The Agitated Patient (Adult)

Stop
Observe for and manage as appropriate: - Hazards - Body fluids - Violence - Sharps - Clear egress - Reduce stimuli - Paramedic safety is paramount
Communicate with Pt - Avoid confrontational behaviour - Gain Pt co-operation for assessment - Utilise verbal de-escalation strategies
Assess and consider
Assess and manage clinical causes (as far as possible) - Hypoglycaemia - Drug withdrawal - Hypoxia - Intracerebral pathology - Post-ictal - Mild to moderate head injury (consult with MTS for sedation) - Drug intoxication (initiate sedation early in hyperthermic psychostimulant Pt) - Acute psychiatric condition

Is there a need for Restraint/Sedation?   Able to Mx without restraint/sedation Does not respond to verbal de-escalation No Mx cause as appropriate Clinical causes have been excluded   Continue to treat cause of agitation Pt risk to themselves or others - e.g. combative, agitated or aggressive   • Be aware Pt condition may change and agitation increase requiring restraint / sedation   Yes

Requires restraint/sedation
Stop
Ensure Pt is NOT recommended under the Mental Health Act (See notes)
Ensure sufficient physical assistance
Mild to moderate head injury GCS 10-14 (consult for sedation) (See notes)
Assess
Age Systolic BP
Reduced sedation dose for Age / BP

Age <60 AND Systolic BP >100			Age >60 and/or Systolic BP <100
Midazolam 0.05-0.1mg/kg IM (max 10mg per dose)   (e.g. 100kg and above: 10mg max dose) - Repeat initial dose 10 minutely IM (max. 4 doses) as required			Midazolam 0.05mg/kg IM (max 5mg per dose)   (e.g. 100kg and above: 5mg max dose) - Repeat initial dose 10 minutely IM (max. 4 doses) as required

Apply mechanical restraint devices if required

Above doses may be given IV and repeated 5 minutely as required

IM injections may be indicated until IV access has been established

Special Notes

This Guideline does not apply to Pts who have been recommended for transport under the Mental Health Act. If sedation is required in these circumstances then the Act requires that this only be administered by a prescribed Medical Practitioner or Registered Nurse.

Head Injury In Pts with mild to moderate head injury (GCS 10-14), sedation cannot be given without medical consultation with a Major or Regional Trauma Service.

Hyperthermia Sedation should be initiated early in hyperthermic Pts who have been using psychostimulants to assist with cooling and avoid further increases in temperature secondary to agitation.

The indications for the use of sedation and/or restraint must be clearly documented on the PCR.

Mechanical restraint may also be utilised without the use of sedation in circumstances where the Pt will not sustain further harm by fighting against the restraints.

Mechanical restraints must be removed if there is any indication that the restraint is compromising the provision of supportive care.

The type of restraint used and its time of application and/or removal must be clearly documented on the PCR.

General Care

Paramedic safety is to be considered paramount at all times. Do not attempt any element of this Guideline unless all necessary assistance is available.

Provide supportive care in all cases where sedation administered.

Provide airway management appropriate to the clinical condition.   - administer oxygen to all Pts and assist ventilation as required.

If less than adequate perfusion manage as per Inadequate Perfusion (Non-cardiogenic / Non-hypovolaemic).

Continue to assess Pt temp. and manage as per CPG A0902 Environmental Hyperthermia / Heat Stress, or CPG A0901 Hypothermia / Cold Injury.

If not already completed, ensure that all possible clinical causes of agitation are assessed and managed by the appropriate Guideline.