20.2 Behavioural Emergencies, Severe Agitation & Safe Restraint

20.2 Behavioural Emergencies, Severe Agitation & Safe Restraint

A behavioural emergency is any presentation in which a patient's behaviour poses a risk to themselves or others, or prevents necessary assessment and care. CPCF Appendix A knowledge #4 and #13 and skill #17 all require competence here, and competencies B1.5 (manage disagreements and emotionally charged conversations using de-escalation), F1.2 (minimize personal and cognitive bias), and A1.1 (compassion and respect) all apply simultaneously. This is also the area where paramedic actions have most often caused patient death, which is why every step below has a safety rationale.

Terminology: Why "Excited Delirium" Is No Longer Used

The term excited delirium should not be used. It was never recognized as a diagnosis by the World Health Organization's International Classification of Diseases or by the DSM-5, the scientific basis for it as a distinct syndrome was not supported, and its application was disproportionately directed at racialized people and used to explain deaths in restraint. In 2023 the American College of Emergency Physicians formally withdrew its earlier white paper on the subject and stated the term should not be used in medical, public health, law enforcement, or expert-witness contexts. Canadian coroners' inquests and provincial reviews have reached similar conclusions.

The descriptive replacement is hyperactive delirium with severe agitation: a potentially life-threatening clinical state characterized by severe agitation, altered mental status, abnormal vital signs including hyperthermia, and metabolic derangement. The change matters clinically, not just linguistically: "excited delirium" framed the patient as a behavioural problem, while hyperactive delirium names it as delirium — a medical emergency requiring a search for the cause.

Assessment: The Cause Determines the Management

Every behavioural emergency is worked as Section 20.1 requires — organic causes excluded first, blood glucose checked, AEIOU-TIPS considered. The common reversible drivers of severe agitation:

• Hypoglycaemia and hypoxia
• Head injury, including a fall that preceded the behaviour
• Sepsis and infection, particularly in older adults
• Intoxication and withdrawal — stimulants, alcohol, benzodiazepines (Section 20.3)
• Pain, urinary retention, constipation, and a blocked catheter — the commonest reversible causes of agitation in frail and non-verbal patients
• Post-ictal states
• Hyperthermia, which both causes and is caused by severe agitation

De-escalation Is a Clinical Intervention

De-escalation is first-line treatment, not a preliminary courtesy. Done well it resolves most behavioural emergencies without restraint.

Environment:

• Reduce stimulation — sirens and lights off, radio volume down, unnecessary people removed, lighting softened where possible.
• One clinician talks. Everyone else is silent and still. Multiple voices escalate arousal reliably.
• Position for safety — no one between you and the exit, nothing in the patient's hands, a comfortable distance of roughly two arm-lengths, an angled rather than square-on stance, hands visible and open.
• Remove triggers — an aggressive family member, a crowd, a uniformed officer standing over the patient.

Approach:

Warning signs of imminent violence, in rough order of appearance: increasing volume and speed of speech; pacing and inability to sit; clenched fists or jaw; invasion of your space; direct threats; fixed staring; and — the most important and least taught — sudden stillness and silence after agitation, which frequently precedes an attack. Watch the hands, not the face.

Restraint

Restraint is a last resort used only when a patient poses an immediate risk of serious harm to themselves or others and de-escalation has failed or is not possible. It is a clinical intervention with a defined indication, a defined duration, and known lethal complications.

Principles

1. Least restrictive option that will work, for the shortest possible time.
2. Never as punishment, for convenience, or for staff comfort.
3. Adequate numbers before you start. Attempting restraint with too few people is how both patients and paramedics are injured. Plan the roles, brief them, and have police present where indicated.
4. One person leads and communicates with the patient throughout, including during and after the restraint. Talking does not stop because restraint has begun.
5. Follow local directive and legislation. Authority to restrain, and to transport against a patient's wishes, is set by provincial mental health legislation and service policy.

Positioning: The Rule That Prevents Deaths

[!CAUTION] Never restrain a patient in the prone position, and never apply weight or pressure to the back, chest, neck, or abdomen. Prone restraint with applied pressure causes restraint asphyxia by preventing chest-wall and diaphragmatic movement, and it has killed patients — disproportionately racialized patients. If a patient is found prone and restrained by others on arrival, turning them is an immediate clinical priority. Restrain supine with the head elevated, or in the lateral position, and continuously monitor the airway and breathing.

Additional positioning rules:

• Never hobble, hogtie, or secure limbs together behind the patient.
• Never sandwich a patient between mattresses or boards, or cover the face.
• Do not obstruct the mouth or nose in any way; if there is a spitting risk, use a purpose-designed spit guard that does not impede breathing, per policy.
• Secure limbs individually to the stretcher frame, never to each other, with the ability to release each independently and immediately.

Monitoring a Restrained Patient

A restrained patient is a high-acuity patient and must never be left unobserved. Monitor and document at frequent intervals:

• Airway, breathing, and oxygen saturation continuously — waveform capnography where available
• Pulse, blood pressure, and temperature — hyperthermia is a leading marker of severe illness in this group
• Blood glucose
• Level of consciousness — a restrained patient who becomes quiet and still may be deteriorating, not settling
• Distal circulation, sensation, and skin integrity at every restraint point
• Time each restraint was applied, by whom, the indication, and each reassessment

Documentation

Record the behaviour that made restraint necessary, the de-escalation attempted and why it failed, the least restrictive option chosen and why, who was present, the exact times, every reassessment, and the patient's response. Use objective descriptions of behaviour, never labels. Write "the patient swung a closed fist toward the paramedic's head and struck the stretcher rail" — not "the patient was violent."

After the Event

• Debrief the crew (Section 4.1). Restraint events are among the most distressing calls in paramedicine for everyone involved, including the crew.
• Report injuries to the patient or the crew through the service process.
• Review the decision in a just-culture framework (indicator G3.2), looking for the system contribution — was there a delay in resources, an unavailable de-escalation space, inadequate numbers?
• Reflect on bias. Restraint is applied disproportionately to racialized patients, Indigenous patients, and people who use substances. Indicators F1.2, F2.4, and F3.3 require paramedics to practise self-awareness about bias, challenge structures that marginalize, and eliminate Indigenous-specific racism. Ask honestly whether the same behaviour in a different patient would have produced the same response.