First line in psychiatric emergency: pre-hospital emergency protocol for mental disorders in Iran

Introduction This article is a report of designing a rapid and effective guide for paramedics who take care of patients in a pre-hospital setting to answer developing demands. Methods The relevant literature was reviewed, and the topics were extracted. Then, the extracted items were discussed in an expert panel. Finally, items were discussed in a meeting including emergency technicians and emergency technical assistants to identify implementation problems. Results Important topics for managing psychiatric patients were categorized at three levels: 1) Patient safety and security issues, 2) Patient status assessment and diagnosis, and 3) Patient management (medical, behavioral management, and referral to a treatment center). Discussion This protocol can be a solution to improve emergency technician training. Such summarized protocols can be used for rapid review immediately before exposing a patient with an acute psychiatric condition. Due to specific cultural and different access to medicines in Iran, some issues are different.


Background
Mental health problems are quite prevalent and pose a heavy burden on a society. According to the Burden of Disease study performed in Iran in 2003, mental and behavioral disorders were ranked as the second in intentional and unintentional injuries [1]. Moreover, the latest national survey on mental disorders has shown that a one-year prevalence of psychiatric disorders in Iran is 23.6% [2]. A small but significant proportion of these patients would need intensive care, sometime during the course of their disease. In such a psychiatric emergency, paramedics are in the front line of emergency medical service (EMS) for assessing, managing and transferring patients to the emergency wards of hospitals. Therefore, the role of paramedics is critical in rapid and accurate decision making.
Despite the vital role of paramedics in pre-hospital management of psychiatric problems, little evidence exists on the issue [3]. Paramedics have three major needs for a good performance: knowledge, skill for an appropriate clinical decision making, and organizational factors [3]. Educational courses have been shown to improve their knowledge, attitude, skill, and self-efficacy in performing the job and also will help them in better decision making on the scene [4][5][6].
Emergency paramedic may face many difficulties in making decisions for emergency patients with mental illness [7]. They should prioritize safety in the first place and simultaneously assess the patients for possible physiological, psychiatric, pathological, socio-cultural, and legal aspects to reach an accurate diagnosis and also manage plans [8,9]. Additionally, they are frequently exposed to the aggressive behavior of violent patients [10] and inappropriate management of aggressive behavior can have severe consequences. In the case of highly aggressive patients, chemical and physical restraint should be performed very cautiously [11] under clinical guidelines [10].
Emergency staffs are at the risk of cumulative stress because of the high amount of stress they experience; and if it is not adequately addressed, emotional trauma and its related dysfunction would appear [12]. Paramedic's workloads for mental illness are growing and their ability for decision making in the complex situation of psychiatric emergency should be amended [4]. Furthermore, their ability to triage patients with psychiatric problems is limited and, in some cases, paramedics admitted the necessity of assessment tools and training courses for maintaining the capability of emergency services [4,6,12,13]. Therefore, they will benefit from educational courses and rapid clinical protocols that would help them with their clinical decision making [6]. This article is a report of the process of designing a rapid and effective guide for paramedics who take care of patients to answer increasing demands in a pre-hospital setting.

Methods
This project was conducted at the request of the Technical Assistance and Operations Department of the Iranian Emergency Organization. Firstly, the relevant literature was reviewed. To prevent bias and to enrich resources, in addition to the chapters on managing patients with acute psychiatric symptoms in psychiatric textbooks, more specialized resources in the field of emergency psychiatric patient's management were also reviewed. We also searched for recent related articles in PubMed, Scopus, and Web of Knowledge databases.
We combined keywords related to emergency situation including "psychiatric emergency", "behavioral emergency", "agitated behavior", "agitation", "violence", and "aggression" with terms of "management", "protocol" and "prehospital care". Mesh terms, expert opinion, and some keywords from the existing literature review were used to select these keywords. Then, we screened the retrieved articles and removed the unrelated articles.
17 documents out of 56 primitive cases were selected which their information has been presented in Table 1. The criterion for omitting the articles was decided by research team based on the critical appraisal using peer review checklist for protocol recommended by Cochrane Community [14].
Finally, we extracted the topics in the remaining related articles. The extracted topics were then classified based on seven criteria as follows: 1) Order of execution (at what stage they should execute), 2) first encounter with the patient and maintaining safety, 3) Evaluation and taking a medical history, 4) The primary differential diagnoses, 5) Behavioral and drug therapy and management, 6) Decreasing life-threatening risks in patients, and 7) Repeatable rate in different sources. Based on these categories, an early draft of the protocol was written. The draft was sent to 10 psychiatrists who expert in emergency psychiatry and their initial feedbacks were collected. Some changes were made in the protocol, according to the experts' comments. In the next step, an expert panel was held.
The panel included experts from psychiatry, forensic medicine, clinical psychology, emergency medicine, Emergency Technical Assistant (deputy) and a general physician. In the panel, each expert commented on each of the items and stages according to the following questions: Each item was scored using a Likert scale from very low [1] to very high [9]. After adding the scores based on the expert's decisions, Items with a mean score 6 and higher, remained unchanged in the protocol and those with a mean score of 3 and lower were eliminated from the protocol. Other Items were discussed once more and were finally agreed upon with some minor changes.
The above case was presented in a meeting of 60 emergency technicians (with more than 15 years of working experience) from different cities of Iran. Applicability, clearness and comprehensibility of items were discussed. The ambiguities of the protocol were addressed, and the implementation issues of the protocol were identified. The protocol was finalized in 2 pages that were applicable in an ambulance for reviewing important points when confronting with psychiatric patients.

Results
Based on the findings from the literature review and discussed issues in the expert panel, important topics for managing psychiatric patients were categorized in three levels: 1) Patient safety and security issues, 2) Patient status assessment and diagnosis and 3) Patient management (medical, behavioral management, and referral to a treatment center).

Primary actions
The first step is to ensure the safety of the patient, technicians, and people on the scene [15]. This stage includes: a) pre-scene assessments of site security, escape routes, and safe locations in the event of violence from the patient, b) assessment of patient's access to weapons and equipment that could threaten his/her own life, technicians or attendees [16], C) Assessment for risk and need for back up and the presence of police, which includes anticipating their entrance method and avoidance of entering the place alone, D) using family capacities to provide security [16] and E) Assessment of risk factors for violence and predicting it Symptoms of imminent aggression include: 1) Motor restlessness and agitation, 2) The loud and threatening tone of voice, 3) Threatening behavior and gestures, 4) Verbal Threats, 5) Staring and angry face mode, 6) Sudden behaviors (He throws the object in his hand suddenly), 7) Bizarre behavior due to delusion and hallucination.

Patient assessment
Patient evaluation includes the following: A) Urgent physical needs by evaluating vital signs (Airway, presence of respiratory distress, and pulse), B) Obtaining a targeted mental health history of the patient from his or her family including: Demographic characteristics (sex, age, occupation), history of psychiatric illness, history of physical and primarily neurological diseases, history of drug abuse, history of violence or suicide [15], C) Differential diagnoses (psychological causes versus physical causes of symptoms) and physical risk factors (sudden onset of symptoms without previous history, age younger than 12 years and older than 60 years, known neurological diseases such as seizures or dementia, existence

Patient management
Patient management includes: a) behavioral management, b) pharmacological management, c) patient family management.
a) Patients' behavioral management includes following recommendations on how to behave and speak to the patient: Speak to the patient in a calm, measured and confident tone Reduce external stimuli, such as the noise and the provocative behavior of others [18] Reduce internal triggers like hunger and thirst, and offer water and food to the patient whenever possible. have empathic and non-judgmental attitudes and behaviors accept the patient's hallucinations and delusions appropriately Don't make a false promise to the patient Use short, simple sentences and repeat the sentences if necessary Listen to the patient Use patients' words as much as possible Reassure the patient that you understand the problem Encourage the patient to provide information to those who can help Attempt to meet the patient's spiritual needs (include general spiritual principles in the patient-therapist relationship, showing compassion and unconditional acceptance to the patient) Encourage the patient to provide information to those who can assist him/her.
In case of aggression, in addition to the mentioned points, Keep the patient at least 2 m away, tell the patient that aggression is unacceptable, offer medication and in order to prevent harm themselves or others, use physical restraint if s/he continues [19]. b) Pharmacological management: There are several important principles to consider in drug administration. The aim of emergency medical treatment should be to calm down the agitated patient as quickly as possible without reducing the patient's level of consciousness. Like all emergencies, oral drugs are preferred to injectable ones. The drug should be selected based on the onset of action and availability. Short-acting drugs are preferred over long-acting drugs. Medicines with fewer side effects are also preferred. Thus, in the first step, oral medications such as benzodiazepines or lorazepam with or without typical antipsychotics such as risperidone may be used.
In the second line, other antipsychotics such as haloperidol may be administered. If the patient's condition does not improve or he/she does not cooperate in the treatment, intramuscular antipsychotics such as Amp haloperidol 5 mg along can be used. If necessary, these medications can be repeated with cardiac and blood pressure monitoring. Other medicines such as promethazine or injectable benzodiazepines may also be used to increase the effectiveness of the administered drugs [19][20][21] (Table 3).
Restraints may use with the pharmacological methods. This treatment option is used as the last choice in patients who are uncooperative and physically dangerous and may harm themselves or others, and when nonpharmacological and primary pharmacological methods are ineffective. In these cases, special care should be taken to protect the patient from life-threatening situations (Table 4).
In addition to the above-mentioned points, consider the Contraindications of restraining which include the followings [22,23]: Cases in which patients used Phencyclidine (PCP) based on the family history Patients with recent surgery in the eye or central nervous system (Because of an increase in intracerebral or intraocular pressure) patients with a low level of consciousness or with delirium c) Intervention in the patient family including having empathy and understanding of the critical situations and psycho-education about the conditions and places that they can attend [24].
Management of suicide emergencies requires special consideration. The expert panel suggests that suicide emergencies need a separate protocol. Moreover, while drug and alcohol poisoning and deprivation have similar symptoms with psychological emergencies, they have a completely different treatment, and they need another protocol.

Discussion
A psychiatric emergency refers to any disturbances in a patient's thinking, emotions, or behavior that requires immediate intervention. This disruption usually puts patients in critical conditions, which can put them, their family, and people around them in danger. These emergencies include hurting others or themselves, aggression, restlessness, acute behavioral symptoms caused by drug poisoning, depression, and severe anxiety [15].
It is essential to distinguish between the physical and psychological causes of these symptoms because it completely changes the course of treatment. In some reference books and articles, there are general protocols for managing psychotic patients [25]. But in most of the previously written protocols, the management of a symptom such as aggression or agitation has been considered [24][25][26][27]. Allen, et al. recommended different pharmacological and behavioral interventions inpatient with agitation in different situations [24,28].
Gargia et al. suggested several recommendations on the assessment of agitation emphasize the importance of identifying any possible medical cause [29]. Most of the existing protocols are related to patient management in the hospital emergency department, and less attention has been paid to earlier stages, such as the pre-hospital stage.
In the current protocol, the first thing is the safety of technicians, their patients, and people who are in the scene. Almost all references related to acute psychotic symptoms consider the existence of a safe environment as the necessary precondition for patient management [15,16]. These include the safety of the environment and the management of patients' behaviors that may be harmful to themselves and others. Therefore, this protocol as well as predicting such behaviors and managing them according to international protocols is also considered.
Because of the legal aspects, police presence was also expected in the case of using mandatory treatments. This is also important for the safety of the technician, and it has been addressed in previous protocols [30]. Also, considering the priority of saving a patient's life, early assessment of his/her vital signs is a priority [31] which we put in the primary steps of treatment. Because of the importance of diagnosing physical disorders that have symptoms similar to mental disorders, we placed making a differential diagnosis after examining vital signs.
The second point in the present protocol is to consider the overlap of many symptoms of physical illness with psychiatric disorders and to consider the differential diagnosis. Therefore, vital signs and evidence of lifethreatening disorders should be examined. Impairment of the judgment and lack of co-operation in psychiatric patients can worsen the situation according to the cultural conditions in Iran.
In majority of patients' cases, living with families and intervention of families in the process of the treatment  as well as utilizing the capacity of families in the evaluation of the patient can be very helpful, which is highly considered in the present protocol. Also, in addition to the common spiritual principles associated with each patient (such as empathy, complete acceptance and being non-judgmental, etc.) paying attention to the specific religious and spiritual cultures and areas of each region that affect the therapeutic relationship with the patients is of great importance [32].
In the current protocol, like previous ones, nonpharmacological management is preferred over pharmaceutical methods. Calming the patient without medication is the priority, and drug therapy is the next priority. At the time of drug administration, in compliance with the general principles of pharmacological therapy, the priority is with the minimum dose and the oral administration root. Injectable drugs are the next priority [29]. The goal of drug therapy is to calm agitated patients without decreasing their level of consciousness [33]. However, based on available drugs and their side effects, and the possibility of drug abuse, we chose different types of drugs for the protocol. Lorazepam can be a useful drug, given the short time in the pre-hospital emergency and the need to calm the patient down with the least side effect. Lorazepam can be used in mild to moderate emergencies and in patients who are more cooperative [34].
Injectable benzodiazepines and antipsychotics such as olanzapine (considering its interaction with lorazepam and the possibility of cardiovascular collapse), ziprasidone and haloperidol are the last lines of treatment [19,35,36]. The use of injectable midazolam as recommended in other protocols [37] was not approved by experts despite its rapid and practical effect on sedation, because of the risk of abuse. Other antipsychotics such as aripiprazole were not approved in previous protocols like our protocol and are not recommended [29]. The use of physical restraint is proposed for patients who have not responded to primary treatments and may harm themselves and others. In some protocols, special beds with certain height are recommended for physical restraint. Given that these beds do not exist in Iran, restraint with ordinary beds and wide and leather straps was recommended. Indications, safety recommendations, and limitations for using physical restraint in our protocol are consistent with other protocols. The use of physical restraint should be accompanied by chemical restraint (use of medication to calm the patient) [22,23]. Special attention for patients with delirium is similar to previous protocols [23].

Study limitations
The study has several limitations. Firstly, a systematic review of the study has not been conducted and only a review of existing articles was undertaken. And secondly, Due to the limited availability of medicines in the emergency room of Iran, the suggested treatments may not necessarily be the best choices.

Conclusion
It seems that, given the lack of similar protocols in our country in the past, this protocol can be a solution to improve emergency technician training. Such summarized protocols can be used for rapid reviews immediately before being exposed to a patient with an acute psychiatric condition.
Additional file 1. Pre-hospital emergency protocol for mental disorders.