The document discusses the assessment and management of agitated patients who may need to be placed in restraints. It provides guidance on: 1) Who should be restrained, including those who are a danger to themselves or others due to medical conditions, intoxication, or psychiatric disorders. 2) Why restraints should be used - to protect medical staff, the patient, and allow for proper assessment and treatment. The least restrictive methods should be attempted first. 3) The different types of restraints that can be used including verbal de-escalation, seclusion, physical restraints, and chemical restraints using medications like haloperidol or lorazepam. Proper documentation of the restraint procedure

1. The Agitated Patient
Dr. Anoop James
DNB Trainee
Emergency Medicine

2. Key Questions
1. Who should be placed in restraints?
2. Why should I use restraints?
3. What restraints should I choose?
4. What are the implications?

3. Who should be placed in restraints?
Agitation - abnormal increase in psychological or motor hyperactivity
Any patient can become violent/agitated
Increased propensity in :
• Organic disorders such as dementia and delirium
• Intoxicated
• Functional disorders such as mania and schizophrenia

4. Medical Causes of Aggression
• Head injury
• Substance abuse & intoxication
• Hypoxia
• Metabolic disturbances/ Hypoglycemia
• Infection: Meningitis, encephalitis, sepsis
• Hypo/Hyperthermia
• Seizures
• Stroke/IC bleed

5. Assessment of Potentially Violent Patient
A = Assessment B = Behavioral Indications C = Conversation
Appearance Irritable Admits to weapon
Current Medical Status Impulsivity Admits to history of violence
History Of Violence Hostility , Anger Threats to harm
Intoxicated Restlessness, pacing Admits to substance abuse
Disoriented Intimidating Behaviour Admits to extreme anger

6. Warning Signs
• Exhibits or threatens violence
• Makes ED staff anxious
• Wide swings in behavior
• Expresses fear of losing control
• Uncooperative, agitated, pacing
• Intoxicated: alcohol or
drugs
• Past history of violence
• Tense, rigid posture
• Gang signs or symbols

7. Why should I use restraints?
1. To protect the medical personnel and other staff
2. To protect the patient
3. To assist in assessing and
management of the patient

8. Decision To Restrain
• Assess the competency of the patient.
• EM physician must weigh the patient’s right to autonomy with that of
the patient’s health and the safety of the ED staff.
• Once the decision to restrain a patient is made use a team approach.

9. How Do I Restrain An Agitated Patient?
• “Least restrictive method of restraint”
• Avoid Violence
• Maintain a good working doctor/patient relationship
• Maintain the dignity of the patient
• Enlist the help of family or friends
• Restraints

10. Types Of Restraints
Verbal Restraints = verbal de‐escalation
Seclusion
Physical Restraints
Pharmacological Restraints

11. Talking the patient down
The preferred intervention for calming the agitated patient
• Avoid eye contact
• Always leave a way out
• Maintain a safe distance - do not invade
the patient’s “space”
• Adopt passive, non-confrontational
posture
• Treat patient as you expect him to behave
• Offer food or drink
• Avoid provocative remarks
• Do not turn your back
• Never underestimate
potential for violence

12. Seclusion
• Placing a patient alone in a locked room
• Specific room that is safe for the patient
• Requires monitoring – CCTV surveilance
• Documentation of reason for seclusion
• If the patient does not respond to seclusion
then physical restraints may be necessary.

13. Physical Restraints – A Team Approach
• Ideally with six members, one for each extremity, one for head, and one to
apply restraints.
• The team members should remove all objects from themselves which could
be used as weapons by the violent patient, i.e., ID pins, reflex hammers etc.
• Team should advance as a unit from all directions, restraining their
assigned extremity.
• Team members should wear protective gear, at least gloves, to minimize
possible contamination of themselves.

14. Physical Restraints
• 4 point restraints
• Explain to the patient that the restraints are being applied for his protection and
the protection of others
• Once decided, do not negotiate
• Document the reason for restraining
• Undress patient and search for concealed weapons or chemicals after the
restraints are applied
• Patient should be kept in open area where he can be observed and monitored

15. Chemical Restraints
• The order in which restraints are used does NOT have to be physical and then
chemical
• If the patient is willing to take medication prior to the use of physical restraints
then administer medication first
• Chemical restraints may be used if the patient continues to struggle against
physical restraints and shows a persistence of uncontrolled behavior
• Psychiatry consultation prior to initiating chemical restraints

16. Chemical Restraints
Haloperidol alone - 83% efficacy rate within 30 minutes^
Lorazepam and Haloperidol
• More rapid tranquilization occurring with the combination treatment*
• Two major side effects
35% of the patients were still asleep at 12 hours
6% - 20% of patients receiving haloperidol experienced extrapyramidal symptoms (EPS)
* Battaglia, J. et al. "Haloperidol, lorazepam, or both for psychotic agitation? A multicenter, prospective, double-blind, emergency department study." Am.J.Emerg.Med. 15.4
(1997): 335-40.
^ Clinton, J. E. et al. "Haloperidol for sedation of disruptive emergency patients." Ann.Emerg.Med. 16.3 (1987): 319-22.

17. Chemical Restraints
• The most common IM antipsychotic medications are haloperidol and ziprasidone.
• The atypical antipsychotics have a decreased incidence of EPS when compared to
the classic antipsychotics.
• Frequently the antipsychotics are combined with a benzodiazepine such as
lorazepam
Droperidol
Antipsychotic and antiemetic
2001 the FDA placed a black box warning for prolonged QT, risk of torsades de
pointes

18. Atypical Antipsychotics
• Clozapine - High doses are needed to cause an immediate change of
behavior. Serious side effects agranulocytosis and seizures.
• Quetiapine - Recommended slow titration of dose so cannot be used in
doses needed to change behavior abruptly
• Potentially beneficial sedating effect 160 times the antihistamine potency
of diphenhydramine
• Equivalent to haloperidol in the treatment of psychosis: may be more
effective than haloperidol in treating aggression

19. Implications of Restraints
• Competency of the patient
• Patient right to refuse
• Protection of the patient and other ED staff
• Protection of third parties
• There have been many more malpractice suits lost for having NOT detained a
patient who went on to commit suicide, then there have been for unlawful
imprisonment.

20. Documentation
• Reason for restraints (patient has the potential to harm self
or others)
• What measures have been taken to avoid restraints, such as
“talking down” or enlisting family help
• Type of restraints being employed and rationale
• A plan for removal of restraints when the patient exhibits
behavior of self-restraint

21. Key Learning Points
• Who needs to be restrained
• Competency, autonomy, threat to others
• Which chemical restraints
• Oral vs. IM
• oral haloperidol and risperidone
• IM haloperidol and ziprasidone
• Legality of restraints
• Protect the patient
• Protect the ED staff
• Protect third parties

22. Thank You