Managing the Violent Patient in the Transition from Prehospital Care to the Emergency Department

Jim Holliman, M.D., F.A.C.E.P.Professor of Military and Emergency MedicineUniformed Services University of the Health SciencesClinical Professor of Emergency MedicineGeorge Washington UniversityBethesda, Maryland, U.S.A.

Managing the Violent Patient in Transition from Prehospital Care to the E.D.

Lecture Goals :ƒ Present considerations in prehospital management of violent & potentially violent patients–To ensure patient safety–To ensure safety of prehospital personnel–To ensure safety of E.D. staff–To maximize quality and efficiency of patient care

Prehospital Dispatch Considerations

Prehospital responders need to be notified right away about any potential violence situations

Concurrent or primary dispatch of police units

May need dispatch of more than one EMS unit

Presence of weapons at the scene

Potentially Violent Situations for Which Dispatchers Need to Obtain More Information Over the Phone

"Person down"ƒ Might be victim of violence / assault

Patients with suicidal ideationInjuries in a residenceAddress where prior violent events reportedPatients with prior psychiatric problems

Initial On-Scene Management of Potentially Violent SituationsEMS should not enter scene until secure by police

Rescue in weapons situation should only be by police

Do not allow patient to get between EMS personnnel & scene exit

Always keep violent patient in sightRemove potential weapons from scene

ƒ Caution if handling will alter evidence needed by police

Actually of course this approach should be left for the police

Options to Consider in Disposition of Violent Patients Arrest & restraint by police, then transport by policeƒ To jailƒ To medical facility

Police assist in restraint, then transport in EMS vehicle to medical facilityƒ With or without police in EMS vehicle

If police unwilling to assist in restraint, should call physician medical command to talk to police directly

Sequence of Events Needed to Physically Restrain a Violent Patient

Collect at least 5 strong personnelDesignate one person in chargePreposition belts & wraps & backboard or scoop stretcher on litter

Body fluid precautionsOne person preassigned to take each limb & one person immobilizes head

May be safer for some patients to restrain on their side on the stretcher

Can pin patient to ground with mattress

Initial Considerations Once the Patient is Physically RestrainedSearch clothes for weapons or meds & remove

Quickly check for hypoxia, hypoglycemia, hyperthermia, and treat if identified

Precautions against aspirationƒ Suction should be ready

Keep stretcher close to ground levelDecide if > 1 person needed in back of ambulance for safety

Personal Protective Measures for Prehospital PersonnelBody armor / bullet-proof vests

ƒ Protect also well against stabs and blunt chest trauma from MVC's

Weaponsƒ Should be carried by EMS personnel only if trained equivalent to police

ƒ Taser, Mace, or pepper spray may be allowed as last resort in some areas

Restraint Considerations on the Ambulance StretcherCervical collar if any possible neck traumaLegs or ankles should not be crossedAdditional belts or straps needed across knees, pelvis or lower back, & upper trunk (extending underneath either arm at the axilla)

Oxygen mask with high flow O2 if patient is spitting at EMS personnel

Provide padding for stretcher contact points if transport prolonged

Check restrints every 10 minutes for tightness

Arms crossed with physical restraints

Restraining patients on their side on the stretcher (safer if any risk of emesis and aspiration)

How to securely tie a wrist restraint

Prone restraint position

Use of On-Line Physician Medical Command to Assist in Managing Violent Patients

Should contact medical command if :ƒ Patient refusing care but not competentƒ EMS personnel need more help from policeƒ Proper disposition of patient is unclear to EMS personnel

ƒ Use of medications for chemical restraint is needed

Use of Chemical RestraintsChoices include :

ƒ Narcotics (morphine)ƒ Benzodiazepines (midazolam, diazepam)–Advantage of these is that they can be reversed by naloxone or flumazenil

ƒ Haloperidolƒ Neuromuscular blockers–Require endotacheal intubation & adavanced training

Use of any agent requires close monitoring

Considerations in Use of Haloperidol for Chemical RestraintOften is agent of choice because does not cause respiratory depression or hypotension

Can be given IM or IV (same dose)Dose 1 to 10 mg IM or IV

ƒ Generally should use 10 mg at a time & may repeat q 10 to 20 minutes if insufficient tranquilization achieved

Can cause dystonic reactionsƒ Treat with 25 mg diphenhydramine IV

Considerations in Use of Benzodiazepines for Chemical Restraint

Can cause respiratory depression and sometimes hypotension

Have adjuctive additional effect to use of haloperidol

Rarely can cause paradoxical agitationAdvantage of midazolam is that it can be given IM (dose 0.5 to 2 mg IM or IV, repeat as needed)

Diazepam dose 2 to 5 mg IV & repeat as needed

Considerations in Use of Narcotics as Chemical RestraintsCommonly cause respiratory depression & / or hypotension

Also may cause nausea / emesisUseful if concurrent pain from injury contributing to patient's combativeness

Morphine dose is 1 to 5 mg IM or IV, & repeat as needed

Considerations in Transferring Care of the Violent Patient at the E.D.

Important to bring combatants from different "sides" in the same altercation to different hospitals so they do not resume combat in the E.D.

Patient should be directly delivered to E.D. personnel & not left alone

Need to mobilize at least 5 personnel prior to releasing or reapplying any restraints

Obtain pulse oximetry, temp., and fingerstick glucose if not done yet

Considerations in Further Care of the Violent Patient in the E.D.Patient at risk for pressure ulcers and rhabdomyolysis with prolonged physical restraint, so early establishment of chemical restraint often preferable

Advise all personnel (radiology, etc. ) about need for continued physical restraints

Should have formal restraint protocol to follow

Recheck patient frequentlyDon't leave patient unobserved

Managing Violent Patients from Prehospital to E.D. Care : Summary

Prehospital communication by dispatchers is important

EMS personnel should first assure their own safety

Adequate personnel should be mobilized prior to any physical restraint attempt

Once restraint is achieved, rapid evaluation for medical problems should ensue

Continued monitoring is important if chemical restraint is used