More so today than previously, first aiders on a scene and First aid providers in the health care environment encounter people presenting with abnormal behavior, including agitation, aggression and abnormal thinking or thoughts.
While alcohol and recreational drugs are a common cause of the abnormal behavior, they are not the only causes, and First Aid responders should use caution when providing assistance to an agitated person without obvious trauma or injury due to the high probability of a mental disturbance like schizophrenia that may result in an unprovoked physical assault on the first aider by the person they are attempting to treat.
The Australian and New Zealand Committee on Resuscitation (ANZCOR) had established a well-planned summary for First Aid Management of the Agitated Person that delineates how to appropriately approach the agitated person.
Behavioral disturbances can range from mild to life-threatening for both the person and the First Aid provider. Professional healthcare assessment is needed to determine the most likely cause of the abnormal behaviour, and that determination will guide the appropriate treatment. The immediate goal of First Aid for the agitated/behaviorally 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. It may include threatening harm or death to the provider, aggressive behaviour and explicit language, extreme distress, and serious self-harm, which could cause significant injury or death.
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 and behavioural disturbance, including:
• Medical conditions and allergic reactions to medication
• Head injury or tumours
• Hypoxia (low oxygen levels in the blood)
• Infections of the brain like meningitis
• Seizures, metabolic derangements from low blood sugar, electrolyte disturbance
• Organ failures
• Dementia and delirium
• Intoxication or withdrawal from substances of addiction
• Stimulants (amphetamine-type substances, cocaine, cannabis, synthetics, opioids, sedatives
• Mental health conditions & psychotic disorders like schizophrenia
• Anxiety disorders and multiple personality disorders
• Developmental disorders, intellectual disability, autism spectrum disorders,
• Grief and bereavement
• Unrelenting situational stress and pressure (‘Postal Worker’ syndrome)
These causes may apply 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 and behavioural disturbance may simultaneously apply to one or more people, such as in motor vehicle accident scenes.
Recognition Of Someone Displaying Disturbed Behaviour
Agitation and behavioural disturbance encompass a variety of symptoms and signs as a stand-alone feature or in combination with other symptoms. Diagnosis is primarily based on history and physical findings.
Symptoms and signs are highly variable but include:
• Increased arousal (agitation, excitation, restlessness, pacing, tearful, wringing hands, screaming, yelling, frightened, frantic).
• Rigid body posture and body language (an indicator of an intense effort to control themselves).
• Abnormal or unusual thinking, perception, or ideas (hallucinations).
• Inappropriate clothing for the climate or situation in 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 (maybe walking with a broken leg or severe injury)
• A rapid respiratory rate and rapid pulse rate
• Extreme arousal with aggression or violence.
Management Strategies For Dealing With An Agitated Person
The initial approach to a person with agitation or behavioural disturbance should focus on safety. De-escalation strategies are extremely difficult without training and experience. They can exacerbate the situation if not performed correctly. 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 avoiding further danger to first aiders and bystanders.
Principles Of Safety When Managing An Agitated Person
• Ensure your safety and the safety of others – seek appropriate support and assistance early
(Ambulance, security services, police, mental health professionals).
• Reassure – empathise and listen actively if it is safe. Listen closely and non-judgementally to what the person is saying and feeling. If possible, take notes in dot form of the subject matter or record the conversation on a mobile phone to share with the responding professional service for accurate treatment and assessment.
• Seek advice or assessment from a healthcare professional if the person is a direct family member or friend.
• If the person deteriorates or becomes unconscious, manage the person according to DRSABCD protocols. Manage airway.
• If the person becomes unresponsive and not breathing normally, give resuscitation following the Basic Life Support CPR following DRSABCD protocols.
Staying Safe As A First Aid Responder
Staying safe is a priority. Be aware of the potential danger and ensure the safety of first aiders, others, and the behaviourally disturbed person. If you are unsure or feel threatened, 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 keep at least two arm lengths away when possible.
• 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 the exits.
• Remove any objects that could be used as weapons.
• People who are calming may be of assistance and try to keep conflict partners away from the
• 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 or incite 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 be acting on a delusion or hallucination, and this may not make sense to the first aider but will be experienced as a ‘real phenomenon’ by the person.
• 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.
Behavioural Disturbance In Children
The effective management of behavioural disturbance in children is complex and requires specialised training and extensive experience, increasing the need to seek appropriate support and assistance early. The same general management principles 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 child’s safety. Involvement of the child’s family or carer (if available and appropriate) will generally be helpful in the first aid setting. The child’s family or carer will be able to provide advice and assistance to determine the most likely effective de-escalation strategies, such as age-appropriate distraction techniques like toys or shiny, flashing objects, or items of comfort.
The Use Of Physical Restraint
Physical restraint is associated with potential harm to both the aggressive or agitated and behaviourally disturbed person, and the care provider. The risks of physical restraint in most cases typically outweigh the benefits.
ANCOR recommends avoiding the physical restraint of aggressive, agitated or behaviorally disturbed persons by bystanders, first aiders and first aid providers unless there is a life-threatening reason that would require restraint to treat them, such as an artery puncture leading to imminent death if not treated immediately.