Severe Agitation in the Field
Objective: Keep yourself and the patient alive. Talk first when it is safe. Do not restrain in a position that blocks breathing. Watch the airway after sedation. Use only the drug your protocol names.
Why this matters
The person may be in a public place, and police may want them sedated now. Do not give ketamine and then leave them face-down. Talk first if the scene is safe enough to talk. Do not use prone restraint, which means face-down, or a hobble. A hobble ties the limbs so the chest cannot move well. After any sedating drug, watch them the whole time. Do not chart “excited delirium” as a diagnosis. Describe severe agitation. Look for a cause you can treat: low oxygen, low sugar, heat, head injury, or a toxin.
- The scene has to be safe first. Do not give a medication while you are being hit.
- If you sedate someone, you now have an airway patient. Have suction and a bag-valve mask ready. Watch the sat. Watch capnography, the exhaled carbon dioxide reading, when you have it.
- Do not leave them face-down. Do not hobble them. Do not put a knee on the neck.
Clinical sequence
- Make the scene safe before you try to give a drug.
- While you talk, check sugar, oxygen, temperature, and signs of head injury. Treat what you find.
- If you give a sedating drug, be ready to support breathing. Watch the sat and the carbon dioxide reading.
- Keep them on their back, or on their side, where they can breathe and you can release the restraint. Do not put them face-down. Do not hog-tie them, with the hands and feet bound together. Do not sandwich them between boards.
Teaching points
- Talk first. Use one voice, offer choices, and give time when it is safe. Do not skip talking when talking is still safe.
- Physical restraint. Use the back or a side-lying recovery position. They must be able to breathe, and you must be able to release them. Face-down restraint, a hog-tie, and a board sandwich are prohibited.
- Drugs. Benzodiazepines, antipsychotics, and ketamine appear in many protocols. The doses are not interchangeable. Your protocol owns the milligrams. See the ketamine lesson.
- After the drug. Reassess often. A hot, agitated patient also needs cooling. Check the sugar. Do not leave them alone and unmonitored in the ambulance.
Common errors
- Giving a sedating drug and leaving the patient face-down.
- Not watching the airway after IM ketamine.
- Using “excited delirium” as a diagnosis instead of treating the airway, the heat, and the sugar.
Practice
One-minute check
The patient is hot, agitated, handcuffed, and face-down on the pavement. Name the first two position changes before you talk about a drug.
Sources & Further Study
Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.
- NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; your protocol still decides care
- NAEMSP / NASEMSO / NAEMT / APA 2021 agitation & restraint — de-escalation, no prone/hobble, monitor after chemical restraint
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.