Prehospital Management of the Psychotic and Aggressive Patient with Bipolar Disease

You are dispatched to the home of Norman Smith, age 44, for an unknown problem. When you arrive at the scene, Smith's wife meets you at the ambulance and tells you that her husband just went crazy-throwing things around in the house and talking to people who were not there. For your protection and others, you call the dispatcher for police backup. You decide not to enter the home and park the ambulance a few hundred feet away from the residence after being advised by dispatch not to go into the house until it is secured by the police. Mrs. Smith also stays with you and asks if she can call her son to come over. When asked about weapons, Mrs. Smith says, "I don't remember Norman having any guns in the house!" When the police officers arrive, they find Smith extremely agitated, pacing around and spurting out verbal obscenities. He is uncooperative, irritable, and makes threatening gestures toward the police officers. He will not listen to reason, nor will he calm down for the officers. The police are forced to restrain him in order to protect him and the officers and others involved. The police call in the EMS personnel for treatment, and Smith begins to thrash about, even with the restraints in place.

The patient is placed on a stretcher and loaded into the ambulance, and a police officer hops into the back of the emergency vehicle. The paramedic calls medical control for an Ativan order to calm the patient. Smith is resisting the IV, and three people have to hold him down while the paramedic starts an intravenous line and administers one milligram of Ativan via intravenous push (IVP). In these instances, it is advisable to check blood glucose, as this may be a cause for a psychotic episode, especially in undiagnosed diabetics. You ask Mrs. Smith if her husband has any medical or psychiatric problems, and she says, "Yes. My husband did see his primary care provider, Dr. Jones, about a month ago because he was having a lot of worry and panic. I believe Dr. Jones prescribed him Prozac for depression. Once in a while he would have panic attacks. He just got back last week from an important business trip, and I thought the medication was working. He seemed so happy and confident and said he had big plans for the future. He's very successful in business because he's such a workaholic. He can be up all night working and you would never know it by the way he can wheel and deal the next day. I was starting to worry this time that he was getting ahead of himself with his big plans. He couldn't sleep, and he was talking a mile a minute. I thought it was because he had jet lag, but this morning he was so upset. He accused me and his partner of plotting against him. He wasn't making any sense, and he was in such a rage. He said we would be sorry. I called 9-1-1 because I didn't know why he was behaving like this."

AGITATION
Agitated, psychotic states represent severe brain dysfunction. These states, which can be caused by many medical and/or psychiatric disorders, require emergent treatment due to the life-threatening risk to self and others. One common cause is when a person experiences a manic psychotic phase of a bipolar disorder.

Psychosis, a behavioral emergency, is frequently complex and can be dangerous, especially in the prehospital setting. Psychosis can be a symptom that signals medical problems (e.g., brain trauma, metabolic states, druginduced, withdrawal states, etc.), psychiatric problems (e.g., acute phase schizophrenia, bipolar disorder) or crisis states. The patient is usually uncooperative and out of control. Psychosis is not a separate disease, but rather a state in which the brain can no longer function and interprets reality inaccurately. Patients present with delusions, hallucinations or thought disorders. Delusions can be bizarre ("I have been inhabited by an alien"), persecutory ("Someone is plotting against me") or grandiose ("I have special powers and can rule the world with my will"). Hallucinations, on the other hand, are perceptual or sensory in nature. The patient may have sensory distortion of sound (hearing voices), sight (seeing visions), smell (olfactory) or touch that other people do not experience. A thought disorder is an illogical structure of thought and is present when the person makes incomprehensible statements that are difficult to follow due to rapidity, pressure or use of unusual sentences or word structure.