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<< The Violent Patient: Clinical Management, Use Of Physical And Chemical Restraints, And Medicolegal Concerns

Treatment

Physical Restraints

Patient restraint is a problematic issue. Thirteen percent of hospitals reported injuring a patient while restraining them, including one strangulation death. Litigation was pending in another 16% of surveyed EDs regarding patient restraint.6

Physical restraints should be considered when verbal techniques are unsuccessful or inappropriate in controlling a potentially violent patient. The use of restraints can be humane and can facilitate diagnosis and treatment while preventing injury to the patient and medical staff.54 Their use is supported by the 1982 Supreme Court decision of Youngberg v. Romero, which stated that a patient could be restrained if necessary to protect himself or others. The court emphasized the central role of “clinical judgment” by the health professional.59 The Model Penal Code allows “an exception from the assault statute for physicians...who act in good faith in accordance with accepted medical therapy.”59 Overall, the liability for restraining someone against his or her will is negligible compared to the potential liability for allowing a patient to hurt himself or others.55

Indications for emergency seclusion and restraint are:
  1. To prevent imminent harm to others;
  2. To prevent imminent harm to the patient;
  3. To prevent serious disruption of the treatment program or significant damage to the environment; and
  4. As part of an ongoing behavior treatment program.
Seclusion may be used to decrease environmental stimulation and at the patient’s request.52

If a patient is brought to the ED in restraints by paramedics and police, he or she may likely require continued restraints or sedation. Patients brought by police to the ED for psychiatric clearance are especially likely to be violent in the ED.60

The Joint Commission on Accreditation of Hospital Organizations (JCAHO) has written guidelines governing the use of restraint and seclusion for behavioral health patients that must be reviewed by each hospital using these procedures (TX.7, effective January 1, 1999). The reader is urged to review this publication. Several essential elements must be provided for in a restraint situation, including:
  1. Protection and preservation of patient rights, dignity, and well-being
  2. Use based on patient’s assessed needs
  3. Use of least restrictive method
  4. Safe application and removal by competent staff
  5. Monitoring and reassessment of the patient during use
  6. Meeting of patient needs during use
  7. Time limitation of orders that are provided by licensed practitioners
  8. Documentation in the medical record
Seclusion or restraint may be contraindicated due to the patient’s clinical or medical condition. Seclusion alone should not be used in any unstable patient who requires close monitoring, in cases of any significant overdose, or when suicide, self-abuse, or self-mutilation are concerns.20,52 Restraints are not to be applied solely for convenience or as a punitive response for disruptive behavior, as patient injury and litigious consequences may follow.

Documentation is essential, and it’s the best defense against litigation. Write an order on the chart for restraints and chart why restraints were necessary. Specific rather than general indications are helpful (e.g., “I restrained Mr. Smith because he told me he was going to pull my lungs out my throat” vs “I restrained Mr. Smith because he was agitated”). On occasion, having a colleague document agreement with the application of restraints is useful.

Application Of Restraints

The implementation of restraints should be systematic. Use a standard ED protocol for their institution. (See Table 5.) This protocol begins with the examiner leaving the room once verbal techniques have been unsuccessful and then summoning help (saying, for example, “Excuse me, I’ll be right back”)


It may be helpful to consider the application of restraints as a procedure analogous to running a resuscitation. The restraint team consists of at least five people, including a team leader. The leader will be the only person giving orders and should be the person with most experience in implementing restraints, whether a physician, nurse, or security officer. Some believe the treating physician should not actively participate in applying restraints in order to preserve the physicianpatient relationship and not be viewed as adversarial.54 Before entering the room, the leader outlines the restraint protocol and warns of anticipated danger (e.g., the presence of objects that may be used as weapons). All team members should remove personal effects that the patient could use against them. If police or armed security guards are part of the restraint team, they must remove their weapons and place them in a lock-box before restraining a patient. Guns may easily be wrested from an officer during the frenzy of a restraint; a terrified schizophrenic with a gun can loosen the sphincters of an entire restraint team. If the patient to be restrained is female, at least one member of the team should be a woman to prevent allegations of sexual assault.

The team enters the room in force and displays a professional, rather than threatening, attitude.52 Many violent individuals will decompress at this point, as a large show of force protects their ego—it allows them to rationalize that they would have fought back, but the odds were overwhelming. The leader speaks to the patient in a calm manner, explaining why restraints are needed and what the course of events will be (e.g., “You will receive a medical and psychiatric examination as well as treatment”). The patient is instructed to cooperate and lie down to have restraints applied.

If physical force becomes necessary, one team member restrains a preassigned extremity by controlling the major joint. The team leader controls the head. If the patient is armed with a non-lethal weapon, two mattresses can be used to charge and immobilize or sandwich the patient. Armed police or security must restrain patients who brandish a lethal weapon such as a knife or gun. Restraints are applied securely to each extremity and tied to the solid frame of the bed (not side rails, as later repositioning of side rails also repositions the  patient’s extremity). Leather or specially designed polymer cuffs are optimal restraints, as they are unbreakable and less constricting than typical soft restraints. Avoid using gauze, as gauze bandages can tighten around the limb and restrict distal circulation. Soft restraints simply do not have adequate strength to sufficiently restrain. If chest restraints are used, it is vital to ensure adequate chest expansion. Applying a soft Philadelphia collar to the patient’s neck will prevent head banging and biting.

Restraining patients on their side will help prevent aspiration, although supine with the head elevated is more comfortable for the patient and allows a more thorough medical examination.19,39 Once the patient is immobilized, announcing “the crisis is over” will have a calming effect on the restraint team and the patient.

After The Restraints

After restraints have been applied successfully, the patient should be monitored frequently, and positions changed to prevent neurovascular sequelae such as circulatory obstruction, pressure sores, and paresthesias. The restrained patient may need to be sedated to avoid rhabdomyolysis associated with continued combativeness. (This will be discussed further in subsequent sections.) A standardized form is recommended for the documentation of the monitoring process. It should be used by every ED that physically restrains patients.49 (For an example, see Tool 1.)



After a restraint intervention, the restraint team should review their performance and discuss ways to improve efficiency in the future. Education and rehearsal by staff is imperative to maintain skills.

Restraints And Death

Sudden, unexpected deaths have been reported in patients who have been restrained.61-64 Restraints applied by prehospital personnel in the prone or hobble position (arms and legs restrained behind the patient) have resulted in deaths presumed by some to be due to positional asphyxia.61 Recent research has cast doubt upon this theory.65

Restrained patients who are cocaine intoxicated appear to be at high risk for adverse outcomes. A case series of five patients who sustained cardiovascular collapse while struggling against restraints has been recently reported. All patients had a profound metabolic acidosis (pH, 6.25-6.81) proximate to cardiac arrest.63 Four of these patients died. Three or more of the five had evidence of recent cocaine use, and one had a lactic acid level of 24 meq/L. Increased sympathetic tone and altered pain sensation may allow exertion beyond normal physiologic limits in these patients, while sympathetic induced vasoconstriction could impede lactate clearance.63 Alteration of respiratory mechanics in an acidotic
patient due to restraint position could be a contributing factor. Some recommend avoiding the prone restraint position altogether in this patient population. They suggest aggressive chemical sedation and fluid resuscitation  as well as bicarbonate supplementation to prevent struggling and worsening acidosis.

Chemical Restraints

Chemical restraints may be necessary to control an agitated patient and may be used in conjunction with physical restraints. Rapid tranquilization (or the more clumsy phrase, rapid neuroleptization) is the term applied to quick chemical control of the agitated patient. It allows physicians to quickly calm patients, allowing proper evaluation and treatment, and  prevents the patient from harming him- or herself or others. Physical restraint alone, especially in a struggling patient, may increase the risks for patient morbidity and mortality.

While patients have the right to refuse antipsychotic drugs in non-emergency settings, this right does not extend to the acutely combative patient in the ED where life or limb may be threatened by failure to sedate.66

In the 1950s, chlorpromazine was used; however, orthostatic hypotension, sedation, and tolerance to effects limited its usefulness.54 Rapid tranquilization (RT) with modern neuroleptics such as the butyrophenones (haloperidol and droperidol) provides safe and effective control of psychotic and potentially assaultive patients. 20,67-69 Combining these drugs with benzodiazepines can dramatically contain aggression.

Butyrophenones (Haloperidol And Droperidol)

Haloperidol (Haldol) is generally recommended as a drug of choice to sedate a violent patient, and rapid tranquilization is achieved using dosages of 2.5-10.0 mg intramuscularly at 30- to 60-minute intervals.52,68,69 Elderly patients are usually given 2.5-5.0 mg boluses. After intramuscular injection, effects are typically seen in 10-30 minutes, with most patients requiring less than three  doses to achieve the desired effect.67 Although no ceiling dose has been established, one source  suggests that patients not receive more than six doses in 24 hours.67 However, 300 mg IV has been used over 24 hours without adverse effects.4 While haloperidol is not FDA-approved for IV use, it is widely used via this route, demonstrating  an outstanding safety profile.

Droperidol (Inapsine), an analog of haloperidol, has also been used with success at doses of 5-20 mg IM (most recent studies use 5 mg). Typically, only one or two doses are needed total to control an agitated patient.67,70-72 IV dosing of droperidol starts at 1.25-2.5 mg per dose. Droperidol is approved by the FDA for IV use. One prospective, randomized, double-blind trial of 68 patients showed that 5 mg of IM droperidol resulted in more rapid control of an agitated patient than the same dose of IM haloperidol.73 This difference was not seen with IV administration.73 Droperidol has a shorter half-life than haloperidol but a greater incidence of sedation and orthostatic hypotension. Respiratory distress requiring endotracheal intubation has been reported with droperidol use for sedation in an LSD intoxicated patient, presumed to result from precipitation of serotonin syndrome.74 Despite this isolated report,some consider droperidol a first-line drug for rapid tranquilization.

Contraindications


Neuroleptics should be avoided in pregnant and lactating females, PCP overdose, or anticholinergic drug intoxications. 4 They should not be used as a sole agent to manage combativeness in patients suffering from drug or alcohol withdrawal. However, the only absolute contraindications to neuroleptic medication use are true allergy and anticholinergic drug intoxication, as this syndrome can be exacerbated by neuroleptic medications.19 Neuroleptic medications may theoretically lower seizure threshold; therefore, their use in sympathomimetic intoxicated patients has been controversial.75 However, recent data indicates that haloperidol and droperidol are safe in this setting. A recent retrospective review of patients receiving droperidol for combativeness reveals that of 101 sympathomimetic-intoxicated patients who received droperidol (78 cocaine, 23 amphetamine), none had an adverse outcome.71 Haloperidol actually prevents seizures in cocaine-intoxicated animals76 and reduces mortality in amphetamine intoxication.77 For these reasons, some sources recommend its use in patients with agitation secondary to sympathomimetics.78

Complications


The most common adverse effect of the butyrophenones are extrapyramidal symptoms (EPS). EPS is a dystonic reaction, characterized by involuntary twisting movements seen in the neck (torticollis), back (opisthotonos), and eyes (oculogyric crisis). Rarely, the mouth and tongue can be affected, compromising the airway.67 EPS is not dose-related and can occur after one dose;however, the incidence is low—approximately 1%.54 Akathisia, or a feeling of severe restlessness, can also be seen. The treatment for each of these symptoms is benztropine (Cogentin) 2 mg or diphenhydramine (Benadryl) 50 mg, usually given intramuscularly. Relief occurs within minutes. While some clinicians co-administer benztropine with a butyrophenone, in the hopes of preventing EPS, this practice has not been rigorously studied.

Neuroleptic malignant syndrome (NMS) is an idiosyncratic reaction to neuroleptics such as haloperidol and droperidol. Symptoms include altered mental status, hyperthermia, autonomic lability (dramatic fluctuations in blood pressure), and lead-pipe rigidity of muscles. This reaction occurs in approximately 1% of patients receiving antipsychotic medications.67 Treatment involves rapid cooling and muscle relaxation using benzodiazepines and dantrolene.

Conduction disturbances—specifically, prolongation of the QT interval and torsades de pointes—have been reported in critical care patients sedated with intravenous haloperidol and droperidol. However, the majority of patients with complications were elderly to middle-aged and had pre-existing heart disease. Patients with conduction disturbances also received very high doses of the drug—at least 50 mg in 24 hours and in some, up to 2300 mg in 24 hours.79

Benzodiazepines

Benzodiazepines can also be used for rapid tranquilization of an agitated patient. Lorazepam (Ativan) is superior to other benzodiazepines due to rapidity of action, effectiveness, short half-life, and lack of  active metabolites. It is one of the few benzodiazepines that is rapidly effective when given intramuscularly.20,67,68,80 Midazolam (Versed) has also been reported to be safe and rapid in onset when given intramuscularly, with a shorter half-life than lorazepam.54,81 Benzodiazepines are especially useful in the patient who is agitated due to drug and/or alcohol intoxication, although they are still effective in psychotic patients. Recommended doses of lorazepam begin with 1-2 mg increments IV or IM and are titrated upward as needed, up to 120 mg in 24 hours.67

The most common side effects are sedation, confusion, ataxia, and nausea. Respiratory depression is the most significant risk when benzodiazepines are used in a patient who is already under the influence of a potential  respiratory depressant such as alcohol.

Combining Butyrophenones And Benzodiazepines

Neuroleptics and benzodiazepines can be used alone or in combination. The combination of lorazepam with haloperidol has been studied prospectively and has been shown to be superior to either drug alone.80,82 In a recent study, 98 agitated patients were enrolled in a randomized, double-blind, multicenter trial and given either intramuscular lorazepam 2 mg alone, haloperidol 5 mg alone, or both.80 Doses were repeated as needed at hourly intervals, up to six times. Patients receiving  combination therapy improved significantly more in the first three hours than those receiving either drug alone. More patients experienced EPS in the haloperidol alone group than in the combination group—possibly due to greater number of doses needed. Based on these findings,combination therapy has been recommended as the  treatment  of choice for rapid tranquilization of the acutely agitated patient for optimal effect and minimal side effects.