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Quick Chart
Introduction
  • Active behaviour causing concern with a history of a recent crisis, emotional trauma, bizarre or abrupt changes in behaviour, suicidal ideation, alcohol/drug intoxication, and toxic exposure. Organic causes of the abnormal behaviour, for example hypoxia and hypoglycaemia must be excluded or managed first.
  • ‘Agitated or Excited Delirium’, ‘Acute Behavioural Disturbance’ and ‘Drug Induced Psychosis’ are some alternative terms that might be used by other agencies to describe abnormal behaviours.
  • Read more on Abnormal Behaviour in the Medical Library >  Pathophysiology.
Clinical Presentation
  • Sedation or rapid tranquilisation is indicated if behaviour poses a threat to health and safety of themselves; any other person or to prevent serious damage to property.
Richmond Agitation Sedation Scale (RASS)
4 Severely agitated Overtly combative, Violent, Immediate Danger or Threat
3 Very agitated Aggressive behaviour, Unreasonable
2 Agitated Frequent, Excessively Anxious, Loud outbursts
1 Restless Mildly anxious, Non-Aggressive, Talkative
0 Alert & calm
-1 Drowsy Sustained awakening to voice (>10s)
-2 Light sedation Awakens briefly to voice with eye contact (<10s)
-3 Moderate sedation Movement or eye opening to voice. No eye contact
-4 Deep sedation Movement or eye opening response to physical stimulus
-5 Cannot be roused Unresponsive to voice or physical stimulus
Exclusion Criteria
Exclusion Criteria
Risk Assessment
  • Psychiatric patients may have an organic basis for behavioural disorders.
  • Be aware of personal safety at all times.
  • Only the police and Mental Health Transport Officers have legislated authority to apprehend persons in mental health circumstances (section 156 (1) Mental Health Act 2014). Patients transported under the Mental Health Act of 2014 must be in accordance with the Mental Health Transfer Clinical Practice Guideline and Interfacility Transfers procedure.
  • If the situation appears threatening, a show of force involving Police may be necessary before an attempt to restrain the patient is made. Consider your own safety and limitations. Use enough back-up to be confident and forthright.
  • If emergency treatment is unnecessary, do as little as possible except to reassure while transporting. Be very aware of the patient’s “personal space”.
  • Rarely, adrenal insufficiency patients may present with psychosis in acute crisis – history taking is important.
Warnings:
  • Persons who are physically restrained, particularly prone or in a position that amplifies the risk of positional asphyxia, must be closely observed for signs of air hunger and hypoxia.
  • Estimated patient weight must be agreed between the crew members before administration of any weight based medicines.
    This must be documented in ePCR.
Management
Primary Care
  • Primary Survey
    • Before approaching, ensure safety of self, crewmate(s), bystanders and patient.
    • If required, call for relevant assistance through the State Operations Centre, or urgent assistance (e.g. Police) via 000.
  • Attempt to establish rapport through de-escalation and appropriate questioning and non-confrontational technique. Be aware of body language.
  • Complete Vital Sign Survey, including BGL and Pulse Oximetry
    • Repeat vital signs every 10 minutes, or 5 minutes if time critical
  • Restrain only if essential to protect yourself and the patient using the minimum force necessary.
    • Restraint may be verbal and / or physical depending on the individual circumstances.
    • Section 243 of Criminal Code (7.4.2) states it is lawful for any person to use such force as is necessary in order to prevent a mentally impaired person from doing violence to any person or property.
  • If appropriate, enquire sensitively about possible depression, helpless or hopeless feelings and thoughts of suicide.
    • If patient expresses suicidal thoughts, do not leave patient alone.
    • Carefully remove (have someone carefully remove) dangerous objects (e.g. knives, guns, pills) from the area.
  • If appropriate, quietly question specifically about hallucinations or delusions and decide if patient is likely to act them out.
  • Monitoring, including SpO2 & nasal EtCO2 must be routinely applied post sedation if RASS score falls below zero.
  • Transport patients in the lateral position if the level of response reduces or is anticipated to do so, unless manual airway maintenance is necessary.
  • Sedated patients, if handcuffed, should be handcuffed to the front wherever practicable. Do not allow patients to be handcuffed the stretcher wherever possible. Clearly document reasons if this cannot be achieved.

Patients must not be transported prone

Intermediate Care (EMT / Level 2)
  • Consider and address organic causes for disturbed behaviour as soon as practicable (including but not limited to head injury, hypoxia, hypoglycaemia and overdose, e.g. administer Glucose Oral Gel as indicated for hypoglycaemia)
  • De-escalation techniques should always be adopted (some RASS 3~4 cases may still respond favourably)
  • Consider Secondary and/or CNS Survey.
  • Transport in a calm, quiet manner, monitor vital signs if you can without unduly agitating the patient.
  • Refer to Mental Health Transfer Guidelines for patients being transferred under the Mental Health Act 2014.
Advanced Care (AP)
  • Consider and address organic causes for disturbed behaviour as soon as practicable (including but not limited to head injury, hypoxia, hypoglycaemia and overdose)
  • De-escalation techniques should always be adopted (some RASS 3~4 cases may still respond favourably)
  • Consider Secondary and/or CNS Survey
  • Consider and agree whether sedation is indicated. Choice of agent requires sound judgement on a case basis and should normally align with a RASS score:
    Note: IM Midazolam is not indicated for sedation. It is only to be used IV for maintenance of sedation
  • If sedation is unnecessary, continue de-escalation and reassurance as necessary.
Sedation Choice DAAB
Critical & Extended Care (CCP, PSO)
  • As per Advanced Care (AP) guidelines
Additional Information
  • Police may be required to apprehend the patient or provide restraint in threatening situations.

References
References
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