Who does this guideline apply to?

This guideline applies to adults, adolescents and children

Who is the audience for this guideline?

This guideline is for bystanders, first aiders and first aid training providers

Recommendations

The Australian and New Zealand Committee on Resuscitation (ANZCOR) make the following recommendations:

1. Ensuring your safety and the safety of others; send for help early. [Ungraded, Good practice statement]
2. attempt de-escalation strategies/techniques only if experienced in these techniques. [Ungraded, Good practice statement]
3. identify and treat any medical conditions and/or injuries when safe to do so. [Ungraded, Good practice statement]
4. avoid physical restraint for an aggressive, agitated/behaviourally disturbed person. [Ungraded, Good practice statement]

First aiders and first aid providers may encounter persons presenting with abnormal behaviour including agitation, aggression and abnormal thinking or thoughts.  Behavioural disturbances can range from mild to life threatening.  Professional healthcare assessment is needed to determine the most likely cause of the abnormal behaviour to guide appropriate treatment. 

The immediate goals of first aid for the agitated/behaviourally disturbed person is keeping yourself, others and the person safe from harm.

Severe behavioural disturbance is behaviour that puts the disturbed person or others at immediate risk of serious harm and may include threatening or aggressive behaviour, extreme distress, and serious self-harm which could cause major injury or death. ¹

Agitation or behavioural disturbance can have many causes and may or may not be related to a mental health disorder or other illness. There are many causes of agitation / behavioural disturbance including:

• medical conditions e.g. head injury, hypoxia (low oxygen levels in blood), infections (e.g. meningitis), seizures, metabolic derangements (e.g. low blood sugar, electrolyte disturbance), organ failures (e.g. liver & kidney), dementia and delirium
• intoxication / withdrawal e.g. alcohol, hallucinogens, stimulants (e.g. amphetamine type substances, cocaine), cannabis, synthetics, opioids, sedatives
• mental health conditions e.g. psychotic disorders (e.g. schizophrenia), anxiety disorders, and personality disorders
• others: developmental disorders e.g. intellectual disability, autism spectrum disorders, grief, situational stress and pain.

These causes may be applicable to the person requiring first aid and/or others at the scene such as a parent, friend, partner or family member.  The first aid management of agitation / behavioural disturbance may apply to one or more people at the same time².

Agitation / behavioural disturbance encompasses a variety of symptoms and signs alone or in combination. Diagnosis is largely based on history and physical findings. Symptoms and signs are highly variable but include:

• increased arousal (e.g. agitation, excitation, restlessness, pacing, tearful, wringing hands, screaming, yelling, frightened, frantic)
• a rigid body language (an indicator of an intense effort to control themselves)
• abnormal or unusual thinking, perception or ideas (e.g. hallucinations)
• inappropriate clothing for the climate or context
• altered conscious state
• aggressive / violent / argumentative / bizarre behaviour.

A severe and potentially life-threatening form of behavioural disturbance is present when the person has:

• an elevated body temperature, is hot to touch or is sweating profusely
• insensitivity to pain (e.g. may be walking with a broken leg or severe injury)
• a rapid respiratory rate and rapid pulse rate
• extreme arousal with aggression or violence.

The initial approach to a person with agitation / behavioural disturbance should be focused on safety.  De-escalation strategies are extremely difficult without training and experience.  They can exacerbate the situation if not performed properly.  They should not be attempted unless trained and skilled at the technique.  The important point is to stay safe and seek help.  The points below are given as information on how to avoid further danger to first aiders and bystanders.

Principles

• Ensure your safety and the safety of others – seek appropriate support and assistance early (e.g. ambulance, security services, police, mental health professionals).
• Reassure – empathise and listen actively, if it is safe and trained to do so. Listen closely and non-judgementally to what the person is saying and feeling.
• Seek advice or assessment from a healthcare
• If the person deteriorates or becomes unconscious, manage the person according to ANZCOR Guideline 3.
• If the person becomes unresponsive and not breathing normally, give resuscitation following the Basic Life Support Flowchart (ANZCOR Guideline 8).

Staying safe is a priority. Be aware of the potential danger and ensure safety of first aiders, others and the behaviourally disturbed person. If you are unsure or feel threatened in any way, remove yourself and others from the situation, seek a safe space and send for appropriate support and assistance.

• Avoid being alone with the person and when possible keep at least two arm lengths away.
• Always face the person, maintain visual contact and never turn your back.
• Be vigilant for signs of violence or escalation.
• Make sure there is access to two exits if possible and avoid blocking exits.
• Remove any object that could be used as weapons.
• People who are calming may be of assistance and try to keep conflict partners away from the person.
• Speak politely and with non-threatening body language.
• Reduce external stimuli such as noise, odour, light, and background movement.
• Be aware of the person’s cultural background to avoid words or actions that are taboo or could shame the person.
• It is helpful to find someone the person knows and trusts to help with their care, but do not leave the scene to find that person.
• Be aware the person may act on a delusion or hallucination and this may not make sense to the first aider.
• If a person does become violent or you feel unsafe; stop managing them, move to safety and send for appropriate support and assistance.
• Watch for decreasing level of consciousness.

The effective management of behavioural disturbance in children is difficult and requires specialised training and extensive experience, increasing the need to seek appropriate support and assistance early.  The same general principles of management apply as described above modified to the child’s age and needs. 

The initial focus of management should be on your safety, the safety of others and the safety of the child. Involvement of the child’s family/ carer (if available and appropriate) will generally be helpful in the first aid setting.  The child’s family / carer will be able to provide advice and assistance to determine the most likely effective de-escalation strategies such as age appropriate distraction techniques (e.g. toys).

Physical restraint is associated with potential harm to both the aggressive or agitated / behaviourally disturbed person and the care provider.  The risks of physical restraint typically outweigh the benefits.  ANZCOR recommends avoiding the physical restraint of aggressive, agitated/behaviourally disturbed persons by bystanders / first aiders and first aid providers.

1. New South Wales Health 2015, Management of patients with Acute Severe Behavioural Disturbance in Emergency Departments, viewed 15 March 2019, < https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2015_007.pdf >
2. Iroku-Malize, T. & Grisson, M. The agitated patient: Steps to take, how to stay safe. The Journal of Family Practice. 2018 March; 67(3): 136-147.
3. Zeller S, Nordstrom K, Wilson M, The Diagnosis and management of Agitation. 2017 Cambridge: Cambridge University Press
4. Richmond JS, Berlin JS, Fishkind AB, et al. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012;13(1):17–25. doi:10.5811/westjem.2011.9.6864
5. Robyn L. Langlands, Anthony F. Jorm, Claire M. Kelly, and Betty A. Kitchener First aid recommendations for psychosis: using the Delphi method to gain consensus between mental health consumers, carers, and clinicians.  Schizophr Bull. 2008 May;34(3):435-43.

• ANZCOR Guideline 2 - Managing an emergency
• ANZCOR Guideline 8 - Cardiopulmonary Resuscitation
• ANZCOR Guideline 9.5.1 - Emergency management of a person who has been poisoned
• Kitchener BA, Jorm AF, Kelly CM. Mental Health First Aid Manual. 4^th Melbourne: Mental Health First Aid Australia; 2017