- This CPG is not intended to cover scenarios secondary to organic causes or to seek compliance with treatment of such. The primary strategy must be to address the underlying cause. This extends to circumstances such as CVA, trauma and post-resuscitation care. Consider SOC CSP consult.
- 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.
- ‘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.
Administration of injectable sedatives under this CPG is limited to those with authority to practice per the Medications Schedule
Applying a RASS score for the purposes of sedation should occur after meaningful de-escalation efforts
| 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 |
- Address organic causes for behavioural presentations at all times- eg. CVA, TBI, Hypoxia, Hypoglycaemia, etc.
- Rarely, adrenal insufficiency patients may present with psychosis in acute crisis – history taking is important
- 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 (sedation) is unnecessary, do as little as possible except to reassure while transporting. Be very aware of the patient’s “personal space”
- Sedation is HIGH RISK – must only be carried out after careful deliberation between officers and must not be based primarily at the request or influence of other agencies on scene (e.g. Police etc.)
- Positive RASS score does not automatically infer a need to sedate
- Age <16 years old – sedation should prompt a prior ASMA consult wherever practicable
- ETOH / Intoxication – apply caution
- Repeat & Maintenance doses – have a low threshold to consult with ASMA where repeat or maintenance doses are required
- Monitoring – SpO2 and EtCO2 monitoring must be applied whenever level of consciousness drops (~RASS -2 or below)
- Positioning – DO NOT transport in supine position (increases risk of laryngospasm from secretions) – transport in lateral position
- Airway & Breathing – monitor airway and breathing effort, including chest movement closely for signs of impairment. Prepare to support if required
- Restraint – Prone and/or handcuffed to rear carries excessive risk and MUST NOT occur. Physical restraint in any position that amplifies the risk of positional asphyxia, must be closely observed for signs of air hunger and hypoxia
- RASS scores must be agreed and documented
- Weight – Estimated weight must be agreed before administration of any weight based medicines. This must be documented
The final decision to sedate lies with the most senior clinician on scene
The guiding principle is that non-pharmacological techniques are first line and always preferable. If sedative medications are considered necessary, the most cautious approach should always be adopted.
- 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.
- De-escalation techniques should always be adopted (some RASS 3~4 cases may still respond favourably)
- Complete Vital Sign Survey, including BSL and Pulse Oximetry where safe to do so
- 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 and transport principles as per Warnings above
- Do not allow patients to be handcuffed to the stretcher. Clearly document reasons if this cannot be achieved and the service number of the Police Officer.
- Consider additional support via SOC CSP and/or ASMA consult
Patients must never be transported prone
- 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.
- Consider and address organic causes for disturbed behaviour as soon as practicable (including but not limited to TBI, hypoxia, hypoglycaemia and overdose)
- De-escalation techniques should always be adopted as a first line (some RASS 3~4 cases may still respond favourably)
- Consider Secondary and/or CNS Survey
- Consider and agree whether sedation is appropriate and necessary. Have a high threshold (i.e. sedation should not be routine)
- Choice of agent requires sound judgement on a case basis and should normally align with a post de-escalation RASS score:
Note: IM Midazolam is not indicated for primary sedation. It is only to be used IV for maintenance of sedation - If sedation is agreed as unnecessary, continue de-escalation and reassurance as necessary.
- As per Advanced Care guidelines
- Police may be required to apprehend the patient or provide restraint in threatening situations.
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