101.Issue 10 october 25 - INDO AMERICAN JOURNAL OF PHARMACEUTICAL SCIENCES

Volume : 12, Issue : 10, October – 2025

Title:

PREHOSPITAL MANAGEMENT OF ACUTE BEHAVIORAL CRISES: A SYSTEMATIC REVIEW OF DE-ESCALATION TRAINING AND SEDATION PROTOCOLS FOR EMS PERSONNEL

Authors :

Turki Mohammed Saeed Al-Zahrani, Hassan Fuhayd Hadi Al Mansour, Mousa Hassan Hussain Alnami, Mousa Ali Mohammed Mulayhi, Salem Eid Khalifa Al Dhafeeri, Ahmed Abdullah Ahmed Al Barqi, Hussain Ali Hussain Al Abdulwahab, Faisal Hassan Al Omayrin, Dhifallah Abdullah Dhifallah Al Dawsari, Mohammed Ahmed Sharaf Al Hussain

Abstract :

This systematic review aims to synthesize and evaluate the current evidence on de-escalation training and sedation protocols for Emergency Medical Services (EMS) personnel managing acute behavioral crises in prehospital settings. A comprehensive search of MEDLINE, EMBASE, Cochrane Library, and PsycINFO databases was conducted following PRISMA guidelines, covering literature from 2010 to 2025. Twenty-two studies meeting inclusion criteria were analyzed, including retrospective cohorts, qualitative investigations, clinical guideline analyses, and systematic reviews. The evidence reveals that de-escalation training improves provider confidence and may reduce coercive interventions, though effectiveness depends on training quality and retention. Pharmacological management shows ketamine provides rapid sedation but carries higher risks of respiratory adverse events compared to traditional agents like benzodiazepines and antipsychotics. The review identifies significant variation in practice standards and reveals concerning disparities in restraint and sedation use across patient demographics. Successful management requires integrating communication strategies with pharmacological approaches rather than viewing them as separate interventions. Optimal prehospital management of behavioral crises requires standardized, integrated protocols combining de-escalation techniques with judicious sedation use. Implementation should include tiered treatment guidelines, regular refresher training, and specific safeguards against disparities. Future research should prioritize randomized controlled trials comparing intervention strategies and examining long-term patient outcomes.
Keywords: Prehospital Emergency Care, Behavioral Emergencies, De-escalation Training, Chemical Restraint, EMS Protocols

Cite This Article:

Please cite this article in press Turki Mohammed Saeed Al-Zahrani et al., Prehospital Management Of Acute Behavioral Crises: A Systematic Review Of De-Escalation Training And Sedation Protocols For Ems Personnel , Indo Am. J. P. Sci, 2025; 12(10).

REFERENCES:

1. Bertenshaw, C., & Parker, L. (2024). Acute Behavioural Disturbance: Emergency Pharmacological Sedation. Critical Care Paramedicine: A Case-Based Approach.
2. Bongiorno, D. M., Peters, G. A., Samuels-Kalow, M. E., Goldberg, S. A., Crowe, R. P., Misra, A., & Cash, R. E. (2025). Racial and ethnic disparities in EMS use of restraints and sedation for patients with behavioral health emergencies. JAMA Network Open, 8(3), e251281-e251281.
3. Bongiorno, D. M., Peters, G. A., Samuels-Kalow, M. E., Goldberg, S. A., Crowe, R. P., Misra, A., & Cash, R. E. (2025). Racial and ethnic disparities in EMS use of restraints and sedation for patients with behavioral health emergencies. JAMA Network Open, 8(3), e251281-e251281.
4. Brown, L. H., Crowe, R. P., Pepe, P. E., Miller, M. L., Watanabe, B. L., Kordik, S. S., … & Myers, J. B. (2022). Adverse events following emergent prehospital sedation of patients with behavioral emergencies: A retrospective cohort study. The Lancet Regional Health–Americas, 9.
5. Brown, L. H., Crowe, R. P., Pepe, P. E., Miller, M. L., Watanabe, B. L., Kordik, S. S., … & Myers, J. B. (2022). Adverse events following emergent prehospital sedation of patients with behavioral emergencies: A retrospective cohort study. The Lancet Regional Health–Americas, 9.
6. Brown, N., Edwards, T., McIntyre, I., & Faulkner, M. (2022). A retrospective cohort study of pre-hospital agitation management by advanced paramedic practitioners in critical care. British Paramedic Journal, 7(3), 8-14.
7. Burgos-Esteban, A., Cordón-Hurtado, V., Giménez-Luzuriaga, M., Peinado-Quesada, M., Gómez-Lage, L., Juárez-Vela, R., … & Quintana-Diaz, M. (2025). Intranasal Drug Administration for Psychomotor Agitation as a Safe and Effective Prehospital Intervention: An Integrative Review. Nursing Reports, 15(6), 219.
8. Burgos-Esteban, A., Cordón-Hurtado, V., Giménez-Luzuriaga, M., Peinado-Quesada, M., Gómez-Lage, L., Juárez-Vela, R., … & Quintana-Diaz, M. (2025). Intranasal Drug Administration for Psychomotor Agitation as a Safe and Effective Prehospital Intervention: An Integrative Review. Nursing Reports, 15(6), 219.
9. Cash, R. E., Kinsman, J., Crowe, R. P., Rivard, M. K., Faul, M., & Panchal, A. R. (2022). National characteristics of emergency medical services responses for behavioral health emergencies in the United States. Prehospital Emergency Care, 26(2), 206-215. https://doi.org/10.1080/10903127.2020.1863531
10. Cole, J. B., Klein, L. R., Nystrom, P. C., Moore, J. C., Driver, B. E., Fryza, B. J., Harrington, J., & Ho, J. D. (2022). A prospective study of ketamine versus haloperidol for severe prehospital agitation. Clinical Toxicology, 60(5), 571-577. https://doi.org/10.1080/15563650.2021.1984997
11. Correll, D. (2020). Prehospital use of ketamine for rapid sedation of the acutely agitated patient (Master’s thesis, Boston University).
12. Correll, D. (2020). Prehospital use of ketamine for rapid sedation of the acutely agitated patient (Master’s thesis, Boston University).
13. Cummings, C., Babcock, L., Zhang, Y., Lee, S. H., Schwartz, H., Semenova, O., … & Cincinnati Children’s Prehospital Care Committee. (2024). Prehospital restraint use in pediatric patients with mental and behavioral health emergencies. Pediatric Emergency Care, 10-1097.
14. Donnelly, E. A., Ford-Jones, P., & Oehme, K. (2024). “Treat them like a person”: An exploration of behavioral health emergencies and stigma in the emergency medical services. Stigma and Health.
15. Donnelly, E. A., Ford-Jones, P., & Oehme, K. (2024). “Treat them like a person”: An exploration of behavioral health emergencies and stigma in the emergency medical services. Stigma and Health.
16. Drew, P. (2023). Occupational violence against paramedics: Hostility, mitigation practices and the insight of practice theory (Doctoral dissertation, Queensland University of Technology).
17. Drew, P., Devenish, S., & Tippett, V. (2024). Paramedic occupational violence: A qualitative examination of aggressive behaviour during out-of-hospital care. Paramedicine, 21(6), 248-259.
18. Drew, P., Tippett, V., & Devenish, S. (2021). Paramedic occupational violence mitigation: a comprehensive systematic review of emergency service worker prevention strategies and experiences for use in prehospital care. Occupational and environmental medicine, 78(11), 841-848.
19. Drew, P., Tippett, V., & Devenish, S. (2021). Paramedic occupational violence mitigation: a comprehensive systematic review of emergency service worker prevention strategies and experiences for use in prehospital care. Occupational and environmental medicine, 78(11), 841-848.
20. Dunn, T. (2021). Prehospital Behavioral Emergencies. In Behavioral Emergencies for Healthcare Providers (pp. 269-278). Cham: Springer Nature Switzerland.
21. Dunn, T., & Dempsey, C. (2017). Agitation Emergency Providers in and Medical Field Law Settings: Enforcement. The Diagnosis and Management of Agitation, 156.
22. Dunn, T., Dempsey, C., Zeller, S., Nordstrom, K., & Wilson, M. (2017). Agitation in field settings: emergency medical services providers and law enforcement. The Diagnosis and Management of Agitation, 156.
23. Ford-Jones, P. C. (2023). Enhancing safety and mitigating violence on prehospital mental health calls: for the care providers and care recipients. Canadian Journal of Community Mental Health, 42(2), 17-31.
24. Ford-Jones, P. C. (2023). Enhancing safety and mitigating violence on prehospital mental health calls: for the care providers and care recipients. Canadian Journal of Community Mental Health, 42(2), 17-31.
25. Gardner, A. (2023). An Analysis of the Behavioral Health Response Training Provided to EMS Personnel (Doctoral dissertation, The Ohio State University).
26. Gardner, A. (2023). An Analysis of the Behavioral Health Response Training Provided to EMS Personnel (Doctoral dissertation, The Ohio State University).
27. Gottlieb, M., Long, B., & Koyfman, A. (2018). Approach to the agitated emergency department patient. The Journal of emergency medicine, 54(4), 447-457.
28. Guerrero, P., & Mycyk, M. B. (2020). Physical and chemical restraints (an update). Emergency Medicine Clinics, 38(2), 437-451.
29. Hector, J., & Khey, D. (2022). The frontline: EMS, law enforcement, and probation and parole. In Criminal justice and mental health: An overview for students (pp. 65-95). Cham: Springer International Publishing.
30. Ivancevich, D. M. (2015). Crisis intervention team (CIT) training for emergency medical services (EMS) personnel. Florida Gulf Coast University.
31. Ivancevich, D. M. (2015). Crisis intervention team (CIT) training for emergency medical services (EMS) personnel. Florida Gulf Coast University.
32. Khatri, U. G., & Sondheim, S. E. (2025). Unmasking Racial and Ethnic Disparities in Prehospital Sedation and Restraint Practices—Beyond the Straps. JAMA Network Open, 8(3), e251289-e251289.
33. Knox, D. K., & Holloman, G. H., Jr. (2012). Use and avoidance of seclusion and restraint: Consensus statement of the American Association for Emergency Psychiatry Project BETA Seclusion and Restraint Workgroup. Western Journal of Emergency Medicine, 13(1), 35–40. https://doi.org/10.5811/westjem.2011.9.6867
34. Lee, C. W., McNaughton, H., Smith, M., & Killeen, J. (2023). Prehospital sedation with ketamine for severe agitation: A systematic review and meta-analysis. The American Journal of Emergency Medicine, 68, 1-8. https://doi.org/10.1016/j.ajem.2023.02.001
35. Lee, M. P., Green, K., Naccarato, E., & Kreshak, A. A. (2022). Violence against emergency medical services personnel: A systematic review of the literature. The American Journal of Emergency Medicine, 55, 35-41. https://doi.org/10.1016/j.ajem.2022.02.025
36. Lindridge, J., Edwards, T., & Blackwood, L. (2024). Advanced paramedics’ restraint decision-making when managing acute behavioural disturbance (ABD) in the UK pre-hospital ambulance setting: A qualitative investigation. Plos one, 19(5), e0302524.
37. Lindridge, J., Edwards, T., & Blackwood, L. (2024). Advanced paramedics’ restraint decision-making when managing acute behavioural disturbance (ABD) in the UK pre-hospital ambulance setting: A qualitative investigation. Plos one, 19(5), e0302524.
38. Lindridge, J., Edwards, T., & Blackwood, L. (2025). Decision-making and acute behavioural disturbance (ABD): a qualitative thematic analysis of perspectives on decision-making by UK ambulance paramedics. BMC Emergency Medicine, 25(1), 135.
39. Lindridge, J., Edwards, T., & Blackwood, L. (2025). Decision-making and acute behavioural disturbance (ABD): a qualitative thematic analysis of perspectives on decision-making by UK ambulance paramedics. BMC Emergency Medicine, 25(1), 135.
40. Lowrie, L. N., Duncan, L., Samuels, D. A., Ablah, E., & Ofei-Dodoo, S. (2023). Prehospital clinical decision-making for medication administration for behavioral emergencies. Kansas Journal of Medicine, 16(2), 189.
41. Lowrie, L. N., Duncan, L., Samuels, D. A., Ablah, E., & Ofei-Dodoo, S. (2023). Prehospital clinical decision-making for medication administration for behavioral emergencies. Kansas Journal of Medicine, 16(2), 189.
42. Md, S. S. M. (2024). Prehospital Workplace Violence: Evaluating Prevalence, Impact, and Risk Factors (Master’s thesis, College of Medicine-Mayo Clinic).
43. Mearkle, B., Su, J., & Quinn, E. (2025). A National Analysis on Statewide Prehospital Adult Behavioral Sedation Protocols with a Focus on Trends in Ketamine Administration. The Journal of Emergency Medicine.
44. Mearkle, B., Su, J., & Quinn, E. (2025). A National Analysis on Statewide Prehospital Adult Behavioral Sedation Protocols with a Focus on Trends in Ketamine Administration. The Journal of Emergency Medicine.
45. Ofei-Dodoo, S., Samuels, D., Lowrie, L. N., Duncan, L., & Hoang, M. (2023). Prehospital Clinical Decision-Making for Medication Administration for Behavioral Emergencies.
46. Page, C. B., Parker, L. E., Rashford, S. J., Kulawickrama, S., Isoardi, K. Z., & Isbister, G. K. (2020). Prospective study of the safety and effectiveness of droperidol in elderly patients for pre‐hospital acute behavioural disturbance. Emergency Medicine Australasia, 32(5), 731-736.
47. Patel, M. X., Sethi, F. N., Barnes, T. R., Dix, R., Dratcu, L., Fox, B., … & Woods, L. (2018). Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: de-escalation and rapid tranquillisation. Journal of Psychiatric Intensive Care, 14(2), 89-132.
48. Raab, M., Lizarondo, L., & Brook, C. (2018). Effectiveness and safety of pharmacological sedation for aggressive or agitated adult patients in a prehospital emergency situation: a systematic review protocol. JBI Evidence Synthesis, 16(4), 805-810.
49. Raab, M., Lizarondo, L., & Brook, C. (2018). Effectiveness and safety of pharmacological sedation for aggressive or agitated adult patients in a prehospital emergency situation: a systematic review protocol. JBI Evidence Synthesis, 16(4), 805-810.
50. Reich, J. H., & Ng, A. T. (2021). Behavioral health emergencies. Emergency Medical Services: Clinical Practice and Systems Oversight, 1, 467-479.
51. Richmond, J. S., Berlin, J. S., Fishkind, A. B., Holloman, G. H., Jr., Zeller, S. L., Wilson, M. P., Rifai, M. A., & Ng, A. T. (2012). Verbal de-escalation of the agitated patient: Consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. Western Journal of Emergency Medicine, 13(1), 17–25. https://doi.org/10.5811/westjem.2011.9.6864
52. Roberts, L., Masters, S., & Henderson, J. (2025). Reviewing Australian paramedic clinical practice guidelines for persons experiencing a mental health crisis. Australasian Emergency Care.
53. Roppolo, L. P., Morris, D. W., Khan, F., Downs, R., & Cordova, C. (2021). Improving the management of acutely agitated patients in the emergency department through implementation of Project BETA (Best Practices in the Evaluation and Treatment of Agitation). Journal of the American College of Emergency Physicians Open, 2(5), e12556. https://doi.org/10.1002/emp2.12556
54. Saidinejad, M., Foster, A. A., Santillanes, G., Li, J., Wallin, D., Barata, I. A., … & Gausche‐Hill, M. (2024). Strategies for optimal management of pediatric acute agitation in emergency settings. JACEP Open, 5(4), e13255.
55. Stancliff, H., Buresh, C., Cavaliere, G., Boehmer, S., & Sandelich, S. M. (2025). Social Vulnerability and Pediatric EMS Behavioral Health Activations: Trends in Utilization and Sedation Practices. Prehospital Emergency Care, 1-8.
56. Tosswill, H., Cabilan, C. J., Learmont, B., & Taurima, K. (2023). A descriptive study on the use of restrictive interventions for potentially or actually violent patients in the emergency department. Australasian emergency care, 26(1), 7-12.
57. Turner, S. M., Kroll, M., Barlow, I., & Brown, A. (2022). Prehospital management of acute agitation: A scoping review. Journal of Paramedic Practice, 14(7), 286-295. https://doi.org/10.12968/jpar.2022.14.7.286
58. Wilson, M. P., Pepper, D., Currier, G. W., Holloman, G. H., Jr., & Feifel, D. (2017). The psychopharmacology of agitation: Consensus statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup. Western Journal of Emergency Medicine, 13(1), 26–34. https://doi.org/10.5811/westjem.2011.9.6866
59. Wilson, M., & van Ruiten, S. (2013). Share. Handbook for Artistic Research Education. Amsterdam, Dublin, Gottenburg: SHARE Network.