Neuro & Behavior

Brain & Nerve Emergencies

Seizure Emergencies

Overview

A seizure is a temporary disturbance in neurologic function caused by abnormal, excessive, or synchronized electrical activity within the brain. Seizures may occur as part of epilepsy, in which a person has a predisposition to recurrent unprovoked seizures, or they may occur because of another medical problem such as drug exposure, fever, trauma, metabolic abnormalities, or other neurologic conditions.

Epileptic seizures result from abnormal electrical activity in the brain. Other seizure-like events may occur from non-epileptic causes and can sometimes resemble true seizures in their outward appearance.

Seizure Pathophysiology and Frequency

Normal brain function depends on a balance between electrical excitation and inhibition. During a seizure, this balance becomes disrupted, allowing groups of neurons to fire abnormally and excessively.

The specific symptoms experienced by the patient depend on which areas of the brain are involved. Abnormal electrical activity may affect consciousness, movement, sensation, behavior, emotions, or autonomic functions.

Epilepsy affects a significant portion of the population worldwide, and many individuals will experience at least one seizure during their lifetime.

Major Types of Seizures

Seizures are commonly classified according to where abnormal electrical activity begins. The primary categories include generalized-onset, focal-onset, and unknown-onset seizures.

Generalized-onset seizures involve networks on both sides of the brain from the beginning of the seizure. They may have motor or non-motor manifestations. Motor seizures may involve stiffening, rhythmic jerking, or both, as seen with generalized tonic-clonic seizures. Non-motor generalized seizures include absence seizures, which may present with brief staring episodes, subtle muscle movements, or eyelid fluttering.

Focal-onset seizures begin in one area or network of the brain. Symptoms vary according to the affected region. Motor findings can include repetitive movements, muscle contractions, or spasms. Non-motor findings may involve sensory changes, altered emotions, unusual sensations, or changes in awareness. Some focal seizures can spread to involve both sides of the brain and develop into a bilateral tonic-clonic seizure.

Unknown-onset seizures are seizures in which the beginning of the event cannot be clearly determined. The patient may demonstrate features similar to focal or generalized seizures, but available information is insufficient to establish where the seizure began.

Common Prehospital Causes of Seizures

Seizures encountered by EMS may develop from several different causes.

Epilepsy: Patients with epilepsy have a neurologic disorder that predisposes them to recurrent seizures.

Traumatic brain injury: Damage to the brain may disrupt normal neuronal activity and trigger seizure activity.

Chemical or toxic causes: Recreational drugs, medication toxicity, withdrawal from certain substances, and exposure to toxins may produce seizures.

Pregnancy and eclampsia: A seizure occurring during pregnancy or the postpartum period may be associated with eclampsia, particularly when accompanied by hypertension or other findings suggestive of preeclampsia.

Other possible causes include hypoglycemia, hypoxia, stroke, infection, fever, electrolyte disturbances, and other metabolic or neurologic abnormalities.

Prehospital Management of Seizures

Immediate BLS Care

ALS Management

When permitted by local protocol and provider scope:

Medication doses and routes should always follow the EMS agency’s current protocol and medical direction.

Special Consideration: Eclampsia

When seizure activity is suspected to be related to eclampsia, magnesium sulfate is generally considered the preferred anticonvulsant treatment. EMS providers should follow their local obstetric emergency protocol and contact medical control when required.

Transport Considerations

Patients experiencing a first-time seizure generally require emergency department evaluation to determine the underlying cause.

Following termination of seizure activity, transport priority should be based on the patient’s condition, suspected cause, medical history, recovery, and local EMS protocols.

Rapid transport and advanced treatment are especially important when the patient has:

A patient with a known seizure disorder who has experienced a typical seizure and returns completely to their normal baseline may occasionally meet local criteria for non-transport or refusal. Any such decision should follow local EMS policies, assessment requirements, medical-control guidance, and informed-refusal procedures.

Stroke and Transient Ischemic Attack Emergencies

Overview

A stroke occurs when blood flow to part of the brain is interrupted, depriving brain tissue of oxygen and nutrients. The two primary types of stroke are ischemic stroke and hemorrhagic stroke. Both are serious neurologic emergencies that can result in permanent disability or death if blood flow or oxygen delivery to the brain is not restored or managed promptly.

Ischemic Stroke: An ischemic stroke occurs when a blood clot blocks an artery supplying the brain. As blood flow decreases, affected brain cells receive inadequate oxygen and nutrients and may begin to die. Ischemic strokes may be classified as thrombotic or embolic. A thrombotic stroke occurs when a clot develops within a blood vessel supplying the brain, while an embolic stroke occurs when a clot or other material forms elsewhere in the body, travels through the bloodstream, and becomes lodged in a cerebral artery. Ischemic strokes account for the majority of stroke cases.

Hemorrhagic Stroke: A hemorrhagic stroke develops when a blood vessel in or around the brain ruptures and causes bleeding. The affected area may lose an adequate blood supply, while the accumulating blood can also increase intracranial pressure (ICP) and compress surrounding brain tissue. This combination can produce additional neurologic damage and potentially life-threatening deterioration.

Prehospital Stroke Recognition

Stroke patients may initially present with altered mental status, weakness, speech difficulty, or other sudden neurologic changes. Recognizing the onset of these findings is especially important because many stroke treatments are time-sensitive.

Common signs and symptoms may include:

EMS providers use standardized stroke-screening tools to identify patients who may be experiencing an acute stroke. One commonly used assessment is the Cincinnati Prehospital Stroke Scale (CPSS).

The CPSS evaluates three major findings:

An abnormal finding in any of these areas may increase suspicion for an acute stroke and should prompt further evaluation according to local EMS protocols.

Some EMS systems use expanded stroke-screening tools that also evaluate mental status, balance, vision, coordination, or findings associated with a possible large-vessel occlusion. Providers should also consider other conditions that can imitate a stroke, including hypoglycemia, seizures, intoxication, head injury, and other causes of altered mental status.

Determining the patient’s last known well time is a critical part of the assessment. This refers to the last time the patient was known to be neurologically normal and helps the receiving stroke team determine which treatments may be appropriate.

If a patient has a positive prehospital stroke screen, EMS providers may perform an additional evaluation using the Cincinnati Stroke Triage Assessment Tool (C-STAT).

C-STAT is designed to help identify patients who may have a large vessel occlusion (LVO), which is a blockage involving one of the major arteries supplying the brain.

A positive C-STAT result increases concern for a possible LVO. When local protocols and transport conditions allow, these patients may benefit from transport to an appropriate stroke center capable of performing mechanical thrombectomy.

Mechanical thrombectomy is a procedure used to physically remove certain large clots from cerebral arteries. Because treatment for an LVO is highly time-sensitive, rapid recognition, early hospital notification, and appropriate destination selection are important parts of prehospital stroke care.

Prehospital Stroke Management

Begin with scene safety and an initial scene size-up, followed by a rapid primary assessment. Evaluate the patient’s airway, breathing, circulation, and overall responsiveness while identifying any immediate life threats.

Because patients experiencing a stroke may present with altered mental status or neurologic deficits, perform a focused neurologic evaluation without unnecessary delay. Stroke care is highly time-sensitive, since prolonged interruption of cerebral blood flow can result in increasing brain injury.

If stroke is suspected, promptly perform an appropriate prehospital stroke screening assessment and evaluate for focal neurologic deficits.

Important assessments should include:

While evaluating the patient, also consider other conditions that may imitate or contribute to stroke-like symptoms, including trauma, infection or sepsis, seizures, hypoglycemia, intoxication, medication effects, or poisoning.

Definitive treatment for an acute stroke occurs at the hospital. EMS providers cannot reverse most strokes in the field, making rapid recognition, appropriate destination selection, early notification, and efficient transport major priorities.

The receiving facility should be chosen according to the patient’s stroke assessment and local EMS destination protocols. Some hospitals may be capable of treating uncomplicated strokes but may not have the resources to manage suspected large vessel occlusions requiring mechanical thrombectomy. EMS providers should therefore understand the stroke capabilities of hospitals within their service area.

When ALS care is available and permitted by protocol, establish IV access when it can be accomplished without delaying transport. A suitable IV may assist the receiving hospital with medication administration, diagnostic testing, or contrast-enhanced imaging such as CT angiography.

Throughout transport, continue reassessing the patient’s airway, breathing, circulation, neurologic status, vital signs, and level of consciousness, while notifying the receiving stroke center as early as possible.

Cranial Nerves: Functions and Prehospital Assessment

Overview of Cranial Nerve Anatomy and Physiology

The human body has 12 pairs of cranial nerves that arise primarily from the brain and brainstem. Cranial nerves may be classified as sensory, motor, or mixed nerves.

Sensory, or afferent, nerves carry information from sensory receptors toward the central nervous system (CNS). Motor, or efferent, nerves transmit impulses from the brain and CNS to muscles and other structures, producing movement and other responses. Mixed nerves contain both sensory and motor fibers.

I: Olfactory Nerve — Sensory

The olfactory nerve is responsible for the sense of smell. It receives information from odor molecules detected within the nasal cavity and transmits those signals to the olfactory bulb for processing.

II: Optic Nerve — Sensory

The optic nerve carries visual information from the retina toward the brain. Fibers from each optic nerve meet at the optic chiasm, where some of the fibers cross to the opposite side before continuing toward the visual centers of the brain.

III: Oculomotor Nerve — Motor

The oculomotor nerve controls most movements of the eye. It also participates in pupil constriction and helps regulate the pupillary response to light.

IV: Trochlear Nerve — Motor

The trochlear nerve controls the superior oblique muscle of the eye. This muscle contributes to downward and inward eye movement and helps coordinate normal eye positioning.

V: Trigeminal Nerve — Mixed

The trigeminal nerve is the largest cranial nerve and has both sensory and motor functions. It is divided into three major branches:

VI: Abducens Nerve — Motor

The abducens nerve controls the lateral rectus muscle, allowing the eye to move outward, away from the midline.

VII: Facial Nerve — Mixed

The facial nerve performs both sensory and motor functions. It contributes to facial expressions, carries taste sensation from part of the tongue, and helps control tear and salivary gland activity.

VIII: Vestibulocochlear Nerve — Sensory

The vestibulocochlear nerve has two major divisions.

The vestibular division receives sensory information related to balance, head position, and spatial orientation.

The cochlear division carries auditory information from the inner ear and is responsible for detecting sound and pitch.

IX: Glossopharyngeal Nerve — Mixed

The glossopharyngeal nerve has both sensory and motor functions. It contributes to swallowing, taste sensation from part of the tongue, and the gag reflex.

X: Vagus Nerve — Mixed

The vagus nerve is the longest cranial nerve and extends from the brainstem into the chest and abdomen. It provides an important portion of the body’s parasympathetic nervous system and influences organs such as the heart, lungs, and digestive tract.

XI: Spinal Accessory Nerve — Motor

The spinal accessory nerve controls muscles involved in movement of the head, neck, and shoulders. It is particularly associated with shoulder elevation and head rotation.

XII: Hypoglossal Nerve — Motor

The hypoglossal nerve controls movement of the tongue and plays an important role in speech and swallowing.

Prehospital Cranial Nerve Evaluation

A focused cranial nerve assessment can provide valuable information when evaluating patients with suspected neurologic injury, minor head trauma, or subtle neurologic changes.

In patients with obvious severe head trauma or a major stroke, the presence of neurologic injury may already be apparent. Cranial nerve testing can be especially useful in less obvious situations, such as a patient who sustained a minor fall or reports subtle symptoms without dramatic findings.

A cranial nerve examination can help EMS providers identify abnormalities, monitor changes, and better communicate neurologic findings to receiving healthcare personnel.

Pupillary Response

Use a penlight to assess the pupils for size, equality, and response to light. Pupillary abnormalities may indicate neurologic dysfunction or cranial nerve involvement.

Eye Movement

Ask the patient to follow an object with the eyes while keeping the head still. Assess movement through the major directions of gaze and look for:

Eyelid Strength

Ask the patient to close both eyes tightly. Gently attempt to open the eyelids using light pressure. Compare resistance on both sides and look for weakness or asymmetry.

Hearing

Compare the patient’s ability to hear on both sides. Ask whether there is:

Facial Sensation and Mastication

Assess the sensory and motor functions associated with the trigeminal nerve.

Ask the patient to clench or move the jaw as though chewing while observing and palpating for equal muscle strength.

With the patient’s eyes closed, lightly touch corresponding areas of the face and ask whether the sensation feels the same on both sides.

Facial Movement

Ask the patient to smile, raise the eyebrows, close the eyes tightly, or make another facial expression. Observe for equal movement and facial symmetry.

Facial droop or unequal movement may suggest neurologic dysfunction.

Uvula and Palate

Ask the patient to open the mouth and say “ah.” Observe the soft palate and uvula for symmetry and normal movement.

The uvula should generally remain near the midline without obvious abnormal deviation.

Tongue Movement

Ask the patient to extend the tongue. Observe whether it protrudes normally and remains approximately midline.

Abnormal deviation or weakness may suggest impairment of the hypoglossal nerve.

Swallowing

Ask the patient about difficulty swallowing and assess swallowing ability when it is safe and appropriate to do so.

Difficulty swallowing may indicate dysfunction involving the cranial nerves responsible for pharyngeal and tongue movement.

Shoulder Shrug

Place your hands lightly on the patient’s shoulders and ask them to shrug against resistance. Compare the strength of both sides.

Unequal strength or inability to elevate one shoulder may suggest dysfunction involving the spinal accessory nerve.

Brain Structure, Function, and Altered Mental Status

Review of Brain Anatomy and Physiology

The nervous system is divided into two major components: the central nervous system (CNS) and the peripheral nervous system (PNS). The brain and spinal cord make up the CNS. Within the brain are neurons and glial cells. Neurons transmit and receive electrical and chemical signals, while glial cells provide structural support, protection, and nutrients to help neurons function properly.

The skull, consisting of the cranium and facial bones, protects the brain from injury. Beneath the skull are three protective tissue layers known as the meninges:

The area between the dura mater and arachnoid mater is called the subdural space. The region between the arachnoid mater and pia mater is the subarachnoid space, which contains cerebrospinal fluid.

Beginning at the lower portion of the brain, the spinal cord connects with the brainstem. The brainstem includes the midbrain, pons, and medulla oblongata. It carries information between the brain and the rest of the body and plays an important role in controlling breathing, blood pressure, consciousness, and alertness.

Several additional areas of the brain perform specialized functions:

Identifying Altered Mental Status

EMS providers do not need to memorize every detail of neuroanatomy, but they must be able to recognize changes in a patient’s mental status. Altered mental status (AMS) may have an obvious cause, such as a traumatic head injury, or it may require a systematic assessment to identify the underlying problem.

A commonly used mnemonic for evaluating possible causes of AMS is AEIOU-TIPS:

Another useful EMS approach is Oxygen, Glucose, Pump, and SITS, which directs attention toward several rapidly identifiable causes of AMS:

Once a patient is identified as having AMS, following an organized assessment process can help EMS personnel narrow the differential diagnosis and identify time-sensitive problems.

Management of Altered Mental Status

Treatment of AMS begins with determining and correcting the underlying cause whenever possible. Initial care should focus on the patient’s airway, breathing, circulation, oxygenation, blood glucose, and neurologic status. Depending on the cause, treatment may range from supplemental oxygen or glucose administration to more advanced interventions, including airway management and rapid sequence intubation when clinically indicated and within the provider’s scope and protocol.

Autonomic Nervous System

Introduction

The nervous system is one of the most complex systems in the human body. It allows us to interpret and respond to both internal needs and external stimuli. Because of its complexity, the nervous system is divided into smaller parts to better understand its functions.

The first two major divisions are the central nervous system (CNS) and the peripheral nervous system (PNS). The CNS consists of the brain and spinal cord. The PNS includes all nerves that branch out from the CNS to organs and muscles throughout the body.

To better understand the PNS, it can be divided further into the autonomic nervous system (ANS) and the somatic nervous system (SNS). Some organs and muscles function involuntarily, meaning they are outside of conscious control. These include the heart, kidneys, and digestive tract, and they are regulated by the ANS. Other organs and muscles are largely voluntary, meaning they are under conscious control. These include the muscles of the arms and legs and are part of the SNS.

ANS Overview

What is the ANS?

The autonomic nervous system (ANS) is the division of the peripheral nervous system responsible for controlling automatic or involuntary body functions.

What does the ANS encompass?

The ANS regulates involuntary functions such as:

The ANS is divided into two major branches:

The parasympathetic nervous system is responsible for relaxation and slowing involuntary body processes, such as lowering the heart rate during rest or sleep.

The sympathetic nervous system is commonly known as the fight-or-flight system. It speeds up body processes, such as increasing the heart rate during exercise or in threatening situations.

Key Terms

Lessons and Concepts

Neurons are the basic functional cells of the nervous system. They can be classified according to their role and the way they transmit information.

Types of Neurons

Nerves and Tracts

Sensory, Motor, and Mixed Nerves

An example of a mixed nerve is the facial nerve, which controls facial movement (motor function) and also contributes to taste sensation (sensory function).

Nerve tracts are located in the CNS, specifically within the white matter of the brain, which lies deeper than the gray matter and makes up much of the brain’s internal tissue.

For example, when something causes pain, the body naturally withdraws from the source of the pain.

Membrane Potential and Action Potential

Membrane potential is the difference in electrical charge between the inside and outside of a cell.

This is important because when membrane potential changes, an action potential can occur, allowing messages to be sent to and from the CNS.

Phases of the Action Potential

This electrical activity makes normal body functions possible, including processes such as heartbeat regulation.

Impulse Transmission

Nerve impulses can be transmitted in two main ways:

Sympathetic and Parasympathetic Divisions of the ANS

Sympathetic Division

The sympathetic division is responsible for the fight-or-flight response.

Its effects include:

Norepinephrine is the primary neurotransmitter of the sympathetic nervous system. It functions as both a hormone and a neurotransmitter and helps increase blood pressure and heart rate.

Parasympathetic Division

The parasympathetic division is responsible for the rest-and-digest response.

Its effects include:

Acetylcholine (ACh) is the primary neurotransmitter found at parasympathetic target organs.

Effects of the ANS on Organs and Organ Systems

Eyes

Skin

Cardiovascular System

The medulla helps regulate arterial blood pressure through both sympathetic and parasympathetic pathways.

Baroreceptors are part of a negative feedback system that helps regulate arterial pressure.

There are two main sites of arterial baroreceptors:

Small changes in mean arterial pressure (MAP) activate these receptors, which help restore blood pressure toward normal by increasing or decreasing autonomic output.

Cardiac Effects

Adrenal Glands

Respiratory System

The respiratory system can be controlled both involuntarily and voluntarily.

Its involuntary functions, such as ventilation and gas exchange, are regulated by the autonomic nervous system. Changes in oxygen, carbon dioxide, and pH levels can automatically increase or decrease the respiratory rate.

Involuntary changes in breathing can also occur when we laugh, speak, or sing, which may alter the rate or depth of breathing.

At the same time, we are able to voluntarily control our breathing rate and volume when needed, such as when trying to calm ourselves during an emotional event.

Digestive System

The digestive system has its own specialized division of the autonomic nervous system called the enteric nervous system (ENS).

It is sometimes referred to as the “second brain” because it can regulate many digestive activities independently while still communicating with the central nervous system.

The enteric nervous system helps coordinate functions such as:

Muscle Control

Muscle activity may be controlled voluntarily or involuntarily, depending on the type of muscle and its function.

The autonomic nervous system influences the contraction and relaxation of cardiac and smooth muscle through sympathetic and parasympathetic pathways.

Some automatic functions, including cardiovascular and respiratory regulation, are coordinated by centers within the brainstem.

Urinary System

The urinary system responds to both parasympathetic and sympathetic nervous system activity.

During urination, parasympathetic activity promotes bladder emptying by:

Sympathetic activity supports urine storage by:

Together, these autonomic responses help regulate when urine is stored and when the bladder is emptied.

Reproductive System

Like the urinary system, the reproductive system is influenced by both the parasympathetic and sympathetic divisions of the ANS.

Although male and female reproductive organs differ anatomically, autonomic nerves regulate several similar functions in both.

Parasympathetic Activity

Parasympathetic stimulation contributes to sexual arousal by:

Sympathetic Activity

Sympathetic activity plays an important role in later phases of the sexual response, particularly:

Both sympathetic and parasympathetic pathways work together during normal sexual function.

Autonomic Nervous System Dysfunction

Dysautonomia, also called autonomic dysfunction or autonomic neuropathy in some conditions, refers to disorders in which the autonomic nervous system does not regulate body functions normally.

The severity, cause, and age of onset can vary considerably from one person to another.

Types of Dysautonomia

Common Signs and Symptoms of Dysautonomia

Because the autonomic nervous system affects many organ systems, symptoms may vary widely.

Urinary Symptoms

Cardiovascular Symptoms

Neurologic and General Symptoms

Temperature and Sweating Problems

Respiratory Symptoms

Digestive Symptoms

Metabolic Symptoms

Some autonomic disorders may interfere with normal recognition or regulation of blood glucose changes, particularly in people with conditions such as diabetes.

Sexual and Reproductive Symptoms

Visual Symptoms

Treatment and Management

Management of dysautonomia focuses on identifying the patient’s immediate needs, stabilizing abnormal vital signs, and addressing complications caused by autonomic dysfunction.

Prioritize Patient Needs

Patients experiencing dizziness, weakness, or hypotension may be at increased risk for falling, particularly when moving from a sitting or lying position to standing.

These patients may require additional assistance, equipment, or personnel during movement and transport to reduce the risk of injury.

Initial Assessment and Care

Initial management should focus on identifying and treating immediate life threats.

Because symptoms of dysautonomia may resemble other medical emergencies, the assessment should also consider conditions such as stroke, cardiac abnormalities, hypoglycemia, dehydration, medication effects, and other causes of hypotension or altered neurologic function.

Ongoing Care and Treatment Goals

Continued treatment depends on the patient’s symptoms and overall condition.

Possible interventions may include:

The overall goal is to maintain adequate oxygenation, ventilation, circulation, and perfusion while identifying and managing the cause of the patient’s symptoms.

Mental & Behavioral Emergencies

Psychiatric and Behavioral Emergencies

Introduction

Psychiatric and behavioral emergencies can be challenging for EMS providers because patients may present with many different symptoms, underlying causes, and treatment needs. These emergencies may result from psychiatric illness, medical conditions, substance use, environmental stressors, or a combination of factors.

This section provides an overview of common psychiatric and behavioral emergencies and emphasizes the importance of patient assessment, provider safety, communication, and recognition of possible medical causes.

Pathophysiology

Causes of Abnormal Behavior

Abnormal behavior can develop from several different causes. EMS providers should avoid assuming that unusual behavior is caused only by a psychiatric disorder.

Biological or Organic Causes

Changes in normal brain function may produce abnormal behavior or altered mental status. Possible causes include:

These conditions can interfere with normal cerebral function and may produce behavioral or cognitive changes.

Environmental and Psychosocial Causes

A person’s surroundings, social circumstances, and life experiences can significantly influence behavior. Severe or repeated psychosocial stress may interfere with the person’s ability to cope effectively and may contribute to abnormal emotional or behavioral responses.

Injury and Illness

Acute illness or injury can also cause significant changes in behavior. Examples include severe infection, electrolyte abnormalities, metabolic disorders, hypoglycemia, hypoxia, and traumatic injuries.

Serious medical problems can overwhelm normal coping mechanisms and may produce confusion, agitation, anxiety, or other behavioral changes.

Substance-Related Causes

Alcohol, medications, illicit drugs, and other chemicals may alter a person’s:

Both intoxication and withdrawal should be considered when evaluating abnormal behavior.

Psychiatric and Behavioral Signs and Symptoms

Psychiatric and behavioral abnormalities may affect several areas of mental and physical functioning.

Level of Consciousness

Changes may include:

Significant alterations in consciousness should raise concern for an underlying medical or neurological cause.

Motor Activity

Changes in motor behavior may include:

Speech

Speech abnormalities may include:

Thinking

Disorders of thought may affect either the organization of thoughts or their content. A patient may demonstrate disorganized thinking, unusual beliefs, delusions, or difficulty maintaining a logical progression of ideas.

Mood and Affect

Abnormalities may include:

Memory

Memory disturbances may include:

Orientation

Patients may become disoriented regarding:

Perception

Disturbances in perception may include:

Cognition and Learning

Some conditions may interfere with the patient’s ability to process information, concentrate, understand instructions, or learn new information.

Safety Guidelines

Provider and patient safety are major priorities during psychiatric and behavioral emergencies.

Specific Psychiatric and Behavioral Emergencies

Acute Psychosis

Acute psychosis is a condition in which a patient has significant difficulty distinguishing reality from thoughts, beliefs, or perceptions that are not based in reality.

Psychosis may result from psychiatric illness, neurological conditions, metabolic abnormalities, substance intoxication or withdrawal, medications, or other medical problems.

Possible findings include:

Some patients may experience unusual thought disturbances such as believing that others can hear their thoughts, that thoughts have been placed into their mind, or that thoughts have been removed.

Because medical conditions can produce psychosis-like symptoms, EMS providers should assess for possible underlying physiological causes.

Acute Delirium With Severe Agitation

Delirium is an acute disturbance in attention, awareness, and cognition that commonly results from an underlying medical condition, toxin, medication, withdrawal state, infection, or metabolic abnormality.

Patients may demonstrate:

Severely agitated patients may become combative when overwhelmed by internal or external stimuli.

Because delirium often represents a medical emergency, providers should search for and treat possible causes such as hypoxia, hypoglycemia, infection, hyperthermia, intoxication, withdrawal, or metabolic disturbances while maintaining scene safety.

Suicidal Thoughts or Behavior

Any patient expressing suicidal thoughts, intent, or behavior should receive a careful and respectful assessment.

Important areas to evaluate include:

Patients at risk for self-harm should not be left alone when doing so would create an immediate safety risk, and local EMS protocols should be followed regarding evaluation, transport, and involvement of additional resources.

Violence, Abuse, and Neglect

Behavioral emergencies may involve violence, abuse, neglect, or unsafe interpersonal situations. Providers should remain professional and assess both the individual patient and the surrounding environment.

Abuse and Neglect

Patients involved in abusive or neglectful situations may also have medical, psychiatric, or substance-related conditions that complicate assessment.

EMS providers should look for:

Findings should be documented objectively, and suspected abuse or neglect should be reported according to applicable laws, regulations, and local protocols.

Managing Potential Violence

Many agitated patients can be de-escalated through calm communication.

Helpful approaches include:

If the patient becomes violent or threatens violence, provider safety becomes the priority. Request appropriate assistance and withdraw from the immediate area when the situation cannot be safely controlled.

EMS professionals may encounter verbal threats, intimidation, physical aggression, harassment, or other inappropriate behavior. Such behavior should not be considered acceptable simply because it occurs during patient care.

Risk Factors and Warning Signs for Violence

The likelihood of violent behavior may increase in certain situations, although no single factor reliably predicts that a patient will become violent.

Factors that may increase concern include:

Providers should continually observe the patient’s:

A sudden increase in agitation, threatening movements, clenched fists, pacing, shouting, or attempts to move into the provider’s personal space may indicate an increasing risk of aggression.

Managing the Potentially Violent Patient

When caring for an agitated or potentially violent patient, the first priority is maintaining the safety of the patient, EMS personnel, and bystanders. The provider should evaluate the entire scene and consider medical, psychiatric, substance-related, and environmental factors that may be contributing to the behavior.

Psychiatric Disorders

Psychiatric disorders include a broad range of conditions affecting a person’s mood, thoughts, perceptions, behaviors, and ability to function. EMS providers do not generally diagnose psychiatric disorders in the field, but recognizing common presentations can help guide assessment, safety measures, and transport decisions.

Mood Disorders

Mood disorders primarily affect a person’s emotional state and may involve persistent periods of depression, elevated mood, or significant changes between mood states.

Patients experiencing a severe mood disturbance may require emergency evaluation when symptoms interfere with normal functioning or are associated with suicidal thoughts, self-harm, psychosis, or dangerous behavior.

Schizophrenia Spectrum Disorders

Schizophrenia is a chronic psychiatric disorder that can affect thought processes, perception, emotional expression, behavior, and daily functioning. Symptoms most commonly begin in late adolescence or early adulthood, although the timing varies among individuals.

The development of schizophrenia is believed to involve a combination of genetic, neurobiological, developmental, psychological, and environmental factors.

Possible manifestations include:

Symptoms and severity vary significantly among patients.

Anxiety and Related Disorders

Older sources may refer to some anxiety-related illnesses as neurotic disorders. Current terminology generally classifies them more specifically as anxiety disorders and related conditions.

Anxiety becomes clinically significant when fear or worry is excessive, persistent, difficult to control, and interferes with normal activities.

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) involves excessive and persistent worry about multiple areas of life, often without a single identifiable cause.

The anxiety:

Treatment may involve psychotherapy, medications, or a combination of approaches.

Phobias

A specific phobia is an intense and disproportionate fear of a particular object, activity, or situation.

Exposure to the feared stimulus may trigger:

The fear may significantly interfere with normal activities despite the patient recognizing that the reaction may be excessive.

Panic Disorder

Panic disorder involves recurrent panic attacks, which are sudden episodes of intense fear or discomfort that may occur unexpectedly.

Symptoms associated with a panic attack can include:

Because these symptoms can resemble serious medical conditions, EMS providers should evaluate for medical causes rather than automatically assuming anxiety is responsible.

Substance-Related and Addictive Disorders

Substance-related disorders involve the use of alcohol, medications, illicit drugs, or other substances that affect behavior, cognition, mood, or physical functioning.

These conditions are complex medical and behavioral disorders rather than indications of poor character or moral weakness.

Common Substance-Related Presentations

Older terms such as substance abuse and substance dependence have largely been replaced by the diagnosis substance use disorder, which can range from mild to severe.

EMS involvement commonly occurs because of an acute complication such as:

Eating Disorders

Eating disorders are serious psychiatric conditions involving disturbed eating behaviors and abnormal thoughts or concerns regarding food, body weight, or body image.

Two major examples are anorexia nervosa and bulimia nervosa.

Anorexia Nervosa

Anorexia nervosa involves significant restriction of energy intake, intense fear of gaining weight, and behaviors or perceptions that interfere with maintaining an appropriate body weight.

Potential medical complications include:

Bulimia Nervosa

Bulimia nervosa involves recurrent episodes of binge eating followed by inappropriate compensatory behaviors, such as self-induced vomiting, fasting, excessive exercise, or misuse of certain medications.

Possible complications include:

Eating disorders can affect individuals of any sex, gender, age, or body size.

Somatic Symptom and Related Disorders

Older materials may use the term somatoform disorders. Current terminology generally refers to somatic symptom and related disorders.

These conditions involve significant distress or excessive thoughts, emotions, or behaviors related to physical symptoms.

Patients may present repeatedly with physical concerns and may experience genuine distress even when the severity of symptoms cannot be fully explained by available medical findings.

Important principles for EMS include:

Examples within this broader category include somatic symptom disorder and illness anxiety disorder.

Factitious Disorder

Factitious disorder occurs when a person intentionally produces, exaggerates, or falsifies physical or psychological symptoms in order to assume the role of a patient, without an obvious external reward being the primary motivation.

A severe or recurrent presentation has historically been referred to as Munchausen syndrome, although modern clinical terminology generally uses factitious disorder imposed on self.

A patient may:

EMS providers should still perform an appropriate medical assessment because genuine illness or injury may coexist with factitious behavior.

Impulse-Control Disorders

Impulse-control disorders involve difficulty resisting urges or impulses that may result in harmful behavior.

Examples include:

Although older references may include pathological gambling among impulse-control disorders, current classifications generally place gambling disorder with substance-related and addictive disorders.

Impulse-control conditions may occur along with other psychiatric disorders.

Personality Disorders

Personality disorders involve long-standing patterns of thinking, feeling, behaving, and interacting with others that differ substantially from cultural expectations.

These patterns are typically:

Patients with personality disorders may also have additional psychiatric conditions, including mood disorders, anxiety disorders, substance use disorders, or trauma-related disorders.

Psychiatric Medications and Behavioral Emergency Care

Patients with psychiatric or behavioral conditions may take many different medications to help manage symptoms and maintain mental health stability. The medications listed below represent only a portion of the drugs that may be prescribed for psychiatric conditions. Some medications may also be used off-label, depending on the patient’s diagnosis and treatment plan.

For EMS providers, obtaining an accurate medication history can provide important information about the patient’s condition, possible adverse effects, medication interactions, and potential causes of behavioral changes.

Major Medication Categories

Antidepressants

Antidepressants are commonly prescribed for depressive disorders and may also be used for anxiety disorders and several other psychiatric conditions.

Major classes include:

These medications work primarily by altering levels or activity of neurotransmitters such as serotonin, norepinephrine, and dopamine within the central nervous system.

Each medication class has different indications, side effects, interactions, and overdose risks. EMS providers should identify the medication when possible and assess the patient based on their clinical presentation.

Benzodiazepines

Benzodiazepines may be prescribed for conditions such as severe anxiety, panic symptoms, acute agitation, seizures, or other short-term indications.

They generally enhance the effects of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA), producing calming and sedative effects.

Common examples include:

Benzodiazepines are often intended for short-term or carefully monitored use because they can produce sedation, tolerance, physical dependence, and withdrawal symptoms.

Excessive doses, particularly when combined with alcohol, opioids, or other CNS depressants, may contribute to respiratory depression and altered mental status.

Antipsychotic Medications

Antipsychotics are used primarily to treat conditions involving psychosis, including schizophrenia and certain mood disorders. They may also be used for severe agitation or other psychiatric symptoms in selected situations.

Antipsychotics are commonly divided into:

Possible adverse effects vary by medication and may include:

Acute Dystonic Reaction

An acute dystonic reaction may occur after certain antipsychotic medications, particularly early in treatment or after a dose change.

The patient may develop involuntary muscle contractions involving areas such as the:

Severe dystonia can occasionally affect the airway and requires prompt assessment and treatment according to local protocols.

Stimulant Medications

Prescription stimulants act primarily on the central nervous system and increase the activity of neurotransmitters such as dopamine and norepinephrine.

They are commonly prescribed for conditions such as attention-deficit/hyperactivity disorder (ADHD) and, in some cases, narcolepsy.

Possible effects include:

At excessive doses, stimulants may contribute to:

A commonly prescribed stimulant is mixed amphetamine salts (Adderall).

Medication Adherence

Some patients may have difficulty consistently taking prescribed psychiatric medications.

Possible reasons include:

Suddenly stopping certain psychiatric medications may result in withdrawal symptoms, recurrence of psychiatric symptoms, or worsening of the patient’s condition.

EMS providers should approach medication adherence without judgment and document what medications the patient reports taking, missing, or recently discontinuing.

Emergency Medication Use

Medications may be considered during a behavioral emergency when severe agitation creates an immediate risk of injury to the patient, EMS personnel, or others and less restrictive measures have not been successful.

The specific medication and method of administration depend on factors such as:

Whenever medication is used for severe agitation, the patient requires continued monitoring of airway, breathing, circulation, mental status, oxygenation, and vital signs.

Therapeutic Communication in Behavioral Emergencies

Effective communication may reduce anxiety, improve cooperation, and help EMS providers obtain important clinical information.

Begin With Open-Ended Questions

Open-ended questions allow patients to describe what they are experiencing in their own words.

Examples include:

This approach allows the provider to gather information while giving the patient space to describe concerns without feeling interrogated.

Allow the Patient to Speak

Give the patient time to explain the situation without unnecessary interruption.

Allowing the patient to speak freely can help them regain a sense of control while giving the EMS provider an opportunity to assess:

Listen and Demonstrate Attention

Active listening involves both verbal and nonverbal communication.

Maintain a calm posture and appropriate eye contact while paying attention to your facial expression, tone of voice, and body language.

Useful responses may include:

These responses encourage the patient to continue without making assumptions about what they are experiencing.

Allow Periods of Silence

Silence does not always need to be immediately filled with conversation.

A patient may pause because they are:

Remain attentive and relaxed while allowing the patient time to continue.

Avoid Arguing

If a patient is experiencing delusions, hallucinations, or another altered perception of reality, avoid arguing or aggressively challenging what they believe.

The patient’s experience may feel completely real and may be frightening.

When necessary, provide a brief and neutral statement about reality without becoming confrontational. For example:

“I understand that you are hearing something. I don’t hear it, but I can see that it is upsetting you.”

The goal is to acknowledge the patient’s distress without reinforcing the false perception.

Encourage Communication

Use supportive verbal and nonverbal techniques to help the patient continue communicating.

Helpful techniques include:

For example, the provider might say, “It sounds like things became much harder after that happened. Can you tell me more?”

Focus the Patient’s Attention

If the patient’s thoughts become scattered, gently redirect the conversation toward the most important issue.

The provider can describe observed behavior without sounding judgmental.

For example:

“I notice that you seem very anxious right now. Can you tell me what is making you feel unsafe?”

This can help organize the conversation while allowing the patient to remain involved.

Ask Appropriate Questions

After allowing the patient to explain the situation, ask more focused questions to obtain essential information.

Questions should generally be clear, simple, and nonjudgmental.

Important topics may include:

Direct questions about suicide or violence are appropriate when clinically indicated and do not create suicidal or violent thoughts.

Modify the Approach When Necessary

Not every communication technique works for every patient.

If an open conversation increases anxiety or confusion, the provider may need to use a more structured and direct interview.

This may be particularly helpful for patients who are:

Crisis Intervention and Patient Restraint

Crisis Intervention Skills

Effective crisis intervention focuses on maintaining safety, reducing anxiety, building trust, and helping the patient regain a sense of control. EMS providers should remain calm, respectful, and flexible throughout the encounter.

Remain Calm and Direct

Your behavior can strongly influence the patient’s response. Speak in a calm, confident manner and use simple, direct statements.

Avoid appearing frightened, rushed, angry, or confrontational, because these behaviors may increase the patient’s anxiety or agitation. Communicate in a way that shows you believe the patient can participate in maintaining control of the situation.

Limit Disruptive People and Stimuli

When appropriate, reduce unnecessary noise, crowds, and distractions around the patient.

Nonessential family members, friends, or bystanders may be asked to step away if their presence increases the patient’s distress. However, some patients may become more anxious when separated from a trusted person.

If the patient wants a supportive person to remain nearby, allow this when:

Use a Nonthreatening Position

When safe and appropriate, position yourself at a comfortable distance and slightly to the side rather than directly face-to-face with the patient.

A relaxed position can:

Avoid blocking the patient’s movement unless required for immediate safety.

Maintain a Nonjudgmental Attitude

Patients have the right to experience and express their emotions.

Do not:

Focus instead on understanding what the patient is experiencing and determining what help is needed.

Provide Honest Reassurance

Support the patient with truthful and realistic information.

Avoid making promises that cannot be guaranteed or repeatedly telling the patient that “everything will be fine.” Excessive reassurance may make the patient feel that their concerns are being minimized.

Instead, explain:

Develop a Clear Plan

After the patient has had an opportunity to explain their concerns and the initial assessment has been completed, develop a practical plan for care.

Explain the plan clearly and involve the patient whenever possible.

Giving the patient reasonable choices can help restore a sense of autonomy. For example, the patient may be allowed to choose which belongings to bring or where to sit when doing so does not interfere with safety or treatment.

Once the plan is established, begin carrying it out without unnecessary delay.

Encourage Safe, Purposeful Activity

Some patients may benefit from simple purposeful activity, such as gathering personal belongings before transport.

Safe movement may help reduce anxiety and give the patient a greater sense of participation and control. The patient should still be appropriately supervised when there is a risk of self-harm, violence, elopement, or worsening medical status.

Remain With the Patient When Safe

Once contact has been established, continue appropriate observation and supervision according to the patient’s condition and level of risk.

Patients who are at significant risk for self-harm, violence, or sudden deterioration should not be left unsupervised.

Provider safety remains the priority. Do not enter or remain in an unsafe environment.

Bring Relevant Medications and Medical Information

When possible, bring the patient’s medication containers, medication list, or other relevant treatment information to the receiving facility according to local procedure.

Knowing what medications the patient currently takes can help healthcare professionals identify:

Do not delay necessary emergency transport solely to collect medications.

Continue Attempting Respectful Communication

Do not assume that a patient cannot communicate simply because they are silent, withdrawn, severely depressed, psychotic, or minimally responsive to conversation.

Continue to speak to the patient respectfully and explain what you are doing, even when the patient does not immediately respond.

Every patient experiencing a psychiatric or behavioral emergency should be treated with dignity, empathy, and compassion.

Restraint in Behavioral Emergencies

Restraint should be used only when necessary to protect the patient, EMS personnel, or others from immediate harm and when less restrictive interventions are unsuccessful or inappropriate.

The goal is not punishment or control for convenience. The goal is safe patient care using the least restrictive effective intervention.

Environmental and Verbal Interventions

Environmental modification and verbal de-escalation should generally be attempted first when the situation allows.

Examples include:

These approaches may prevent the need for physical or pharmacologic restraint.

Physical Restraint

Physical restraints may be necessary when a patient presents an immediate danger to themselves or others and cannot be safely managed through less restrictive measures.

Specific devices and techniques depend on local EMS protocols, available equipment, and medical direction.

Before Applying Restraints

Patient Positioning

Patients should generally be positioned in a manner that protects the airway and allows adequate breathing and continuous assessment.

Avoid prone or face-down restraint, especially when pressure could be placed on the patient’s chest, abdomen, neck, or back, because this may interfere with ventilation and increase the risk of positional asphyxia.

Whenever possible:

Monitoring After Restraint

A restrained patient requires frequent and continuous reassessment.

Monitor:

Restraints should never interfere with necessary airway management, ventilation, or circulation.

Alcohol or drug intoxication can increase the risk of complications such as:

Documentation

Document the circumstances thoroughly, including:

Treat the patient with dignity and respect throughout the encounter.

Pharmacologic Management of Severe Agitation

Medication may be used for severe agitation when the patient remains an immediate danger despite appropriate de-escalation measures or when attempting prolonged physical restraint would create greater risk.

Medication selection depends on:

Medication classes used in some EMS systems may include:

After medication is administered, continue close monitoring because sedation can produce complications such as:

Have appropriate airway and resuscitation equipment immediately available.

Special Considerations for Behavioral Emergencies

Pediatric Patients

Children and adolescents may experience many of the same psychiatric and behavioral disorders seen in adults, but symptoms can appear differently depending on age and developmental level.

Mental health conditions frequently begin during childhood or adolescence, making early recognition important.

Assessment can be challenging because normal behavior varies greatly with age and development.

Important considerations include:

Children and adolescents may also have more than one behavioral, developmental, or psychiatric condition at the same time.

Cultural and family factors can influence how symptoms are recognized, expressed, and reported.

Any statement or behavior suggesting suicide or self-harm should be taken seriously, regardless of the patient’s age.

Geriatric Patients

Behavioral and mental-status changes in older adults should not automatically be attributed to aging or psychiatric illness.

Sudden behavioral changes may result from an underlying medical problem such as:

Older adults may also experience chronic conditions such as dementia or may develop anxiety, depression, grief, or other psychiatric concerns.

Changes in routine, loss of independence, financial stress, chronic illness, isolation, and the death or relocation of loved ones may contribute to emotional distress.

When evaluating an older patient with behavioral changes, determine whether the symptoms are acute or chronic. A sudden change from the patient’s normal mental status should raise concern for a potentially serious medical cause.

Suicidal Behavior

Overview

Suicide occurs when a person intentionally ends their own life. It is an important public health concern, particularly among adolescents and young adults. Certain groups may have an increased risk, especially individuals who are experiencing depression, major life changes, social isolation, or the loss of an important relationship. A previous suicide attempt also increases the likelihood of another attempt.

Alcohol misuse is another important risk factor because alcohol acts as a depressant and may reduce judgment and self-control. Other factors associated with an increased risk of suicide include severe or worsening depression, substance misuse, the recent loss of a spouse or significant relationship, long-term or disabling illness, schizophrenia or other serious mental illness, expressed suicidal thoughts, a specific suicide plan, social isolation, financial problems, job loss, a previous suicide attempt, and a family history of suicide.

Suicidal behavior may occur when a person feels that an important emotional relationship is threatened or when they experience a major loss. Someone considering suicide may also experience feelings of worthlessness, poor self-esteem, hopelessness, or a loss of control over their life.

Suicide Risk Assessment

Anyone experiencing depression should be evaluated for possible suicidal thoughts or behaviors. Asking directly about suicide does not usually make the situation worse. In many cases, the person may feel relieved because they are being given an opportunity to talk openly about what they are experiencing.

The assessment may be performed gradually by first asking about emotional distress and then asking more directly about thoughts of self-harm or suicide. Important concerns include whether the person:

A person who has previously attempted suicide, has a detailed suicide plan, or is considered to be at high risk should receive prompt medical and mental health evaluation. Some individuals may make last-minute efforts to communicate their intentions, so any statement suggesting suicide should be taken seriously.

If a person begins talking about suicide, encourage them to continue communicating. Listen calmly and remain with the person until appropriate medical care is available or additional help arrives.

Emergency Care and Management

Mood-Related Disorders

Overview

Mood disorders, previously called affective disorders, are common psychiatric conditions that significantly affect a person’s emotions and daily functioning. They are different from ordinary periods of sadness or happiness because the changes in mood are more intense, persistent, and may interfere with work, relationships, judgment, and everyday activities.

Manic Episodes

Mania involves an unusually elevated, excited, or irritable mood accompanied by increased activity and decreased need for sleep. A person experiencing a manic episode may remain awake for long periods while still appearing energetic and alert.

These individuals are often highly active but may become easily distracted and have difficulty concentrating. Their speech may be rapid, pressured, and difficult to interrupt. Racing thoughts are also common, and the person may quickly move from one idea to another. In more severe episodes, unusual beliefs, poor judgment, or delusions may occur.

During an acute manic episode, a person may participate in impulsive or high-risk activities that could result in injury, financial problems, legal difficulties, or other harmful consequences. Some individuals may not recognize that their behavior has become abnormal and may resist or refuse treatment because they do not believe they are experiencing a mental health problem.

Depressive Disorders

Depression is a mood disorder that can occur at any age and may significantly interfere with a person’s social, occupational, and personal functioning. A person experiencing depression may appear sad, cry frequently, withdraw from others, or show little interest or emotional response to activities around them.

Common emotional symptoms include feelings of worthlessness, guilt, hopelessness, and pessimism. Social isolation may occur because the person feels misunderstood, unwanted, or unsupported. Depression may develop in episodes with a noticeable beginning and may last for varying periods of time.

Major depressive disorder is associated with significant emotional distress and impairment in daily functioning. In some individuals, depressive symptoms may persist for long periods. Chronic depression that continues for an extended period is now commonly referred to as persistent depressive disorder, which was previously known as dysthymic disorder.

Severe depression may interfere considerably with a person’s relationships, employment, education, and ability to care for themselves. Individuals who develop suicidal thoughts or behaviors require immediate assessment and appropriate medical or mental health care.

The major features of depression can be remembered using the mnemonic GAS PIPES: