Severe Agitation in the Field
Objective: Keep you and the patient alive: de-escalate, avoid positional asphyxia, monitor after sedation, and use only the agent your protocol names.
Why This Is Hard
They are in the street screaming and PD wants them “down.” Crews jump to ketamine and then leave them prone in the truck. NAEMSP/NASEMSO/NAEMT 2021: verbal de-escalation, no hobble/prone, continuous observation after chemical restraint.
- Scene safety. You cannot medicate from inside a punch.
- If you sedate, suction, BVM, SpO₂, EtCO₂ when available — you just created an airway patient.
- Never prone, never hobble, never a knee on the neck.
Field Rules (Education)
- Verbal first: one voice, options, time if it is safe.
- Physical restraint: supine or recovery, able to breathe, easy to release. Prohibited: prone, hog-tie, sandwich between boards.
- Meds: benzos, antipsychotics, ketamine appear in many state protocols. Ranges are not interchangeable. See ketamine lesson.
- Aftercare: RASS-style reassessments, temperature (hot + agitated is a cooling problem), glucose.
Field Pitfalls
- Prone chemical restraint.
- No monitoring after IM ketamine.
- Calling it “excited delirium” as a diagnosis instead of treating the airway and the heat.
Practice
60-second drill
Partner: hot, agitated, in cuffs, prone on the pavement. First two positional moves before any drug talk.
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; protocol still wins
- 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
Street decisions from this lesson only. After you check, the key is highlighted. Education practice — not a certification exam.