Date Published

April 8, 2014

Updated For

ALS PCS Version ALS PCS Version 5.2


Question: In the case of a post-ictal combative patient, is time considered a "reversible" cause? I'm hesitant to jump to sedation for somebody who could resolve on their own in a few minutes. However, today we had a case where we held off, but the patient was not improving and beginning to pose a danger to himself so we went ahead with the standing order. Should we have initiated it immediately? Or if safe for the patient wait to see if they do resolve on their own, and what would be an acceptable time frame?


 Great question. You are correct as post-ictal agitated patients often improve over time and depending on their degree of agitation/combativeness, can often be managed non pharmacologically.

The combative patient protocol is designed to protect both the patient and paramedics from sustaining injury and so that paramedics can provide the appropriate care. If in your clinical judgment, the patient is at risk for harming themselves or others, then using midazolam for sedation would be appropriate if there are no contraindications. If however, you feel that the patient is only mild agitated and not combative, can be managed non-pharmacologically, and is not at risk for harm to self or others, then document your clinical judgment and decision.

Short answer, time is not a reversible cause and if in your clinical judgment the patient is combative and at risk for harming themselves, others or sedation is required to provide care, then proceed with your combative patient medical directive.



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