Chapter 31 & Chapter Goal Use assessment findings to form field impression & implement management plan for patients with behavioral or drug abuse emergencies Learning Objectives Distinguish between normal & abnormal behavior Discuss pathophysiology of behavioral emergencies Define active listening, anxiety, behavior, behavioral emergency, body language, confusion, depression, & overt behavior Discuss appropriate measures to ensure safety of patient, EMT-I, & others Identify techniques for physical assessment of patients with behavioral problems 1
Learning Objectives Describe therapeutic interviewing techniques for gathering information from patients with behavioral emergencies List factors that may indicate that patients are at increased risk for suicide Describe methods for managing patients with behavioral emergencies Describe circumstances in which relatives, bystanders, & others should be removed from scene Learning Objectives Describe medical-legal considerations for managing patients with behavioral emergencies List situations in which EMT-Is are expected to transport patients against their will Describe methods of restraint that may be necessary in managing patients with behavioral emergencies Identify 4 conditions that may mimic alcohol or substance abuse Learning Objectives Describe alcohol withdrawal syndrome Identify 5 major classes of abused drugs Describe care given to patients suspected of alcohol or drug abuse Formulate field impression based on assessment findings Develop patient management plan based on field impression 2
Definition: Behavioral emergency Situation where patients feels they have lost control of their lives Common misconceptions Abnormal behavior is always bizarre All mental patients are unstable & dangerous Mental disorders are incurable Having a mental disorder is cause for shame/embarrassment Causes Biological/organic Psychosocial Sociocultural Assessment Observe scene for unsafe situation Initial assessment Signs of violence, substance abuse, environmental conditions Isolate patient from others Stay alert ABCs rapid intervention Observe body language 3
Focused history & physical examination Approach slowly Avoid threatening actions, statement, questions Respect personal space Limit physical touch Remove patient from crisis Center questions around problem Establish rapport Evaluate potential for suicide Pay particular attention to: General appearance Motor activity Physical complaints Intellectual function Thought content Language Mood Management considerations Maintain scene & personal safety Establish rapport Speak in calm, even voice Show willingness to listen Be honest Describe everything you plan to do Avoid sudden moves Management considerations Unrestrained patient Have physical help nearby Allow patient to express emotions verbally Try to understand patient s feelings Avoid eye contact 4
Management considerations Situations with potential for violent behavior: Patient who is pacing Patient who appears to get angrier Patient who is starting to act out Patient who is bragging about being tough Anything domestic violence related Patient suspected of alcohol/drug ingestion Patient who complains about EMS system Legal issues Never jeopardize your safety Follow local laws/protocols Know your local facilities Patients transported against own will: They present threat to themselves or others Ordered by medical direction Enlist law enforcement Use restraints per local protocol Document Common field situations & behavioral problems Neurosis & psychosis Neurosis abnormal anxiety reaction to perceived fear Psychosis no concept of reality Person may present with dangerous behavior 5
Common field situations & behavioral problems Depression Signs & symptoms Unkempt appearance Unusual speech Frequent crying bouts Change in appetite Sleep disturbances Primary responsibility Provide safe, caring environment Arrange for local available resources for support Common field situations & behavioral problems Suicidal patients Gesture Something done to ask for help, rather than die Attempt Desire to die Be direct Common field situations & behavioral problems Suicidal patients Persons at increased risk Males Ages <19 or >45 Presence of depression/loneliness Previous attempts/psychiatric care Loss of rational thinking Separated, widowed, divorced Lack of support system Stated intent/organized plan Major life event 6
Alcohol abuse Patient assessment Odor of alcohol Unsteady gait Slurred, loud, inappropriate speech Nausea, vomiting Flushed face Altered LOC Abnormal behavior Hallucinations Hypotension Slow, labored respirations Marked dehydration Seizures Unconsciousness/coma Alcohol abuse Patient assessment Conditions that may mimic alcohol intoxication: Drug abuse Brain tumor Hypoglycemia Meningitis Head injury Stroke Postictal state DKA Hypoxia Alcohol abuse Emergency care Maintain airway; assist breathing if necessary Administer high-concentration O 2 Check blood glucose level Establish rapport Restrain follow local protocol Summon assistance Transport 7
Alcohol abuse Alcohol withdrawal syndromes Shakes Occur within 24 hrs Alcohol withdrawal seizures Within 24-48 hrs Delirium tremens 12-48 hrs Antabuse reaction O 2 Large bore IV Airway, cardiac monitor Transport Drug abuse Substances Ethical or illicit Drug misuse Antabuse Drug abuse Drug addiction Drug dependence Drug withdrawal Drugs of abuse Stimulants Depressants Hallucinogens Narcotics Volatile chemicals 8
Patient assessment Expect history to be unreliable Look, ask for pill bottles Assess suicidal tendency Expect mixed intoxication Expect violent behavior Ineffective treatments Emergency care Maintain airway, monitor closely, give O 2 Watch for vomiting; be prepared to suction Notify resources PCC Determine blood glucose level Consider 50% dextrose, naloxone Monitor ECG Initiate IV Monitor for shock Restrain follow local protocol Do not be judgmental Summary Behavioral emergencies involve situations where patients feel they have lost control of their lives they may or may not be violent Cardinal principle in dealing with behavioral emergencies try to build good rapport with patient Alcohol abuse includes medical, behavioral, or social problems related to alcohol consumption 9
Summary EMT-Is must always be alert to life-threatening conditions that mimic alcohol intoxication Abrupt cessation of alcohol can cause withdrawal symptoms Drug abuse is common problem 5 categories of drugs of abuse History in any drug abuse patient is usually unreliable Summary An attempt should be made to determine whether patient has tried to commit suicide Airway should be watched carefully in any patient who has ingested drugs Questions? 10