you observe before approaching a behavioral patient?

Behavior, environment, possible weapons, body position, activity, apparent distress, and interaction with others.

What alertness scale does the chapter recommend during the primary assessment?

AVPU.

Should a behavioral patient still receive a standard primary assessment?

Yes. Airway, breathing, circulation, mental status, and life threats still take priority.

What should be evaluated when assessing breathing?

Airway patency, respiratory rate and effort, and pulse oximetry if available.

What should be evaluated under circulation?

Pulse rate, quality and rhythm; bleeding; shock; skin color and temperature; and capillary refill.

What should the EMT look for during a rapid physical examination?

Signs of trauma or another physical cause for the abnormal behavior.

Why is head trauma especially important in a behavioral patient?

Traumatic brain injury can cause altered mental status and abnormal behavior.

What four major contributing areas should be considered during behavioral history taking?

CNS function, drugs/alcohol, significant life changes or illness, and history of behavioral health illness.

What standard history mnemonic should be obtained?

SAMPLE.

What behavioral-health history should be added to SAMPLE?

Previous episodes, treatments, hospitalizations, and medications related to behavioral problems.

Why should medication bottles or substances be noted?

They may identify treatment for an existing condition or a substance contributing to the current behavior.

What is reflective listening?

Listening and responding in a way that demonstrates understanding and helps reveal the patient's thoughts and concerns.

Why is reflective listening useful in behavioral emergencies?

It can build rapport and provide insight into the patient's thinking.

What can facial expressions reveal during a behavioral assessment?

They can provide clues about the patient's emotional state.

What physiologic observations can provide clues about emotional state?

Pulse, respirations, sweating, tears, and blushing.

What may a blank gaze or rapidly moving eyes suggest?

Possible central nervous system dysfunction.

What should be sought on the skin of an unconscious behavioral patient?

Signs of trauma, track marks suggesting drug use, and evidence of self-injury.

What prior events should be considered in an unconscious patient after severe agitation?

Stimulant use, alcohol withdrawal, physical agitation, trauma, and Taser exposure.

If a behavioral patient is medically unstable, should the EMT spend prolonged time trying to obtain rapport before transport?

No. Medical or traumatic instability takes priority and requires prompt care and transport.

If a behavioral patient is medically stable, why may spending some time on scene be useful?

Careful communication and rapport may reduce agitation and improve cooperation.

What should determine transport priority in a behavioral emergency?

Medical/traumatic instability, danger to self or others, and overall assessment findings.

Why may ground transport be preferred for behavioral emergencies according to the chapter?

The chapter recommends ground rather than air transport for these patients.

What should the receiving facility know before a behavioral patient arrives?

The patient's condition, behavior, safety concerns, and whether restraints are being used or may be required.

Why is thorough documentation especially important in behavioral emergencies?

Behavioral calls have significant medical, legal, consent, and restraint considerations.

What should be documented if restraints are used?

Why restraint was necessary, the type used, patient status, reassessments, and relevant behavior.

Should the EMT ever stop monitoring a behavioral patient because the patient becomes quiet?

No. Never let your guard down; behavior and medical status can change.

What is the best overall treatment for some behavioral patients?

Listening, reassurance, and de-escalation while continuing appropriate medical assessment.

How much should an EMT intervene in a behavioral crisis?

Only as much as necessary to safely accomplish patient-care tasks.

When should ALS be requested for possible pharmacologic restraint?

As early as possible when severe continuing agitation suggests chemical restraint may be needed.

What should be checked when a behavioral patient suddenly becomes less responsive?

Immediately reassess airway, breathing, circulation, mental status, glucose/medical causes as appropriate, and trauma.

What NREMT mistake should you avoid when a patient has a psychiatric history?

Do not attribute all current symptoms to the psychiatric history; assess for acute medical and traumatic causes.

What is psychosis?

A state in which a person is out of touch with reality and may experience delusions or other distorted perceptions.

What can cause psychotic episodes according to the chapter?

Mind-altering substances, intense stress, delusional disorders, and schizophrenia.

What is schizophrenia?

A complex psychiatric disorder that commonly begins in early adulthood and can affect perception, thought, speech, and behavior.

What findings are associated with schizophrenia in the chapter?

Delusions, hallucinations, lack of interest in pleasure, and erratic speech.

What is a delusion?

A false belief that is firmly held despite reality.

What is a hallucination?

A sensory perception that occurs without an external stimulus.

What is the FIRST question before approaching a psychotic patient?

Is the situation safe or dangerous?

How should an EMT identify themselves to a psychotic patient?

Clearly and calmly.

What communication style is recommended for a psychotic patient?

Calm, direct, straightforward, and nonjudgmental.

Should you argue with a patient's delusion?

No. Do not argue or aggressively challenge the patient's perception.

Should an EMT pretend that a patient's hallucination is real?

No. Remain grounded in reality without arguing or humiliating the patient.

Why should the EMT maintain emotional distance?

To remain calm, objective, and less likely to escalate the interaction.

Why should you explain what you want to do before touching or treating a behavioral patient?

Explanation reduces surprise, fear, and perceived threat and may improve cooperation.

Who may help gain a psychotic patient's cooperation?

Trusted family members, friends, or others the patient trusts, when appropriate and safe.

How should you approach an anxious or fearful patient physically?

Slowly and purposefully while respecting personal space.

Why should physical contact be limited with an agitated patient?

Unexpected or excessive contact can increase fear, agitation, or aggression.

Why should you avoid saying 'I know how you feel' to a distressed patient?

You cannot truly know the patient's experience; direct, supportive statements are more appropriate.

Which is generally more therapeutic: 'You're wrong' or 'I'm here to help you'?

'I'm here to help you' because it supports cooperation without confrontation.

Why can a calm tone reduce escalation?

It communicates control and safety and may help establish trust.

Should multiple rescuers crowd around an agitated patient?

No. Limiting the number of people can reduce stimulation and perceived threat.

What should an EMT do if a patient's trusted relative is calming them effectively?

Consider involving that person to help gain cooperation, as long as the situation remains safe.

What should you do if a patient becomes increasingly threatening during conversation?

Increase distance, maintain an escape route, request or use law-enforcement assistance, and prioritize safety.

Why should EMTs avoid making sudden movements around a paranoid patient?

Sudden actions may be interpreted as threats and trigger defensive behavior.

What is a useful goal of interviewing a psychotic or agitated patient?

Assess cognitive function and the patient's ability to communicate clearly.

What nonverbal details should be observed during the interview?

Appearance, dress, hygiene, posture, eye behavior, motor activity, and interaction with the environment.

What term does this chapter use for the syndrome also called agitated delirium or exhaustive mania?

Excited delirium.

What is delirium?

Impaired cognitive function that may present with disorientation, hallucinations, or delusions.

What is agitation?

Restless and irregular physical activity.

What findings are listed for excited/agitated delirium?

Hyperactive irrational behavior, vivid hallucinations, hypertension, tachycardia, diaphoresis, and dilated pupils.

Why is excited/agitated delirium a medical emergency?

The chapter warns that it can progress to sudden cardiopulmonary arrest and death.

What substances or conditions may contribute to severe agitation in this chapter?

Stimulant drugs, alcohol withdrawal, and other medical or psychiatric causes.

How should an EMT approach a patient with severe agitation if it is safe to do so?

Be calm, supportive, empathetic, slow, and purposeful while respecting personal space.

Should an agitated-delirium patient be left unattended?

No.

What should be minimized during care of a severely agitated patient?

Unnecessary physical contact and stimulation.

What should you assess during careful interviewing of an agitated patient?

Cognitive functioning and ability to communicate clearly.

What should you observe about an agitated patient's appearance?

Dress, hygiene, overall appearance, and behavior.

What should be done with medication bottles or illegal substances if overdose is suspected and they can be safely collected?

Take them to the medical facility for identification/evaluation.

What type of hospital does the chapter prefer when possible for an agitated behavioral patient?

A hospital with behavioral health facilities.

Does the chapter recommend lights and siren for routine transport of an agitated patient?

No; it recommends refraining from lights and siren when possible.

When should ALS be requested in persistent severe agitation?

When agitation continues and chemical restraint may need to be considered.