Managing an agitated or aggressive patient is one of the countless difficult situations prehospital providers may find themselves in on any given shift. Oftentimes, verbal de-escalation tactics are enough to calm a patient to perform hands-on assessment and emergency treatment, but it is not uncommon—and becoming more common—for physical restraint and sedation to be medically indicated.

After several high-profile cases involving adverse events surrounding the use of sedation, attention has turned to agitated and aggressive patients and the ability to manage them in the prehospital setting. Several medical associations have published position statements, including National Association of EMS Physicians (NAEMSP) and the American College of Emergency Physiciansciting best practices for the management of these medically difficult and vulnerable patients. All position statements are clear: the goals of prehospital sedation are patient safety; facilitating rapid medical assessment, treatment and management; and protecting the public and responding providers.

As Leonie Calver and her co-authors noted in “Sedation assessment tool to score acute behavioral disturbances in the emergency department” (Emergency Medicine Australasia, 2011), an agency should have a patient-centred protocol that is overseen and approved by the medical director. The use of an agitation score in the initial assessment and reassessment of the patient has also been recommended. The Richmond Agitation Sedation Scale (RASS) has been the most common tool, rapidly adopted by many EMS agencies and charting programs, but its development and practice is in the assessment of ICU patients, and its utility in the EMS setting has not been studied.

The Sedation Assessment Tool score (SAT) is a more appropriate tool for the prehospital setting.

Agitated patients

Before exploring the appropriate use of sedation, it is important to understand what defines an “agitated patient” and the complexities of treating this patient population.

First, EMS providers must recognize that these are high-risk patients who require a thorough medical evaluation. Most definitions of an agitated patient cite psychomotor excitability, with the possibility of aggressive or violent behavior that may cause disruption of the patient’s ability to care.

In reality, patients present on a spectrum from mild irritability or anxiety to combative or even violent behavior. The causes of agitation remain broad and may include medical causes such as hypoglycemia, sepsis, seizures and postictal status, traumatic head injury, and spontaneous intracranial bleeding. Some of these can be evaluated and treated in the prehospital setting, but some and a number of other causes require urgent emergency department evaluation.

In short, these patients should be recognized and treated as “mentally altered” patients, and medical causes should be treated or ruled out promptly.

Concomitant psychiatric illness and drug toxicity further complicate patient management, but the suspected presence of these conditions does not exclude the obligation to evaluate other underlying medical causes.

sedation

Historically, agitated patients have been defined using a constellation of symptoms with pain intolerance, superhuman strength, rapid breathing, sweating, hyperthermia, and tachycardia. These patients were thought to have a syndrome labeled “excited delirium.” While it is appropriate to acknowledge the earlier, historical use of the syndrome known as excited delirium, recent medical and lay literature raises questions about the medical validity of the syndrome as a distinct diagnosis or entity. Medicine and the medical evaluation and treatment of patients is an ever-evolving science. It is imperative that we as prehospital medicine practitioners also update our knowledge, practice and skills. As such, we believe that the use of excited delirium as an independent syndrome or diagnosis should be retired from practice.

When patients are cared for in the prehospital setting, the primary goal is to assess immediate life-threatening conditions and treat reversible causes in the field, while protecting the patient from further medical decline and further physical harm from the primary condition. Protection of bystanders and crews is also a concurrent objective. To achieve this, sedation is often necessary.

The use of sedation must balance medical necessity and the principles of implied consent in a patient who lacks medical capacity with the patient’s dignity. Although the use of physical restraints plays a role, it should be recognized that physical restraints have the potential to be harmful.

EMS providers must also ensure that the use of sedation is a medically indicated procedure and is never intended to be punitive or simply to detain individuals.

The decision to use or not to use any form of physical restraint or sedation in prehospital medicine is made for medically indicated reasons, based on the judgment of health care providers who have appropriate training and supervision.