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 Medicine
Uniformed Services University of the Health Sciences
Clinical Professor of Emergency Medicine
George Washington University
Bethesda, 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 ideation
Injuries in a residence
Address where prior violent events reported
Patients with prior psychiatric problems
Initial On-Scene Management of
Potentially Violent Situations
EMS 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 sight
Remove 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 police
To jail
ƒ To medical facility
ƒ
Police assist in restraint, then transport in
EMS vehicle to medical facility
ƒ
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 personnel
Designate one person in charge
Preposition belts & wraps & backboard or
scoop stretcher on litter
Body fluid precautions
One 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 Restrained
Search clothes for weapons or meds & remove
Quickly check for hypoxia, hypoglycemia,
hyperthermia, and treat if identified
Precautions against aspiration
ƒ
Suction should be ready
Keep stretcher close to ground level
Decide if > 1 person needed in back of
ambulance for safety
Personal Protective Measures
for Prehospital Personnel
Body armor / bullet-proof vests
ƒ
Protect also well against stabs and blunt chest
trauma from MVC's
Weapons
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
ƒ
Restraint Considerations on the
Ambulance Stretcher
Cervical collar if any possible neck trauma
Legs or ankles should not be crossed
Additional 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 :
Patient refusing care but not competent
ƒ EMS personnel need more help from police
ƒ Proper disposition of patient is unclear to EMS
personnel
ƒ Use of medications for chemical restraint is
needed
ƒ
Use of Chemical Restraints
Choices include :
Narcotics (morphine)
ƒ Benzodiazepines (midazolam, diazepam)
–Advantage of these is that they can be
reversed by naloxone or flumazenil
ƒ Haloperidol
ƒ Neuromuscular blockers
–Require endotacheal intubation & adavanced
training
ƒ
Use of any agent requires close monitoring
Considerations in Use of
Haloperidol for Chemical Restraint
Often 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 reactions
ƒ
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 agitation
Advantage 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 Restraints
Commonly cause respiratory depression & /
or hypotension
Also may cause nausea / emesis
Useful 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 frequently
Don'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