1. 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.

2. 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

3. 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

4. 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

5. 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

6. Actually of course this approach should be left for the police

7. Options to Consider in Disposition of Violent Patients  Arrest & restraint by police, then transport by police ƒ To jail ƒ To medical facility  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

8. 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

9. 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

10. 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 ƒ 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

11. 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

12. Arms crossed with physical restraints

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

14. How to securely tie a wrist restraint

15. Prone restraint position

16. Use of On-Line Physician Medical Command to Assist in Managing Violent Patients  Should contact medical command if : ƒ 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

17. Use of Chemical Restraints  Choices include : ƒ 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  Use of any agent requires close monitoring

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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