Behavioral / Psychiatric Emergencies¶

Category: Medical Sources: raw/protocols/nm-sop-guidelines-treatment-2022.pdf; UCLA EMT Ultimate Study Guide (2026) Last updated: 2026-05-06

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¶

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

NREMT Differentiators¶

Excited Delirium (ExDS) — High-Priority Warning¶

Excited Delirium Syndrome is a medical emergency with a high risk of sudden cardiac arrest. It is NOT a psychiatric emergency — it is a physiological crisis.

Recognition: - Extreme agitation + apparent superhuman strength - Hyperthermia (hot, sweating despite environmental conditions) - Incoherent speech, disorientation - Clothing removal due to heat - Pain tolerance appears absent

KEY DIFFERENTIATOR — Excited Delirium: This patient looks like a psych patient but is about to code. The risk of sudden cardiac arrest is HIGH — especially after physical restraint. ALS intercept immediately. Do NOT place prone and do NOT sit patient on chest.

EMT-B actions: 1. ALS intercept — chemical sedation (midazolam) is ALS scope 2. Minimize physical restraint — do not go prone 3. High-flow O2 4. Continuous monitoring — cardiac arrest can occur suddenly, even after patient appears to calm

Delirium vs. Dementia¶

Feature	Delirium	Dementia
Onset	Sudden (hours to days)	Gradual (months to years)
Cause	Identifiable medical cause (infection, drugs, metabolic)	Neurodegeneration (Alzheimer's, vascular)
LOC	Fluctuating — worse at night ("sundowning")	Normal consciousness
Attention	Severely impaired	Less impaired early on
Reversibility	Reversible if cause treated	Irreversible (progressive)
In elderly	UTI is #1 cause of delirium in elderly	Chronic baseline condition

KEY DIFFERENTIATOR — Delirium vs. Dementia: Sudden onset confusion in an elderly patient = delirium until proven otherwise. The cause is MEDICAL. Common causes: UTI, pneumonia, medication overdose/interaction, hypoglycemia. Do not attribute to dementia and dismiss it.

NREMT RULE: A patient with known dementia who is suddenly MORE confused than baseline = treat as delirium — find the medical cause.

Medical vs. Psychiatric — Rule-Out Checklist¶

Before attributing AMS to a psychiatric cause, always exclude:

Medical Cause	Clue
Hypoglycemia	Check BGL — agitation, diaphoresis, confusion
Hypoxia	Check SpO2 — confusion + low O2 = medical
Head trauma	Check for mechanism/injury
Stroke	Focal neuro deficits, facial droop, unequal pupils
Seizure (postictal)	Witnessed event, incontinence, tongue bite
Drug/alcohol intoxication	Odor, pill bottles, needle marks
Infection / sepsis	Fever, focal infection signs
CNS infection (meningitis)	Fever + headache + stiff neck = meningitis triad

NREMT RULE: The correct answer is almost always "rule out medical causes first." A patient acting bizarre gets BGL and SpO2 before a psychiatric label.

Restraint Safety¶

Positional Asphyxia is a real risk: - Prone restraint (face down) compresses the chest — patient cannot breathe - Patient on back with weight on chest = same risk - Always monitor airway and breathing continuously when patient is restrained - Move to lateral position as soon as possible

KEY DIFFERENTIATOR — Positional Asphyxia: Restrained patients CAN die even when they appear calm — respiratory compromise from positioning. Monitor continuously; lateral is safer than prone.

Restraint approach: - Verbal de-escalation first — always - One designated EMS communicator; same person stays with patient throughout - Law enforcement present before physical restraint - Document all actions and reasons clearly - No false promises; no threats

scene-size-up — scene safety and law enforcement request; critical in behavioral emergencies
secondary-assessment — glucometry, SpO2, vital signs to rule out medical cause
history-taking — medication history, substance use, psychiatric history
overdose-poisoning — substance-induced behavioral changes
altered-loc — differential for altered LOC includes psychiatric emergency
diabetic-emergencies — hypoglycemia causes behavioral changes
geriatric — delirium vs dementia; AMS in elderly is always an emergency, not baseline

Sources¶

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