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Questions and Answers
What is a possible cause of agitation in patients that Fire Rescue may be called to manage?
What is a possible cause of agitation in patients that Fire Rescue may be called to manage?
Which of the following substances is NOT associated with agitation in patients?
Which of the following substances is NOT associated with agitation in patients?
What is an important consideration when managing the care of agitated patients?
What is an important consideration when managing the care of agitated patients?
Which of the following behaviors is NOT typically associated with agitated patients?
Which of the following behaviors is NOT typically associated with agitated patients?
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What is a possible underlying condition that may contribute to agitation in patients?
What is a possible underlying condition that may contribute to agitation in patients?
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Which of the following behaviors is most likely to be exhibited by a patient with Excited Delirium Syndrome?
Which of the following behaviors is most likely to be exhibited by a patient with Excited Delirium Syndrome?
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A patient with Excited Delirium Syndrome is likely to be attracted to which of the following?
A patient with Excited Delirium Syndrome is likely to be attracted to which of the following?
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Which of the following physical characteristics is commonly observed in patients with Excited Delirium Syndrome?
Which of the following physical characteristics is commonly observed in patients with Excited Delirium Syndrome?
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A patient with Excited Delirium Syndrome may exhibit which of the following unusual physical abilities?
A patient with Excited Delirium Syndrome may exhibit which of the following unusual physical abilities?
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Which of the following is a common finding in patients with Excited Delirium Syndrome?
Which of the following is a common finding in patients with Excited Delirium Syndrome?
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What is the primary purpose of law enforcement agencies using a TASER?
What is the primary purpose of law enforcement agencies using a TASER?
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Why is it important to evaluate a patient for excited delirium syndrome after being TASERed?
Why is it important to evaluate a patient for excited delirium syndrome after being TASERed?
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What is a characteristic of patients with excited delirium syndrome after being TASERed?
What is a characteristic of patients with excited delirium syndrome after being TASERed?
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What should be a primary concern when approaching a patient who has been TASERed?
What should be a primary concern when approaching a patient who has been TASERed?
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What is the primary goal of using a TASER in a law enforcement setting?
What is the primary goal of using a TASER in a law enforcement setting?
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What is the primary reason for securing the scene when managing an agitated patient?
What is the primary reason for securing the scene when managing an agitated patient?
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When attempting to calm an agitated patient, what should be avoided?
When attempting to calm an agitated patient, what should be avoided?
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What is the key benefit of having enough personnel on the scene when managing an agitated patient?
What is the key benefit of having enough personnel on the scene when managing an agitated patient?
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Why is it essential to use universal precautions when managing an agitated patient?
Why is it essential to use universal precautions when managing an agitated patient?
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What is the primary goal of attempting to calm an agitated patient?
What is the primary goal of attempting to calm an agitated patient?
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What is the recommended position for a patient when using physical restraints?
What is the recommended position for a patient when using physical restraints?
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What is the maximum dose of ketamine that can be administered IM for chemical restraint?
What is the maximum dose of ketamine that can be administered IM for chemical restraint?
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In which location should ketamine NOT be administered for chemical restraint?
In which location should ketamine NOT be administered for chemical restraint?
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What is the primary reason for using multiple providers or police present when restraining a patient?
What is the primary reason for using multiple providers or police present when restraining a patient?
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What is the main consideration when deciding to use restraints on a patient?
What is the main consideration when deciding to use restraints on a patient?
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What medication should be administered IV slowly over 1 minute if the patient becomes agitated or aggressive as the effects of the ketamine are starting to wear off and vascular access is available?
What medication should be administered IV slowly over 1 minute if the patient becomes agitated or aggressive as the effects of the ketamine are starting to wear off and vascular access is available?
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If the patient becomes agitated or aggressive as the effects of the ketamine are starting to wear off and vascular access is NOT available, what is the correct dose of midazolam to administer IM?
If the patient becomes agitated or aggressive as the effects of the ketamine are starting to wear off and vascular access is NOT available, what is the correct dose of midazolam to administer IM?
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How soon can both medications be repeated if indicated?
How soon can both medications be repeated if indicated?
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What is the alternative medication to administer IV if the patient becomes agitated or aggressive as the effects of the ketamine are starting to wear off and vascular access is available?
What is the alternative medication to administer IV if the patient becomes agitated or aggressive as the effects of the ketamine are starting to wear off and vascular access is available?
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What is the correct route of administration for midazolam if the patient becomes agitated or aggressive as the effects of the ketamine are starting to wear off and vascular access is NOT available?
What is the correct route of administration for midazolam if the patient becomes agitated or aggressive as the effects of the ketamine are starting to wear off and vascular access is NOT available?
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What is the initial step in assessing an adult patient?
What is the initial step in assessing an adult patient?
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When is administration of dextrose 50% (D50W) indicated?
When is administration of dextrose 50% (D50W) indicated?
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What is the primary focus of the Universal Initial Adult Patient Assessment?
What is the primary focus of the Universal Initial Adult Patient Assessment?
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Why is obtaining a blood glucose level important in the initial assessment of an adult patient?
Why is obtaining a blood glucose level important in the initial assessment of an adult patient?
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What is the first step in managing an agitated patient?
What is the first step in managing an agitated patient?
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What should be monitored in addition to cardiac rhythm and ETCO2?
What should be monitored in addition to cardiac rhythm and ETCO2?
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What is the primary indication for administering sodium bicarbonate in an agitated patient?
What is the primary indication for administering sodium bicarbonate in an agitated patient?
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What is the primary purpose of treating any medical complaint per protocol?
What is the primary purpose of treating any medical complaint per protocol?
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Why should supplemental oxygen be administered if indicated?
Why should supplemental oxygen be administered if indicated?
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What is the dose of sodium bicarbonate when considering its administration in an agitated patient?
What is the dose of sodium bicarbonate when considering its administration in an agitated patient?
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What is the priority action when managing an agitated patient with a temperature of 104°F (40°C) or higher?
What is the priority action when managing an agitated patient with a temperature of 104°F (40°C) or higher?
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What is the maximum dose of morphine sulfate that can be administered to an agitated patient?
What is the maximum dose of morphine sulfate that can be administered to an agitated patient?
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What is the temperature of the normal saline to be administered to an agitated patient?
What is the temperature of the normal saline to be administered to an agitated patient?
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What is the dosage of midazolam to be administered to an agitated patient who is shivering?
What is the dosage of midazolam to be administered to an agitated patient who is shivering?
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What is the volume of cold normal saline to be administered to an agitated patient?
What is the volume of cold normal saline to be administered to an agitated patient?
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When should the temperature of the agitated patient be rechecked?
When should the temperature of the agitated patient be rechecked?
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Study Notes
Agitated Patients
- Agitated patients may present with verbally and/or physically threatening behavior, and may be restless, crying, confused, and appear out of control.
Causes of Agitation
- Agitated behavior may be related to mental illness.
- Agitation may be caused by drug use, particularly stimulants such as cocaine.
- Alcohol withdrawal may contribute to agitation.
- Head trauma may also contribute to agitation.
Excited Delirium Syndrome
- Agitated patients may be experiencing excited delirium syndrome.
- It is important to evaluate agitated patients for possible excited delirium syndrome when managing their care.
Characteristics of Excited Delirium Syndrome
- Patients may exhibit extremely aggressive or violent behavior.
- They may display constant physical activity, appearing restless.
- Individuals may be unresponsive to the presence of authorities, such as police or firefighters.
- They may be attracted to bright lights, loud sounds, and their own reflections in glass or mirrors.
- Patients may be naked or near naked.
- Rapid breathing is a common symptom.
- Profuse sweating is a characteristic of the syndrome.
- Individuals may show little response to pain.
- They may exhibit superhuman strength.
- Patients may feel hot to the touch.
TASER Use in Law Enforcement
- Law enforcement agencies use TASER as a non-lethal method to temporarily incapacitate individuals who exhibit threatening behavior.
Medical Considerations for TASERed Patients
- When approaching a patient who has been TASERed, evaluate them for possible excited delirium syndrome.
- Patients with excited delirium syndrome typically continue to be agitated again after being TASERed.
Treatment Approach
- Ensure adequate personnel are present to handle the situation and physically manage the patient if necessary.
- Secure the scene and implement universal precautions to maintain safety.
- Calm the patient by speaking softly and non-threateningly, avoiding loud noises and sudden movements.
Restraint Methods
- Use the least restrictive method of restraint to ensure patient safety and well-being.
- Prioritize provider safety when dealing with a patient exhibiting inappropriate behavior.
- Allow patients to correct their behavior, if possible, before using restraints.
Restraint Techniques
- Use restraints only when unable to calm the patient and they pose a threat to themselves or others.
- Avoid placing the patient in a prone position (face down) when using restraints.
- Use a supine or recovery position instead.
Chemical Restraint
- Administer ketamine (4 mg/kg IM, maximum dose 400 mg) if chemical restraint is necessary.
- Ketamine can be administered in the mid-shaft anterolateral aspect of the thigh or the lateral deltoid muscle of the shoulder.
- Ketamine can be administered through clothing if necessary.
Managing Agitation or Aggression
- If patient becomes agitated or aggressive as ketamine effects wear off, or if ketamine is not available, alternative medications can be used.
Options for Vascular Access
- If vascular access is available:
- Administer lorazepam (Ativan) 2mg IV slowly over 1 minute
- Administer midazolam (Versed) 5mg IV
Options for No Vascular Access
- If vascular access is NOT available:
- Administer lorazepam (Ativan) 2mg IM
- Administer midazolam (Versed) 10mg IM or IntraNasal
Repeating Medication
- Both medications may be repeated in 3-5 minutes if indicated.
Monitoring and Treatment
- Monitor patient's cardiac rhythm, ETCO2, and SpO2 during treatment.
- Administer supplemental O2 if indicated by the patient's condition.
- Treat any medical complaints according to the appropriate protocol(s).
- Identify disrhythmias indicative of metabolic acidosis, such as a wide QRS and/or loss of P waves.
- Consider administering sodium bicarbonate, 1 mEq/kg IV/IO, if disrhythmias indicative of metabolic acidosis are present.
Agitated Patients and Excited Delirium Syndrome
- Agitated patients may be experiencing excited delirium syndrome, exhibiting verbally and/or physically threatening behavior, restlessness, confusion, and appearing out of control.
- Possible causes of agitated condition include mental illness, drug use (especially stimulants like cocaine), alcohol withdrawal, and head trauma.
Identifying Excited Delirium Syndrome
- Patients with excited delirium syndrome may demonstrate:
- Extremely aggressive or violent behavior
- Constant physical activity and restlessness
- Unresponsiveness to police/fire presence
- Attraction to bright lights, loud sounds, and their own reflections
- Naked or near-naked state
- Rapid breathing
- Profuse sweating
- Little response to pain
- Superhuman strength
- Hot to the touch
Treatment
- Ensure sufficient personnel on the scene to handle the situation and physically manage the patient if necessary.
- Secure the scene and use universal precautions.
- Attempt to calm the patient down using soft speech and non-threatening movements.
- Use the least restrictive method of restraint, prioritizing provider safety.
- If restraint is necessary, use a supine or recovery position, and avoid prone (face down) positioning.
Chemical Restraint
- Administer ketamine, 4 mg/kg IM (maximum dose 400 mg), if chemical restraint is indicated and available.
- Ketamine can be administered through clothing in the mid-shaft anteriolateral aspect of the thigh or the lateral deltoid muscle of the shoulder.
Alternative Medications
- If ketamine is not available or the patient becomes agitated as its effects wear off:
- If vascular access is available:
- Administer lorazepam (Ativan), 2 mg IV slowly over 1 minute
- OR administer midazolam (Versed), 5 mg IV
- If vascular access is not available:
- Administer lorazepam (Ativan), 2 mg IM
- OR administer midazolam (Versed), 10 mg IM / IntraNasal
- If vascular access is available:
- Repeat medications in 3-5 minutes if indicated.
Additional Care
- Perform Universal Initial Adult Patient Assessment / Care.
- Ensure a maintainable airway.
- Obtain a blood glucose level and treat with dextrose 50% (D50W) if indicated.
- Monitor cardiac rhythm, ETCO2, and SpO2, and give supplemental O2 if indicated.
- Treat any medical complaint per the appropriate protocol(s).
- Consider giving sodium bicarbonate, 1 mEq/kg IV/IO, if the patient exhibits disrhythmias indicative of metabolic acidosis.
Managing Agitated Patients with Excited Delirium
- If a patient is exhibiting signs of excited delirium and has a fever (temperature ≥ 104°F/40°C or feels hot to the touch), attempt to cool them down.
Cooling Measures
- Remove as much clothing as possible.
- Move the patient to a cooler environment or use a fan to blow on them.
- Apply ice packs to the neck, axillae, and groin areas if available.
Temperature Monitoring
- Take and document a baseline temperature before administering cold normal saline.
- Take and document a temperature at the time of patient transfer in the ED.
Medication Administration
- Establish vascular access and administer cold (34°F) normal saline, 30 mL/kg IV/IO (maximum 2 Liters).
- If Ativan or Versed have not been given, and the patient is shivering, administer midazolam (Versed), 5 mg IV/IO or 10 mg IM/IntraNasal.
- If the patient is agitated and/or in pain after midazolam, and systolic BP remains ≥ 90 mmHg, administer morphine sulfate, 5 mg IV/IO/IM.
- Morphine may be repeated every 5 minutes as needed, up to a maximum of 20 mg.
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Description
This quiz covers the various factors that contribute to agitation in patients, including mental illness, drug use, and physical trauma. Understand the signs and symptoms of agitation and how to identify the underlying causes.
