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Behavioral / Psychiatric Emergencies

Category: Medical Sources: raw/protocols/nm-sop-guidelines-treatment-2022.pdf Last updated: 2026-04-03

Overview

Behavioral and psychiatric emergencies involve patients with altered mental status, inappropriate behavior, or actions that pose a threat to themselves or others. The EMT-B must always rule out a medical cause for behavioral changes before attributing them to a psychiatric condition — hypoglycemia, hypoxia, head trauma, stroke, CNS infection, and intoxication can all mimic acute psychiatric illness.

Provider safety is the first priority. Verbal de-escalation is always attempted before physical or chemical restraint. NM EMS has specific legal authority for involuntary transport under NMSA 24-10B-9.1 when a patient is incapable of making an informed decision about their safety.

Key Points

  • Rule out medical causes first — glucose, O2, trauma, medications, and history before assuming psychiatric etiology
  • One EMT should be designated as the primary communicator — consistent, calm communication is de-escalating
  • Do NOT argue, threaten, or make false promises
  • Agitated patients on the ground can die from positional asphyxia — prone restraint is hazardous; monitor airway continuously
  • Excited delirium (ExDS): extreme agitation + hyperthermia + incoherence + superhuman strength = medical emergency; high risk for sudden cardiac death
  • Chemical restraint (benzodiazepines) is ALS/paramedic scope in NM — EMT-B requests ALS
  • Involuntary transport: NM law (NMSA 24-10B-9.1) allows transport without consent when patient cannot make informed decision and is likely to suffer disability/death without intervention

Assessment Relevance

History (history-taking): - SAMPLE: Prescription medications (psychiatric meds, missing doses); illicit drugs; alcohol; underlying medical conditions (diabetes, seizure disorder, head injury); prior psychiatric history - Bystander/family history is often more reliable than patient history - Vital signs: tachycardia, hypertension, fever, hypoxia — these suggest medical etiology

Physical exam (secondary-assessment): - LOC (AVPU): altered LOC suggests medical etiology - Pupils: pinpoint (opioids), dilated (stimulants/anticholinergics) - Skin: diaphoresis (hypoglycemia, stimulants), flushed/hot (fever, stimulants) - Glucometry: mandatory — hypoglycemia causes agitation, confusion, bizarre behavior - SpO2: hypoxia causes agitation - Signs of trauma: head injury from fall or assault

Procedures

  1. Scene size-up (scene-size-up): Is the scene safe? Is law enforcement needed? Do not approach until safe.
  2. If danger is present:
  3. Leave scene if necessary; summon law enforcement
  4. Protect patient from injury; consider involuntary restraint if needed to render care
  5. If no immediate danger:
  6. Remove patient from stressful environment if possible
  7. Designate ONE EMS provider as communicator — maintain that assignment through transport
  8. Primary assessment (primary-assessment): airway, breathing, circulation
  9. Obtain history: medical causes, medications, substance use, psychiatric history
  10. Glucometry — mandatory
  11. Check SpO2, manage hypoxia
  12. Treat medical causes per appropriate guideline
  13. Verbal de-escalation — calm, simple, non-threatening communication
  14. Transport with consent if possible; involuntary if patient is incapable of decision-making and life-threat exists
  15. Request ALS if chemical restraint is anticipated

NM Protocol Notes

From NM EMS Treatment Guidelines (2022):

EMT-B scope: - Protect self and others; summon law enforcement if immediate danger - ONE EMS provider as primary communicator; SAME provider remains with patient during transport - Consider all possible medical causes (hypoglycemia, hypoxia, trauma, metabolic — do not assume purely psychiatric) - Verbal de-escalation first — before physical or chemical restraints - Transport with consent if possible; transport without consent per NMSA 24-10B-9.1 if patient cannot make informed decision about safety and life-threat exists - Law enforcement may transport directly to mental health facility if VS normal and EMT does not suspect medical cause - Keep environment quiet during transport - Chemical restraint: benzodiazepines may be considered if patient remains danger after verbal de-escalation — this is ALS/EMT-P scope in NM

Chemical restraint (Paramedic only): - MIDAZOLAM: Adult 5–10 mg IN/IM (max 10 mg, may repeat once after 10 min); OR 2–5 mg SIVP/IO (repeat every 5 min up to 10 mg) - All patients receiving physical or chemical restraints must be continuously observed by ALS personnel - Chemical restraint requires cardiac monitoring, ETCO2 monitoring if available, and frequent reassessment of airway and ventilation

Involuntary restraint (NMSA 24-10B-9.1): - Criteria for involuntary transport: (1) patient displays altered mental status, inappropriate responses, evidence of impairment, disorientation, or suicidal ideation AND (2) life threat suspected - Call for law enforcement assistance - Have enough personnel; ensure all are informed of plan - Adequately restrain to stretcher; at least two EMTs present if combative - EMS provider must be in voice contact with Medical Control - Document all actions, statements, and patient responses supporting decision to treat without consent

NREMT Relevance

Common NREMT question angles: - Always rule out medical causes — glucose, O2, trauma — before assuming psychiatric - Hypoglycemia mimics psychiatric illness — check BGL - One designated communicator - Involuntary transport criteria: incapable of making informed decision + life threat - Positional asphyxia risk with prone restraint — monitor airway continuously - Do NOT make false promises; do NOT threaten - Safety: leave scene if unsafe; summon law enforcement

Sources

  • raw/protocols/nm-sop-guidelines-treatment-2022.pdf — Behavioral/Psychiatric Emergencies (p. 36–37); Involuntary Restraint and Transport (p. 83–84)