patient restraint (2006)

8/6/2019 Patient Restraint (2006)

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Issues in Patient Restraint Issues in Patient Restraint

Bryan Bledsoe, DO, FACEP Bryan Bledsoe, DO, FACEP The George WashingtonThe George Washington

University Medical Center University Medical Center


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D efinitions D efinitions

DeliriumDeliriuma mental disturbance marked by a mental disturbance marked by illusions, hallucinations, short illusions, hallucinations, short unsystematized delusions, cerebral unsystematized delusions, cerebral excitement, physical restlessness and excitement, physical restlessness and

incoherence and having aincoherence and having acomparatively short course. Deliriumcomparatively short course. Deliriumusually reflects a toxic state.usually reflects a toxic state.


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DeliriumDeliriumCauses:Causes:

General medical General medical conditionconditionSubstanceSubstance- -induced deliriuminduced delirium

Multiple etiologiesMultiple etiologiesOther causesOther causes


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Definitions Definitions

Excited Delirium:Excited Delirium: A delirium is characterized by a A delirium is characterized by asevere disturbance in the level of severe disturbance in the level of consciousness and a change inconsciousness and a change inmental status over a relatively short mental status over a relatively short

period of time, manifested by mental period of time, manifested by mental and physiological arousal, agitation,and physiological arousal, agitation,hostility and heightened sympathetic hostility and heightened sympathetic stimulationstimulation


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Positional asphyxiaPositional asphyxia Asphyxia that occurs from positioning Asphyxia that occurs from positioning of the body (i.e., hyperflexion of theof the body (i.e., hyperflexion of theneck, prone positioning) that neck, prone positioning) that interferes with the airway or bellowsinterferes with the airway or bellows

function of the respiratory muscles.function of the respiratory muscles. Also called postural asphyxia. Also called postural asphyxia.


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Restraint asphyxiaRestraint asphyxia Asphyxia occurring during the Asphyxia occurring during the process of subduing and restraining process of subduing and restraining an individual. Often causes anan individual. Often causes aninterference with the bellows action of interference with the bellows action of

the chest inhibiting gas exchangethe chest inhibiting gas exchangethus resulting in hypoxia.thus resulting in hypoxia.


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Patient Restraint Patient Restraint

What is patient restraint? What is patient restraint? The use of a physical or mechanical The use of a physical or mechanical device or chemical to involuntarily device or chemical to involuntarily restrain the movement of the whole or restrain the movement of the whole or a portion of a patients body for thea portion of a patients body for the

reason of controlling physical reason of controlling physical activities in order to protect theactivities in order to protect the patient or others from injury. patient or others from injury.


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When is patient restraint indicated?When is patient restraint indicated?When a person exhibits a behavior or When a person exhibits a behavior or

psychological syndrome that is psychological syndrome that isassociated with a significantly associated with a significantly increased risk of the person suffering increased risk of the person suffering

death, injury, pain, or disability; or death, injury, pain, or disability; or causing death, injury, pain or causing death, injury, pain or disability to another person.disability to another person.


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Patient Restraint through History Patient Restraint through History

Prior to thePrior to thedevelopment of thedevelopment of the

major tranquilizers,major tranquilizers,most patients withmost patients withdelirium, dementia,delirium, dementia,or psychosis wereor psychosis were

restrained in variousrestrained in variousfashions.fashions.


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Patient Restraint Through History Patient Restraint Through History

Mark TwainsMark Twainsyoungest daughter youngest daughter

Jean spent most of Jean spent most of her lifeher lifeinstitutionalized institutionalized because of epilepsy.because of epilepsy.


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Psychosurgery had Psychosurgery had some fleeting some fleeting

success insuccess inmanaging managing psychosis. psychosis.


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Development of theDevelopment of themajor tranquilizersmajor tranquilizers

offered significant offered significant improvements and improvements and allowed someallowed some

people to finally be people to finally be

deinstitutionalized.deinstitutionalized.


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Physical Restraints Physical Restraints

H obble restraintsH obble restraintsare sometimesare sometimes

added if theadded if thehandcuffs or other handcuffs or other measures aremeasures areineffective.ineffective.


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Most EMS systemsMost EMS systemsdo not carry any do not carry any

formalized patient formalized patient restraint system.restraint system.


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The LiteratureThe Literature

Findings:Findings:Patients found in position and asphyxia not Patients found in position and asphyxia not due to restraint.due to restraint.

Average age=50.6 years. Average age=50.6 years.Male:Female ratio=2:1. No racial or gender Male:Female ratio=2:1. No racial or gender differences when compared to total ME differences when compared to total ME

population. population.

Chronic alcoholism or acute alcohol Chronic alcoholism or acute alcohol intoxication was a significant risk factor intoxication was a significant risk factor (average post (average post- -mortem ethanol = 0.240)mortem ethanol = 0.240)Signs of mechanical asphyxiation wereSigns of mechanical asphyxiation werefound in 93% of cases.found in 93% of cases.


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Findings:Findings:43% of victims were found in restrictive43% of victims were found in restrictive

position producing hyperflexion of the head position producing hyperflexion of the head and neck.and neck.2 deaths involved Posey vests and 2 deaths involved Posey vests and elderly patients.elderly patients.Conclusion: Positional asphyxia as a causeConclusion: Positional asphyxia as a cause

of death should not be overlooked in theof death should not be overlooked in thealcoholic who dies suddenly, has aalcoholic who dies suddenly, has anegative autopsy, and variable levels of negative autopsy, and variable levels of drugs and alcohol in the blood or urine.drugs and alcohol in the blood or urine.


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Reay DT, Fligner CL, Stilwell AD,Reay DT, Fligner CL, Stilwell AD, Arnold J. Positional asphyxia during law Arnold J. Positional asphyxia during law

enforcement transport.enforcement transport. A m J Forensic A m J ForensicMed Path.Med Path. 1992;13(2):90 1992;13(2):90- -97 97


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Findings:Findings:3 cases of positional asphyxia3 cases of positional asphyxiaoccurring while victims were in proneoccurring while victims were in prone

position in the rear compartments of position in the rear compartments of patrol cars. patrol cars.


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The LiteratureThe LiteratureCase 1:Case 1:

24 y/o white man with24 y/o white man with pendulant abdomen pendulant abdomenPsychiatric history Psychiatric history Violent arrest (fought PD,Violent arrest (fought PD,struck twice with night stick)struck twice with night stick)H andcuffed and hog tied H andcuffed and hog tied and placed prone in patrol and placed prone in patrol car car Dead after 5 Dead after 5- -7 minute ride7 minute rideto ED (for night stick to ED (for night stick wounds)wounds)

Autopsy relatively Autopsy relatively unremarkableunremarkableTOX: + lithium, caffeineTOX: + lithium, caffeineDeath: Positional asphyxiaDeath: Positional asphyxia


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Case 3Case 334 y/o black man34 y/o black manLong psychiatric history (schizophrenia) and who quit taking Long psychiatric history (schizophrenia) and who quit taking medicinemedicineBegan to behave in bizarre fashion and PD summoned Began to behave in bizarre fashion and PD summoned Violent arrest and scuffle (with PD blows to chest with fists)Violent arrest and scuffle (with PD blows to chest with fists)H og tied and placed in floor of patrol car (officer rode in back H og tied and placed in floor of patrol car (officer rode in back seat with patient)seat with patient)Became quiet during 5 Became quiet during 5- -7 minute transport and dead upon7 minute transport and dead uponarrival at jail.arrival at jail.

Autopsy relatively unremarkable. Autopsy relatively unremarkable.TOX: NegativeTOX: NegativeDeath: Positional asphyxiaDeath: Positional asphyxia


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Conclusions:Conclusions:Diagnosis of positional asphyxia should beDiagnosis of positional asphyxia should beconsidered when:considered when:

Circumstances surrounding death indicate aCircumstances surrounding death indicate abody position that could interfere withbody position that could interfere withrespirationrespirationH istorical information indicates difficulty H istorical information indicates difficulty breathing or unusual respiratory signs such asbreathing or unusual respiratory signs such ascyanosis, gurgling, gasping, or any physical cyanosis, gurgling, gasping, or any physical manifestations that could be interpreted asmanifestations that could be interpreted asrespiratory distressrespiratory distressNo catastrophic findings at autopsy No catastrophic findings at autopsy No fatal levels of drugs or substances areNo fatal levels of drugs or substances aredetected.detected.


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O H alloran RL, Newman LV. Restraint O H alloran RL, Newman LV. Restraint asphyxiation in excited delirium.asphyxiation in excited delirium. A m J A m J

Forensic med PathForensic med Path . 1993;14(4):289. 1993;14(4):289- -295 295


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Findings:Findings:11 cases of sudden death of men11 cases of sudden death of menrestrained in prone position by policerestrained in prone position by policeofficers.officers.9 were hogtied, 1 was tied to hospital 9 were hogtied, 1 was tied to hospital gurney, and 1 was manually held prone.gurney, and 1 was manually held prone.

All were in excited delirious state (3 were All were in excited delirious state (3 were psychotic, 8 from drugs [6 cocaine, 1 psychotic, 8 from drugs [6 cocaine, 1methamphetamine, 1 LSD])methamphetamine, 1 LSD])2 were shocked with stun guns2 were shocked with stun guns


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Findings:Findings:Sudden death of people in a state of agitated Sudden death of people in a state of agitated delirium during prone restraint appears not to bedelirium during prone restraint appears not to beuncommon.uncommon.Mechanism of death is sudden, fatal cardiac Mechanism of death is sudden, fatal cardiac dysrhythmia or respiratory arrest dysrhythmia or respiratory arrest Factors:Factors:

Psychiatric or drug Psychiatric or drug- -induced state causesinduced state causescatecholamine stress on the heart catecholamine stress on the heart H yperactivity coupled with struggling with PDH yperactivity coupled with struggling with PDand against restraints contributes to increasesand against restraints contributes to increasesin oxygen demandsin oxygen demandsH ogtied position clearly impairs breathing inH ogtied position clearly impairs breathing insituations of high oxygen demand by impairing situations of high oxygen demand by impairing chest wall and diaphragmatic movement chest wall and diaphragmatic movement


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Findings:Findings:2 cases of unexpected death in2 cases of unexpected death inrestrained, agitated individuals being restrained, agitated individuals being transported by ALS ambulance.transported by ALS ambulance.Both patients placed in hobbleBoth patients placed in hobble

restraints by law enforcement.restraints by law enforcement.


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Case 1Case 135 y/o agitated, combative man found rolling in the street.35 y/o agitated, combative man found rolling in the street.

Arrested and handcuffed with hands behind back. Arrested and handcuffed with hands behind back.Remained uncontrollable and placed in hobble restraints.Remained uncontrollable and placed in hobble restraints.Placed in prone position on stretcher and transported withPlaced in prone position on stretcher and transported withcardiac monitor attached.cardiac monitor attached.During transport, pulse dropped from 135 to 60, thenDuring transport, pulse dropped from 135 to 60, thenincreased to 102, and then developed asystole.increased to 102, and then developed asystole.Restraints removed, resuscitation attempted and failed.Restraints removed, resuscitation attempted and failed.

Autopsy negative other than antecubital needle marks. Autopsy negative other than antecubital needle marks.TOX: + amphetamine and methamphetamineTOX: + amphetamine and methamphetamineDeath: Methamphetamine intoxication and restrained Death: Methamphetamine intoxication and restrained maneuvers for bizarre behavior.maneuvers for bizarre behavior.


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Case 2 Case 2 30 y/o male who was riding his bicycle in and out of traffic 30 y/o male who was riding his bicycle in and out of traffic Stopped and arrested by police.Stopped and arrested by police.Fought police and placed into hobble restraints after other Fought police and placed into hobble restraints after other methods of restraint failed.methods of restraint failed.EMS summoned and patient placed in prone position.EMS summoned and patient placed in prone position.Initially combative and paramedics unable to obtain vital Initially combative and paramedics unable to obtain vital signs.signs.Within 6 minutes, patient became unresponsive.Within 6 minutes, patient became unresponsive.Restraints removed and resuscitation attempted and failed.Restraints removed and resuscitation attempted and failed.

Autopsy revealed pulmonary edema and congestion, Autopsy revealed pulmonary edema and congestion,otherwise negative.otherwise negative.TOX: ETO H =0.100 + cocaine, + methamphetamineTOX: ETO H =0.100 + cocaine, + methamphetamineDeath: Positional asphyxia during restraint for agitated Death: Positional asphyxia during restraint for agitated deliriumdelirium


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Findings:Findings:Patients should be placed in supine or Patients should be placed in supine or

lateral position rather than prone.lateral position rather than prone.If hobble restraints are used, allow slack If hobble restraints are used, allow slack for ventilatory movement of the chest wall.for ventilatory movement of the chest wall.Patient must be monitored closely.Patient must be monitored closely.EMS crew must have capability toEMS crew must have capability toimmediately release the restraints and immediately release the restraints and

provide ALS. provide ALS.


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Roeggla M, Wagner A, Mueliner M, et Roeggla M, Wagner A, Mueliner M, et al. Cardiorespiratory consequences toal. Cardiorespiratory consequences to

hobble restraint.hobble restraint. W ien KlinW ien KlinW orchenschr W orchenschr . 1997;109:359. 1997;109:359- -361.361.


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Findings:Findings:Study of 6 healthy volunteers restrained withStudy of 6 healthy volunteers restrained withhobble restraints in upright and prone positions.hobble restraints in upright and prone positions.

During hobble restraint in the prone position they During hobble restraint in the prone position they found FVC dropped by 40%, end found FVC dropped by 40%, end- -tidal COtidal CO 2 2 increased by 15%, and the cardiac output increased by 15%, and the cardiac output increased by 37%.increased by 37%.H obble restraints in the prone position leads to aH obble restraints in the prone position leads to adramatic impairment of hemodynamics and dramatic impairment of hemodynamics and respirationrespirationUpright position and frequent control of vital Upright position and frequent control of vital

parameters are necessary to prevent possibly fatal parameters are necessary to prevent possibly fatal outcome in persons in hobble restraintsoutcome in persons in hobble restraints


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Chan TC, Vilke GM, Neuman T,Chan TC, Vilke GM, Neuman T,Clausen JL. Restraint position and Clausen JL. Restraint position and

positional asphyxia. positional asphyxia. A nn Emerg Med A nn Emerg Med ..1997;30:578 1997;30:578- -586 586


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Findings:Findings:Experimental crossExperimental cross- -over trial of healthy volunteersover trial of healthy volunteers

placed in hobble or hogtie restraints. placed in hobble or hogtie restraints.

15 healthy men (ages 18 15 healthy men (ages 18- -40) underwent drug 40) underwent drug screening and pulmonary function testing.screening and pulmonary function testing.11 st st Phase: Exercised for 4 minutes and underwent Phase: Exercised for 4 minutes and underwent PFT sitting, supine, prone and restraint positions.PFT sitting, supine, prone and restraint positions.2 2 nd nd Phase: Subjects underwent 2 exercise and 2 Phase: Subjects underwent 2 exercise and 2 rest periods (seated for first rest period and rest periods (seated for first rest period and restrained for second).restrained for second).


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Findings:Findings: ABGs, pulse and oximetry measured throughout. ABGs, pulse and oximetry measured throughout.Subjects placed in restraint exhibited a reduced Subjects placed in restraint exhibited a reduced

pulmonary function pattern by PFT, but no pulmonary function pattern by PFT, but noevidence of hypoxia or hypercapnia was found.evidence of hypoxia or hypercapnia was found.Restraint position, by itself, was not associated Restraint position, by itself, was not associated with any clinically with any clinically- -relevant changes in respiratory relevant changes in respiratory or ventilatory function (decrease of 13%)or ventilatory function (decrease of 13%)There is no evidence to suggest that There is no evidence to suggest that hypoventilatory respiratory failure or asphyxiationhypoventilatory respiratory failure or asphyxiationoccurs as a direct result of body restraint positionoccurs as a direct result of body restraint positionin healthy, awake, nonin healthy, awake, non- -intoxicated individuals.intoxicated individuals.


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Chan TC, Vilke GM, Neuman T.Chan TC, Vilke GM, Neuman T.Reexamination of custody restraint Reexamination of custody restraint

position and positional asphyxia. position and positional asphyxia. A m J A m JForensic Med Path.Forensic Med Path. 1998;19(3):2011998;19(3):201- -205 205


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Findings:Findings:Collective review of literature on restraint and Collective review of literature on restraint and

positional asphyxia. positional asphyxia.Factors other than body positioning appear to beFactors other than body positioning appear to bemore important determinants for sudden,more important determinants for sudden,unexpected deaths in individuals in the hogtieunexpected deaths in individuals in the hogtiecustody restraint position.custody restraint position.

Factors include: illicit drug use, physiologic stress,Factors include: illicit drug use, physiologic stress,hyperactivity, hyperthermia, catechol hyperactivity, hyperthermia, catechol hyperstimulation, and trauma from struggle.hyperstimulation, and trauma from struggle.


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Ross DL. Factors associated withRoss DL. Factors associated withexcited delirium deaths in policeexcited delirium deaths in police

custody.custody. Mod PatholMod Pathol . 1998;11(11):1127 . 1998;11(11):1127- -1137 1137


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Findings:Findings:Review of 61 cases of excited Review of 61 cases of excited

delirium where patient died in policedelirium where patient died in policecustody.custody.


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Psychological Psychological Physiologic Physiologic Physical Physical

Paranoid Paranoid TachycardiaTachycardia H ypervigilenceH ypervigilenceH allucinationsH allucinations H yperthermiaH yperthermia Extreme StrengthExtreme Strength

Grandiosity Grandiosity H ypertensionH ypertension Incoherent speechIncoherent speech

Extreme agitationExtreme agitation Foaming of theFoaming of themouthmouth

Shouting Shouting

Fear Fear MydriasisMydriasis Violent behavior Violent behavior FornicationFornication Cardiac arrest Cardiac arrest Bizarre behavior Bizarre behavior Thought disorder Thought disorder SeizuresSeizures Kicking/Thrashing Kicking/Thrashing Dysphoric Dysphoric Pulmonary Pulmonary

congestioncongestion

Running/ H iding Running/ H iding

Chest painChest pain Threat to self/othersThreat to self/others

Profuse sweating Profuse sweating Aggression AggressionH

igh pain threshold H

igh pain threshold


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Findings:Findings:Most common aggravating factor was abuse of Most common aggravating factor was abuse of cocaine and cocaine/alcohol.cocaine and cocaine/alcohol.

Restraint equipment that controls a violent Restraint equipment that controls a violent patients legs independent of the wrists, such as a patients legs independent of the wrists, such as aleg wrapping strap device, which allows theleg wrapping strap device, which allows thesubject to be in an upright and seated position at subject to be in an upright and seated position at the scene and during transport should be used.the scene and during transport should be used.The hogtie system should only be used judiciously The hogtie system should only be used judiciously and in situations when there is no alternative. Theand in situations when there is no alternative. The

patient should be placed upright or rolled on his patient should be placed upright or rolled on hisside quickly after restraint and vital signsside quickly after restraint and vital signsmonitored.monitored.


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Findings:Findings:Review of 5 cases (4 fatal) whereReview of 5 cases (4 fatal) wherecardiovascular collapse occurred in EDcardiovascular collapse occurred in ED

patients who were struggling despite patients who were struggling despitemaximum restraint techniques.maximum restraint techniques. All were intoxicated (cocaine, All were intoxicated (cocaine,benzoyleconine [cocaine metabolite])benzoyleconine [cocaine metabolite])Profound metabolic acidosis wasProfound metabolic acidosis wasassociated with cardiovascular collapseassociated with cardiovascular collapsefollowing exertion in a restrained positionfollowing exertion in a restrained position(pH ranges: 6.25 (pH ranges: 6.25- -6.81)6.81)


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Findings:Findings: Avoiding the hobble restraint position and Avoiding the hobble restraint position and

emphasizing side rather than proneemphasizing side rather than prone positioning my eliminate some of the positioning my eliminate some of the problems that contribute to the deaths. problems that contribute to the deaths.Early EMS involvement may help toEarly EMS involvement may help to

prevent in prevent in- -custody deaths through use of custody deaths through use of chemical restraints and bicarbonatechemical restraints and bicarbonatetherapy.therapy.


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Pollanen MS, Chiasson DA, Cairns JT,Pollanen MS, Chiasson DA, Cairns JT,Young JC. Unexpected death related toYoung JC. Unexpected death related to

restraint for excited delirium: arestraint for excited delirium: aretrospective study of deaths in policeretrospective study of deaths in policecustody.custody. C M A JC M A J . 1998;158:1603. 1998;158:1603- -7.7.


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Findings:Findings:Review of 21 Canadian cases of Review of 21 Canadian cases of

unexpected death in persons with excited unexpected death in persons with excited delirium.delirium.Deaths were all associated with restraint Deaths were all associated with restraint either with the person in the prone positioneither with the person in the prone position

or subject to pressure on the neck.or subject to pressure on the neck. All lapsed into tranquility shortly after being All lapsed into tranquility shortly after being restrained.restrained.


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Findings:Findings:58% had psychiatric disorder 58% had psychiatric disorder

38% had cocaine38% had cocaine- -induced psychosisinduced psychosisRestraint may contribute to the death of Restraint may contribute to the death of people in states of excited delirium. people in states of excited delirium.Law enforcement personnel should bear inLaw enforcement personnel should bear in

mind the potential for the unexpected mind the potential for the unexpected death of people in excited states of death of people in excited states of delirium who are restrained prone or with adelirium who are restrained prone or with aneck hold.neck hold.


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Schmidt P, Snowden T. The effects of Schmidt P, Snowden T. The effects of positional restraint on heart rate and positional restraint on heart rate and

oxygen saturation.oxygen saturation. J Emerg MedJ Emerg Med ..1999;17(5):777 1999;17(5):777- -782.782.


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Findings:Findings:18 healthy subjects (ages 2118 healthy subjects (ages 21- -42 years)42 years)were studied.were studied.Resting heart rates and SpOResting heart rates and SpO 2 2 waswasmeasured.measured.Randomly assigned to seated unrestrained Randomly assigned to seated unrestrained or hogtied position, with protocols switched or hogtied position, with protocols switched after 15 minutes rest.after 15 minutes rest.Phase 1: Each exercised until their heart Phase 1: Each exercised until their heart rate was > 120 (124rate was > 120 (124- -150).150).


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Findings:Findings:Phase 2: Students paired with other student withinPhase 2: Students paired with other student within5 pounds of body weight and ran simulated police5 pounds of body weight and ran simulated police

chase course.chase course.Exercise intensity was high (pulse rates 175 Exercise intensity was high (pulse rates 175- -212).212).

At the end of the chase, the chaser was placed in At the end of the chase, the chaser was placed inthe seated position and the chased was placed inthe seated position and the chased was placed inthe hogtied position.the hogtied position.

The chased subject then struggled for 30 secondsThe chased subject then struggled for 30 secondsand SpOand SpO 2 2 measured. Roles reversed and processmeasured. Roles reversed and processrepeated.repeated.


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Stratton SJ, Rogers C, Brockett K,Stratton SJ, Rogers C, Brockett K,Gruzinski G. Factors associated withGruzinski G. Factors associated with

sudden death of individuals requiring sudden death of individuals requiring restraint for excited delirium.restraint for excited delirium. A m J A m JEmerg MedEmerg Med . 2001;19:187 . 2001;19:187- -191.191.


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Findings:Findings:Retrospective review of the LA County Retrospective review of the LA County EMS and LA Coroners records from 1992 EMS and LA Coroners records from 1992- -

1998.1998.216 cases of excited delirium located.216 cases of excited delirium located.18 deaths reported 18 deaths reported 20 cases of excited delirium witnessed by 20 cases of excited delirium witnessed by

EMS personnel.EMS personnel. All had been hobble restrained. All had been hobble restrained.81% prone81% prone9% lateral 9% lateral

10% undetermined 10% undetermined


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Findings:Findings:Multiple factors associated with sudden deathMultiple factors associated with sudden deathwhile restrained for excited delirium.while restrained for excited delirium.

Excited delirium (100%)Excited delirium (100%)H obble restraint (100%)H obble restraint (100%)Prone position (100%)Prone position (100%)Forceful struggle against restraint (100%)Forceful struggle against restraint (100%)Positive stimulant use (78%)Positive stimulant use (78%)

Autopsy evidence of chronic disease (56%) Autopsy evidence of chronic disease (56%)Obesity (56%)Obesity (56%)


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The data do not support or refute theThe data do not support or refute the prone position while hobble restraint prone position while hobble restraint

was independently associated withwas independently associated withsudden death.sudden death.


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Position appears not to be significant factor inPosition appears not to be significant factor inhealthy patients.healthy patients.Patients with excited delirium at markedly Patients with excited delirium at markedly

increased risk for restraint asphyxia.increased risk for restraint asphyxia.Stimulants contribute to problem of restraint Stimulants contribute to problem of restraint asphyxia.asphyxia.Prone position is best avoided.Prone position is best avoided.H

obble restraints are best avoided.H

obble restraints are best avoided.Chronic alcoholism or alcohol intoxicationChronic alcoholism or alcohol intoxication puts patients at risk for positional asphyxia. puts patients at risk for positional asphyxia.


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Cardiac dysrhythmias may be a causativeCardiac dysrhythmias may be a causativefactor.factor.Metabolic acidosis may play a major role inMetabolic acidosis may play a major role indeaths and is possibly preventable.deaths and is possibly preventable.Restraint asphyxia appears multi Restraint asphyxia appears multi- -factorial.factorial.Beware when the restrained patient becomesBeware when the restrained patient becomestranquil.tranquil.Often, deaths happen regardless of careOften, deaths happen regardless of carerendered.rendered.


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W hy has this all become such aW hy has this all become such abig deal in EMS?big deal in EMS?


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How does this affect EMS? How does this affect EMS?

1995 DOT National Standard 1995 DOT National Standard Curriculum for EMT Curriculum for EMT- -Basic:Basic:

Turn patient face down on stretcher Turn patient face down on stretcher Secure to stretcher with multipleSecure to stretcher with multiplestraps straps

Cover face with surgical mask if Cover face with surgical mask if spitting on EMT spitting on EMT- -Basic Basic

New EMT New EMT- -I and EMT I and EMT- -P curriculum doP curriculum do

not address patient restraint in detail.not address patient restraint in detail.


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W hat should we do?W hat should we do?

NAEMSP.NAEMSP.National National

Association of Association of

EMS PhysicianEMS PhysicianPaper, Patient Paper, Patient Restraint for EMS Restraint for EMS Systems.Systems. PrehospPrehosp

EmergC

areEmergC

are ..2002;6(3): 340 2002;6(3): 340- -345.345.


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NA EMSP NA EMSP

Look for and treat reversible conditionsLook for and treat reversible conditionsbefore restraining patient.before restraining patient.

In one EMS system, 9% of violent In one EMS system, 9% of violent patients were suffering hypoglycemia. patients were suffering hypoglycemia.Use oxygen, dextrose, and naloxoneUse oxygen, dextrose, and naloxone

when appropriate (not a Comawhen appropriate (not a ComaCocktail!)Cocktail!)


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NA EMSP NA EMSP

Factors that contribute to adverseFactors that contribute to adversemedical conditions:medical conditions:

Agitated delirium Agitated deliriumDrug overdose or intoxicationDrug overdose or intoxicationComorbid medical conditionsComorbid medical conditionsRecent extreme exertionRecent extreme exertionFighting against restraintsFighting against restraintsInappropriate restraintsInappropriate restraints


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NA EMSP NA EMSP

These conditions include:These conditions include:Positional asphyxiaPositional asphyxia

Aspiration AspirationSevere acidosisSevere acidosisRhabdomyolysisRhabdomyolysisSudden cardiac deathSudden cardiac death


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NA EMSP NA EMSP

Restraint in hobble or hogtie isRestraint in hobble or hogtie is particularly dangerous. particularly dangerous.

Method of patient restraint must allow Method of patient restraint must allow for continuous patient assessment and for continuous patient assessment and for medical interventions during for medical interventions during transport.transport.

Many EMS educational programs do not Many EMS educational programs do not address agitated delirium and itsaddress agitated delirium and itscomplications.complications.


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NA EMSP NA EMSP

Local laws should always be followed.Local laws should always be followed.EMS systems should have protocols for EMS systems should have protocols for

patient restraint. patient restraint.Patient should be accompanied by person of Patient should be accompanied by person of the same gender during transport.the same gender during transport.Overstepping the boundaries of restraint may Overstepping the boundaries of restraint may

be perceived as battery, assault, or falsebe perceived as battery, assault, or falseimprisonment.imprisonment.


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NA EMSP NA EMSP

Types of Restraint:Types of Restraint:Verbal deescalationVerbal deescalation

Physical restraint Physical restraint Chemical restraint Chemical restraint


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NA EMSP NA EMSP

EMS personnel EMS personnel should anticipate theshould anticipate the

potential for potential for exposure to blood exposure to blood and body fluids.and body fluids.Law enforcement Law enforcement

should be involved if should be involved if at all possible.at all possible.


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NA EMSP NA EMSP

Verbal deescalation:Verbal deescalation: Application of verbal techniques should be Application of verbal techniques should beapplied first.applied first.Providers should avoid direct eye contact.Providers should avoid direct eye contact.

Avoid encroachment on the patients Avoid encroachment on the patients personal space. personal space.

Always leave an escape route open. Always leave an escape route open.Sometimes defuses the situation avoiding Sometimes defuses the situation avoiding the need for further restraint tactics.the need for further restraint tactics.


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NA EMSP NA EMSP

Physical restraint:Physical restraint:EMS personnel must make every effort to avoid EMS personnel must make every effort to avoid injuring the patient and choose restraint devicesinjuring the patient and choose restraint devicesthat are associated with the least chance of injury.that are associated with the least chance of injury.EMS personnel, in general, should avoid the useEMS personnel, in general, should avoid the useof hard restraints. If used, personnel must beof hard restraints. If used, personnel must betrained in their use and the patients extremitiestrained in their use and the patients extremities

frequently evaluated for injury or neurovascular frequently evaluated for injury or neurovascular compromise.compromise.


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NA EMSP NA EMSP

Physical restraint:Physical restraint:Minimum of 5 people should ideally beMinimum of 5 people should ideally be

present to safely apply physical restraint present to safely apply physical restraint (allowing for control of the head and each(allowing for control of the head and eachlimb).limb).44--point restraints are preferred over 2 point restraints are preferred over 2- -point point restraints.restraints.Often helpful to tether the hips, thighs and Often helpful to tether the hips, thighs and chest.chest.


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NA EMSP NA EMSP

While gaining initial control of the patient, it While gaining initial control of the patient, it may be acceptable to temporarily restrain themay be acceptable to temporarily restrain the

patient in a prone position or sandwich the patient in a prone position or sandwich the patient with a mattress. patient with a mattress.This limits patients visual awareness of theThis limits patients visual awareness of theenvironment and decreases the range of environment and decreases the range of motion of the extremities.motion of the extremities.Personnel must be extremely vigilant for Personnel must be extremely vigilant for respiratory compromise.respiratory compromise.


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NA EMSP NA EMSP

As soon as the patient is subdued and As soon as the patient is subdued and controlled, the team should work tocontrolled, the team should work to

move them into a supine 4move them into a supine 4- -point point restrained position.restrained position.During transport, a patient should During transport, a patient should never never be restrained to a stretcher in a pronebe restrained to a stretcher in a prone

position or sandwiched between position or sandwiched betweenbackboards or mattresses.backboards or mattresses.


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NA EMSP NA EMSP

Physical restraint:Physical restraint:The patient should never be left The patient should never be left

unattended once restrained.unattended once restrained.Providers should perform and Providers should perform and document frequent neurovascular document frequent neurovascular assessment of the extremities.assessment of the extremities.

Patient should not be allowed toPatient should not be allowed tostruggle against the restraints thusstruggle against the restraints thusleading to severe acidosis and leading to severe acidosis and dysrhythmias.dysrhythmias.


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NA EMSP NA EMSP

Physical restraint:Physical restraint: As a rule, physical restraints applied As a rule, physical restraints applied

in the field should not be removed in the field should not be removed until the patient is in the ED.until the patient is in the ED.


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NA EMSP NA EMSP

Patient restraint:Patient restraint:Weapons used by law enforcement are not Weapons used by law enforcement are not appropriate for EMS as they may appropriate for EMS as they may exacerbate the patients agitation.exacerbate the patients agitation.

Pepper spray Pepper spray MaceMaceDefensive spray Defensive spray

Stun gunsStun guns Air tasers Air tasersStun batonsStun batonsTelescoping steel batonsTelescoping steel batons


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NA EMSP NA EMSP

Chemical restraint:Chemical restraint:The addition of specific The addition of specific

pharmacological agents to decrease pharmacological agents to decreaseagitation and increase theagitation and increase thecooperation of patients who requirecooperation of patients who requiremedical care and transportation.medical care and transportation.


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NA EMSP NA EMSP

Chemical restraint:Chemical restraint:Goal is to subdue excessive agitationGoal is to subdue excessive agitation

and struggling against physical and struggling against physical restraints.restraints.Intervention should change theIntervention should change the

patients behavior without reaching patients behavior without reaching the point of amnesia or altering thethe point of amnesia or altering the patients level of consciousness. patients level of consciousness.


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NA EMSP NA EMSP

Chemical restraint:Chemical restraint:Butyrophenones and/or Butyrophenones and/or

benzodiazpines are most frequently benzodiazpines are most frequently used.used.


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NA EMSP NA EMSP

Chemical restraint:Chemical restraint:Butyrphenones:Butyrphenones:

H aloperidol ( H aldol)H aloperidol ( H aldol)Droperidol (Inapsine)Droperidol (Inapsine)

Benzodiazepines:Benzodiazepines:

Diazepam (Valium)Diazepam (Valium)Lorazepam (Ativan)Lorazepam (Ativan)Midazolam (Versed)Midazolam (Versed)

All can be given IV or IM All can be given IV or IM


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NA EMSP NA EMSP

Chemical restraint:Chemical restraint:Common combination:Common combination:

H aldol 5 mg/Ativan 2 mg (oftenH aldol 5 mg/Ativan 2 mg (oftencalled H alivan or B52)called H alivan or B52)


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NA EMSP NA EMSP

Chemical restraint:Chemical restraint:Droperidol has been tested in 2 EMS Droperidol has been tested in 2 EMS

studies and found to be effective.studies and found to be effective.In 53 EMS patients, droperidol quickly and In 53 EMS patients, droperidol quickly and effectively sedated 87% of the patientseffectively sedated 87% of the patientswithout any serious adverse effects.without any serious adverse effects.

Another study found droperidol more Another study found droperidol moreeffective than lorazepam in the emergency effective than lorazepam in the emergency setting.setting.


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C hemical Restraint C hemical Restraint

Perhaps atypical antipsychotics should bePerhaps atypical antipsychotics should beconsidered:considered:

Respiridone (Respiridal)Respiridone (Respiridal)

Ziprasidone (Geodon)Ziprasidone (Geodon)Olanzepine (Zyprexia Zydis)Olanzepine (Zyprexia Zydis)Recent review suggests these with or without Recent review suggests these with or without benzodiazepines should be considered first.benzodiazepines should be considered first.

Yildiz A, Sachs GS, Turgay A.Yildiz A, Sachs GS, Turgay A.Pharmacological management of Pharmacological management of agitation in emergency settings.agitation in emergency settings. EmergEmergMed J.Med J. 2003;20:3392003;20:339- -346 346


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NA EMSP NA EMSP

Benzodiazepines may be the drug of Benzodiazepines may be the drug of choice in patients who are agitated fromchoice in patients who are agitated from

the effects of toxicological syndromes or the effects of toxicological syndromes or drug overdose.drug overdose.


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NA EMSP NA EMSP

Chemical restraint:Chemical restraint:Neuromuscular blockers withNeuromuscular blockers with

endotracheal intubation should never endotracheal intubation should never be used solely for the purpose of be used solely for the purpose of restraining violent behavior.restraining violent behavior.


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My Recommendations My Recommendations

1.1. Look for and treat medical conditionsLook for and treat medical conditionsthat may cause the delirium.that may cause the delirium.

2.2. If the patient may need restraint,If the patient may need restraint,summon additional help and law summon additional help and law enforcement.enforcement.

3.3. Begin verbal deescalation whileBegin verbal deescalation whileawaiting the arrival of other rescuers.awaiting the arrival of other rescuers.


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4.4. Always withdraw if you feel your personal Always withdraw if you feel your personal safety or the safety of your crew issafety or the safety of your crew isthreatened.threatened.

5.5. When at least five people are available,When at least five people are available,assign each a body appendage and assign each a body appendage and approach the patient in an organized fashion.approach the patient in an organized fashion.

6.6. Initially control the patient in a prone position,Initially control the patient in a prone position,

but move to supine position as soon asbut move to supine position as soon as possible. possible.7.7. Apply 4 Apply 4--point restraints using soft material point restraints using soft material

such as roller bandages or gauze.such as roller bandages or gauze.


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9.9. If the patient requires considerableIf the patient requires considerableadditional restraint, involve law additional restraint, involve law enforcement personnel.enforcement personnel.

10.10. Patient should never be left unattended.Patient should never be left unattended.11.11. Physiological monitors should be applied.Physiological monitors should be applied.12.12. Frequent assessment including Frequent assessment including

neurovascular checks.neurovascular checks.13.13. If patient struggles against restraints,If patient struggles against restraints,

consider addition of chemical restraints.consider addition of chemical restraints.


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Chemical restraint:Chemical restraint:Midazolam (Versed) [2 Midazolam (Versed) [2- -5 mg IM] 5 mg IM]

Lorazepam (Ativan) [2 Lorazepam (Ativan) [2- -4 mg IM] 4 mg IM] Diazepam (Valium) [5 Diazepam (Valium) [5- -10 mg IM] 10 mg IM] Olanzepine (Zyprexia Zydis) [5 Olanzepine (Zyprexia Zydis) [5- -10 mg 10 mg

PO] PO] Ziprasidone (Geodon) [10 Ziprasidone (Geodon) [10- -20 mg IM] 20 mg IM]


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14.14. Leave restraints on until patient isLeave restraints on until patient isdelivered to ED and evaluated.delivered to ED and evaluated.

15.15. Document the reason for restraint,Document the reason for restraint,the method of restraint, thosethe method of restraint, thoseinvolved, and results of repeated involved, and results of repeated assessments during monitoring.assessments during monitoring.


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SummarySummary

Beware of the patient with agitated or excited Beware of the patient with agitated or excited delirium.delirium.Never attempt restraint without adequateNever attempt restraint without adequatehelp.help.If the patient becomes suddenly tranquil If the patient becomes suddenly tranquil during restraint, promptly evaluate.during restraint, promptly evaluate.

Never transport a patient with a restraint that Never transport a patient with a restraint that you do not have the immediate capability toyou do not have the immediate capability toremove.remove.


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SummarySummary

Drug intoxication is a significant risk factor Drug intoxication is a significant risk factor (especially stimulants).(especially stimulants).Patients who recently ran or struggled are at Patients who recently ran or struggled are at

increased risk.increased risk.Obese patients appear at increased risk.Obese patients appear at increased risk.Never hogtie or use hobble restraints.Never hogtie or use hobble restraints.Never restrain prone (except to gain control).Never restrain prone (except to gain control).Do not allow the patient to fight restraint, add Do not allow the patient to fight restraint, add chemical restraint.chemical restraint.


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SummarySummary

Try and have a person of the same gender Try and have a person of the same gender ride with the patient during transport.ride with the patient during transport.

Always look for medical causes and treat Always look for medical causes and treat

appropriately.appropriately.There is no shame in withdrawing fromThere is no shame in withdrawing fromdangerous scene and requesting assistance.dangerous scene and requesting assistance.Involve law enforcement in cases that do not Involve law enforcement in cases that do not respond to simple forms of restraint and haverespond to simple forms of restraint and havethem accompany patient them accompany patient in the ambulancein the ambulance totothe ED.the ED.


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SummarySummary

Chemical restraints should be available to all Chemical restraints should be available to all ALS systems. ALS systems.Do not be afraid to inject IM medicationDo not be afraid to inject IM medication

through the patients clothing.through the patients clothing.Use appropriate physiological monitors (ECG,Use appropriate physiological monitors (ECG, pulse oximetry). pulse oximetry).Patient dignity should be maintained during Patient dignity should be maintained during restraint.restraint.EMS personnel should never use weapons toEMS personnel should never use weapons torestrain a patient (including metal flashrestrain a patient (including metal flashlights!)lights!)


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SummarySummary

Each systemEach system mustmust have patient restraint have patient restraint protocols that include: protocols that include:

Indications for restraint Indications for restraint Patient assessment to identify and Patient assessment to identify and manage medical conditionsmanage medical conditions

Types of restraints permitted, when toTypes of restraints permitted, when tobe used, who can apply them, and be used, who can apply them, and when medical oversight must bewhen medical oversight must beinvolved.involved.


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SummarySummary

H ave a low threshold for contacting H ave a low threshold for contacting medical control medical control

Document Document Document Document Document Document


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A nd then, there are Stun Guns A nd then, there are Stun Guns


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patient restraint (2006)

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