Transcript a01648-23-ppt 1236KB Jan 14 2015 08:21:45 AM

Copyright © 2004, Mosby Inc. All rights reserved.
Chapter 23
Behavioral Emergencies
Slide 1
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Case History
You arrive at the scene of a disturbance.
You find a 30-year-old male throwing
articles out the window of the house. He
is screaming that everyone is out to get
him and he tells you that he will not let
anyone touch him.
Slide 2
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Behavioral Emergency
Definition:
An occurrence in which the patient
exhibits abnormal behavior within a
given situation that is unacceptable or
intolerable to the patient, family, or
community
Slide 3
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Scope of the Problem
• Depression is often underemphasized in
EMS.
• Depression is present in at least 11% of
population in U.S.
• 20% of adults experience at least one
episode of clinical depression.
Slide 4
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Suicide –
Scope of the Problem
• 28,000 suicides each year
• Men >65 y/o have three times higher suicide
rate.
• Young person attempts suicide every 90
seconds.
• Successful suicide every 90 minutes
Slide 5
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Behavioral Change
• General factors that may alter a patient's
behavior
 Situational stresses
 Medical illnesses
 Psychiatric problems
 Alcohol or drugs
Slide 6
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Common Factors
• Low blood sugar
• Lack of oxygen
• Inadequate blood
flow to the brain
• Head trauma
Slide 7
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Common Factors
• Mind-altering substances
• Psychogenic – resulting in psychotic thinking,
depression, or panic
• Excessive cold
• Excessive heat
Slide 8
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Situational Reactions
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Panic
Agitation
Anger
Anxiety
Paranoia
Denial
Withdrawal
Slide 9
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Personality Disorders
• Definition: Character traits that interfere with a
person’s ability to function successfully in
work or personal relationships
• Patient can be manipulative and self-focused.
• Avoid getting angry with the patient.
• Be positive but establish limits.
Slide 10
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Depression and Suicide
• Symptoms of depression
 Loss of sleep, appetite, sex drive
 Sad, tearful
 Guilt
 Hopelessness
 Thoughts of death or taking one’s life
 Physical symptoms
Slide 11
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Suicide –
Assessment of Risk Factors
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Male
Individuals over 40
Single, widowed, or divorced
Socially isolated
Alcoholic, drug abuse
Recent diagnosis of serious illness
Recent loss of significant loved one
Slide 12
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Suicide –
Assessment of Risk Factors
• Previous history of self-destructive behavior
• Arrest, imprisonment, loss of job
• Lethal plan of action that has been verbalized
• Gathering of articles that can cause death
 Gun
 Large volumes of pills
Slide 13
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Suicide –
Assessment Findings
• Patient in an unsafe environment?
• With unsafe objects in hands?
• Displaying self-destructive behavior?
Slide 14
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Suicide – Important Questions
• How does the patient feel?
• Suicidal tendencies in the past?
 If so, what interventions have occurred?
• Is patient a threat to self or others?
• Is there a medical problem?
Slide 15
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Emergency Medical Care
• Perform scene size-up.
• Personal safety is a priority.
• Conduct patient assessment.
• Calm the patient.
• Do not leave patient alone.
Slide 16
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Emergency Medical Care
• Restrain, if necessary.
• Consider need for law
enforcement.
• Transport.
• If overdose, bring
medications or drugs.
Slide 17
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Psychosis
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Disordered thoughts
Disordered perceptions of reality
Hallucinations
Inappropriate responses to environment
Possible communication difficulty
 Speaks incoherently
 Out of control
 May need to obtain history from others
Slide 18
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Organic Brain Syndrome
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Medically caused brain syndrome
Disordered thoughts
Disorientation
Delirium
Hallucinations
Numerous causes
 Tumor
 Trauma
 Infection
Slide 19
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Scene Size-up
• Most important aspect of assessment
• Can present a serious threat to EMT safety
• Try to identify potential causes of presenting
problem.
 Aggressive or bizarre behavior
 Open bottles of medications, syringes, track marks
Slide 20
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Scene Safety
• Be aware of potential dangers
• If notified of a violent patient, wait for police
before entering scene.
• First priority is prevention of further injuries.
• Environmental dangers may exist.
 Gas exhaust
 Carbon monoxide
Slide 21
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Violent Behavior
• Recognizing impending violence is vital.
• Do not put yourself in jeopardy.
 Assess what can be done to avoid
outburst.
 Leave yourself an escape route.
Slide 22
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Signs of a
Potentially Violent Patient
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Angry voice
Pressured speech
Pacing
Expressions of violence
Psychiatric history of emotional disturbance
Drug intoxication
Situational frustration
Threatening posture or movements
Presence of heavy or threatening objects
Slide 23
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Principles for Assessing
Behavioral Emergency
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Identify yourself.
Let the person know you are there to help.
Inform the patient of what you are doing.
Ask questions in a calm, reassuring voice .
Allow the patient to tell what happened.
Do not be judgmental.
Slide 24
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Principles of Assessing
Behavioral Emergency
• Rephrase or repeat to confirm
communication.
• Acknowledge the patient’s feelings.
• Assess the patient's mental status.
 Appearance
 Activity
 Speech
 Orientation for time, person, and place
Slide 25
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Assessment of
Potential Violence
• Scene size-up
• History
 Check with family and bystanders.
 Known history of aggression or combativeness?
• Posture
 Stands or sits in a position which threatens self or
others
 Fists clinched or lethal objects in hands
Slide 26
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Assessment of
Potential Violence
• Vocal activity
 Yells or verbally threatens harm to self or others
• Physical activity
 Moves toward caregiver
 Carries heavy or threatening objects
 Has quick, irregular movements
 Tenses muscles
Slide 27
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Methods to Calm Behavioral
Emergency Patients
• Acknowledge that the person seems upset.
• Restate that you are there to help.
• Inform the patient of what you are doing.
• Ask questions in a calm, reassuring voice.
• Maintain a comfortable distance.
• Encourage the patient to state what is troubling him.
Slide 28
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Methods to Calm Behavioral
Emergency Patients
• Do not make quick moves.
• Respond honestly to patient's questions.
• Do not threaten, challenge, or argue.
• Tell the truth.
• Do not “play along” with visual or auditory disturbances.
Slide 29
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Methods to Calm Behavioral
Emergency Patients
• Involve trusted family members or friends.
• Be prepared to stay at scene for a long time.
• Always remain with the patient.
• Avoid unnecessary physical contact.
• Call additional help, if needed.
•
Maintain good eye contact.
Slide 30
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Medicolegal Considerations
• Management of emotionally or mentally disturbed patient
presents high legal risk.
• When emotionally disturbed patients consent to care,
legal problems are greatly reduced.
• Patient will often resist treatment.
• Patient may threaten EMT-Basics and others.
• To provide care against patient's will, you must show a
reasonable belief patient would harm self or others.
Slide 31
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If Patient Resists Treatment
• If a threat to self or others,
may be transported without
consent.
 Contact medical direction.
• Law enforcement is usually
required.
Slide 32
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Reasonable Force
Definition:
Action necessary to
keep patient from
injuring self or others
Slide 33
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Determining
Reasonable Force
• Patient’s size and strength
• Type of abnormal behavior
• Sex of patient
• Mental state of patient
• Method of restraint
Slide 34
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Using Force
• Calm patients may cause unexpected and
sudden injury to self and others.
• EMS personnel may use reasonable force to
defend against an attack.
• Avoid acts or physical force that may cause
injury to the patient.
Slide 35
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Police and Medical Direction
• Seek medical direction
when considering
restraining a patient.
• Ask for police assistance,
if during scene size-up the
patient appears or acts
aggressive or combative.
Slide 36
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Accusations
• Protection against false accusations
 Documentation of abnormal behavior important
 Witnesses in attendance, especially during
transport
• Accusations of sexual misconduct are
common.
 Same-sex attendants and third-party
witnesses can prove beneficial.
Slide 37
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Restraining Patients
• Avoid restraints, if possible.
• Use only when patient is a danger to self or
others.
• Have police present.
• Get approval from medical direction.
Slide 38
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Restraining Patients
• Be sure to have adequate help.
• Plan your activities.
• Use only the force necessary for restraint.
• Estimate range of motion of patient’s arms
and legs.
Slide 39
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Restraint Technique
• Act quickly.
• Have one EMT-Basic talk
to patient.
• Approach with four
persons.
 One assigned to each limb,
all at the same time
Slide 40
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Restraint Technique
• Secure limbs
together with
equipment approved
by medical direction.
• Turn patient face up
on stretcher.
Slide 41
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Restraint Technique
• Secure patient to
stretcher with
multiple straps.
• Cover patient’s face
with surgical mask if
spitting.
Slide 42
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Restraining Technique
• Reassess circulation
frequently.
• Document indication for
restraining patient and
technique of restraint.
• Avoid unnecessary
force.
Slide 43
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Other Behavioral Problems –
General Principles
• Always try to talk patient into cooperating.
• Do not belittle or threaten patients.
• Be calm and tolerant in your attitude.
• Do not agree with disturbed thinking.
• Be reassuring.
Slide 44
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Other Behavioral Problems –
General Principles
• Avoid arguing with irrational patients.
• Suggest appropriate steps to take.
• Lower distressing stimuli.
• Avoid restraints unless necessary.
• Treat with respect.
Slide 45
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