Restraint is used by EMS personnel to protect patients from harming themselves or others and to allow for medical assessment and treatment. Verbal de-escalation is always the first approach, with physical and chemical restraint only used as a last resort when safety cannot be ensured through other means. When restraint is necessary, it must be done carefully according to protocols to avoid injury and ensure the patient's airway, breathing, and circulation are not compromised. EMS personnel must be properly trained in restraint techniques and closely monitor any patients who are restrained.

1. Restraint andRestraint and
the Streetthe Street
MedicMedic
Steve ColeSteve Cole
One Cool DudeOne Cool Dude

2. Revision InfoRevision Info
 Disclosures:Disclosures:
No Commercial AffiliationNo Commercial Affiliation
No Paid Product EndorsementsNo Paid Product Endorsements
 Revised 08-09Revised 08-09
 For more information, contactFor more information, contact
Steve ColeSteve Cole

4. Not that kind of restraint!Not that kind of restraint!

6. Not that!Not that!

7. Not that either!Not that either!

8. RestraintsRestraints
 BackgroundBackground
 Important ConceptsImportant Concepts
 Who do we restrain?Who do we restrain?
 Why do we restrain them?Why do we restrain them?
 How do we restrain them?How do we restrain them?
 Verbal and Non VerbalVerbal and Non Verbal
 Physical RestraintsPhysical Restraints
 Chemical RestraintsChemical Restraints
 Improper RestraintsImproper Restraints
 What are the risks?What are the risks?

9. BackgroundBackground

10. Definition of Restraint
Restraint
Physical restraint Chemical restraint
Use of sedatives,
psychotropics, or hypnotics to
control a
potentially violent patient.
application, monitoring,
and removal of mechanical
restraining devices or manual
restraints that are used to limit
physical mobility of a patient.

11. Important ConceptsImportant Concepts
Restraints are any physical or
pharmacological means used to restrict a
patient’s movement, activity, or access to
their body.
Patients generally have a right to be free
from restraints unless restraint is
necessary to treat their medical symptoms
or to prevent patients from harming
themselves or others.

12.  "...As a matter of law, any individual who"...As a matter of law, any individual who
chooses to restrain someone may bechooses to restrain someone may be
charged and found responsible for thecharged and found responsible for the
intended or unintended impact."intended or unintended impact."

13. COBRA Speaks out!COBRA Speaks out!
This law provides that
patients "have the right to
be free from... any physical
or chemical restraints
imposed for purposes of
discipline or convenience
and not required to treat
the residents’ medical
symptoms."

14. Minimum Restraint required?Minimum Restraint required?
 Different rules for different situationsDifferent rules for different situations
 In EMS we have:In EMS we have:
Limited resourcesLimited resources
More Scene HazardsMore Scene Hazards
Limited diagnostic equipment to rule out nonLimited diagnostic equipment to rule out non
life threatening cause of abnormal behaviorlife threatening cause of abnormal behavior
 If we restrain a pt, we must be prepared toIf we restrain a pt, we must be prepared to
assume TOTAL CONTROL.assume TOTAL CONTROL.

15. Who can we restrain?Who can we restrain?
 Any person we can assume a “duty to act” withAny person we can assume a “duty to act” with
providing:providing:
 We have a legal grounds for doing soWe have a legal grounds for doing so
 Mental HoldsMental Holds
 Ward of the stateWard of the state
 Implied consentImplied consent
 We have a medical justification for doing so
 We do it in a way that protects the pt
 We assume FULL custodianship of the pt’s
well being until transfer of care.

16. Some people need to be restrainedSome people need to be restrained
for their own safetyfor their own safety

17. Why Restrain?Why Restrain?
 Protect patients from physically harming themselves
 self-extubation
 Deliberate Self Harm
 Falling
 Protect staff and/or patients' families from patient
violence
 Allow assessment of disoriented and uncooperative
patients or those under the influence of alcohol or
drugs
 Facilitate medically necessary procedures (eg,
gastric lavage) in uncooperative patients
 Prevent runners while patients are being evaluated
for potential suicidal or homicidal behavior

18. Why not?Why not?
 Taking actions that lead to the death of aTaking actions that lead to the death of a
person because they were rude,person because they were rude,
belligerent and aggressive is abelligerent and aggressive is a
questionable action.questionable action.
 Restraint isRestraint is notnot a 1a 1stst
line of action unlessline of action unless
the person is anthe person is an eminenteminent danger todanger to
themselves or others.themselves or others.

19. Remember:Remember:
 Scene Management is vital to insure thatScene Management is vital to insure that
you protect yourself, as well as your pt.you protect yourself, as well as your pt.
 Move furniture, other itemsMove furniture, other items
 Assign personnel to body partsAssign personnel to body parts
 Don’t get angryDon’t get angry
 Its not a rodeo!Its not a rodeo!

20. How do we restrain?How do we restrain?
 VerbalVerbal
 Non VerbalNon Verbal
 PhysicalPhysical
 ChemicalChemical

21. Important Concept!Important Concept!
 When is Enough;When is Enough;
Enough?Enough?
 Pt calms downPt calms down
 Pt stops strugglingPt stops struggling
 Enough help on handEnough help on hand
for handle furtherfor handle further
outburstsoutbursts
 Further violence isFurther violence is
preventedprevented
 Environment is safe.Environment is safe.
 Total Control isTotal Control is
assured.assured.

22.  Verbal De-escalation
 The application of verbal technique to calm the patient is usual the
first methods that EMS personnel should employ. This method is
safest because it does not require any physical contact with the
patient. The conversation must be honest and straightforward with a
friendly tone.
 Providers should avoid direct eye contact and encroachment upon
the patient’s personal space, as this may provoke stress and
anxiety.
 EMS personnel should always attempt to have equally open escape
routes for both the EMS personnel and the patient.
 Providers should assess the patient for suicidal and/or homicidal
ideation.
 Verbal intervention sometimes diffuses the situation, can prevent
further escalation, and may avoid the need for further restraint
tactics.

23. Verbal and Non VerbalVerbal and Non Verbal
 Initial MethodInitial Method
 De-escalation toolDe-escalation tool
 FirmFirm
 ForcefulForceful
 FairFair
 Body LanguageBody Language
 NumbersNumbers How's this body
language?

24. Physical RestraintsPhysical Restraints
 Control the SituationControl the Situation
 Do not attempt to restrain an agitatedDo not attempt to restrain an agitated
patient until you have them thoroughlypatient until you have them thoroughly
outnumberedoutnumbered
 Limits the risk of harm to yourselfLimits the risk of harm to yourself
 Rapidly controls the patient in order toRapidly controls the patient in order to
minimize the risk of patient traumaminimize the risk of patient trauma

25. “…When physically restraining a patient,
EMS personnel must make every effort to
avoid injuring the patient, and PPR
policies must choose restraint devices
that are associated with the least
chance of injury.”

26. Physical RestraintPhysical Restraint
Proper restraint requires at least five toProper restraint requires at least five to
six rescuerssix rescuers
A.A. One person handles each extremityOne person handles each extremity
B.B. One person manages the head andOne person manages the head and
airwayairway
C.C. One person coordinates the activityOne person coordinates the activity
D.D. Universal precautions should be utilizedUniversal precautions should be utilized
at all timesat all times

27. Physical RestraintPhysical Restraint
 One hand justOne hand just
proximal andproximal and oneone
hand just distal to thehand just distal to the
jointjoint
•• Immobilize bothImmobilize both
elbows and knees inelbows and knees in
extensionextension
•• Restricts movementRestricts movement..

28. Team leader secures the patient’s head by grasping theTeam leader secures the patient’s head by grasping the
forehead with one hand and securing the chin with theforehead with one hand and securing the chin with the
other.other.
No Arm Locks or Choke Holds over Neck!No Arm Locks or Choke Holds over Neck!

29. •Check each limb for discoloration and any compromise of pulse andCheck each limb for discoloration and any compromise of pulse and
capillary refill.capillary refill.
•• Must be able to place two fingers under the restraint.Must be able to place two fingers under the restraint.
•• Patient’s face, mouth, and neck must not be covered or restrained.Patient’s face, mouth, and neck must not be covered or restrained.

30. Correct restraintCorrect restraint
Photo Courtesy of Charlie D. Miller.

31. Correct restraintCorrect restraint
Photo Courtesy of Charlie D. Miller.

32. Correct restraintCorrect restraint
Photo Courtesy of Charlie D. Miller.

33. Correct restraintCorrect restraint
Photo Courtesy of Charlie D. Miller.

34. Important goalsImportant goals
 Pt must not be able to reach you, IV lines,Pt must not be able to reach you, IV lines,
or other medical devicesor other medical devices
 Pt’s respiratory excursion MUST NOT BEPt’s respiratory excursion MUST NOT BE
COMPROMISED.COMPROMISED.
 O2 and SAO2 should be in place. ECGO2 and SAO2 should be in place. ECG
preferred as well.preferred as well.
 Pt should not be left unattended.Pt should not be left unattended.
 ABC’s should be easily monitored. (noABC’s should be easily monitored. (no
pillow cases)pillow cases)

35. Improper restraint positionsImproper restraint positions
 ProneProne
 SandwichedSandwiched
 HobbledHobbled
 Body bagsBody bags
 PapoosesPapooses

36. “…In general, EMS protocols should avoid the
use of hard restraints. If a system chooses to use
hard restraints, all personnel should be
trained in their use, and the patient’s extremities
should be evaluated frequently for injury or
neurovascular compromise.”

37. Chemical RestraintsChemical Restraints

38. Basic Premise of ChemicalBasic Premise of Chemical
RestraintsRestraints
Chemical restraints are an adjunct toChemical restraints are an adjunct to
physical restraint.physical restraint.
Chemical restraints are used toChemical restraints are used to
increase pt safety, and to facilitateincrease pt safety, and to facilitate
medical care, when physical restraintmedical care, when physical restraint
alone increases pt risk.alone increases pt risk.
Struggle against physical restraintsStruggle against physical restraints
may lead to fatal eventsmay lead to fatal events

39. Advantages of chemicalAdvantages of chemical
restraintsrestraints
 Control violent behavior and patientControl violent behavior and patient
agitationagitation
 May reduce need for physical restraintsMay reduce need for physical restraints
 Decreases Exertional demands of ptDecreases Exertional demands of pt
 Allows basic assessments and proceduresAllows basic assessments and procedures
 Allow examination and performance ofAllow examination and performance of
radiographic imaging at ERradiographic imaging at ER

40. Disadvantages of chemicalDisadvantages of chemical
restraintsrestraints
 Respiratory DepressionRespiratory Depression
 Loss of GagLoss of Gag
 Occasional paradoxical reaction results inOccasional paradoxical reaction results in
increased agitationincreased agitation
 Increase effect of other CNS depressantsIncrease effect of other CNS depressants
 Limit mental status assessment andLimit mental status assessment and
neurologic examination during sedationneurologic examination during sedation

41. A good general rule:A good general rule:
 When the pt cannot be safely or properlyWhen the pt cannot be safely or properly
restrained using physical means alone, thenrestrained using physical means alone, then
chemical restraints is a viable option.chemical restraints is a viable option.
 In some hospital settings, chemical restraint isIn some hospital settings, chemical restraint is
sometimes used alone. However for EMS, if theysometimes used alone. However for EMS, if they
need chemical restraints, then some form ofneed chemical restraints, then some form of
physical restraint should be in place.physical restraint should be in place.
 The exact degree is dependant on situation andThe exact degree is dependant on situation and
clinical needsclinical needs

42. AgentsAgents
 BenzodiazepinesBenzodiazepines
 Tranquilizers / neuropletic agentsTranquilizers / neuropletic agents
 Phenothiazines and ButyrophenonesPhenothiazines and Butyrophenones
 AntihistaminesAntihistamines

43. Other notesOther notes
 May call OLMC to exceed max dosageMay call OLMC to exceed max dosage
 Allow for longer elimination and retentionAllow for longer elimination and retention
periods in elderly, and those withperiods in elderly, and those with
liver/kidney disfunctionliver/kidney disfunction
 Use lower initial doses when alcohol isUse lower initial doses when alcohol is
involvedinvolved

44. Benzo’sBenzo’s
 In the prehospital setting, Benzodiazapines areIn the prehospital setting, Benzodiazapines are
your first line choice for chemical restraint!your first line choice for chemical restraint!
 Prehospital pt’s requiring restraint are oftenPrehospital pt’s requiring restraint are often
either drug, hypoxia, or neuro insult induced.either drug, hypoxia, or neuro insult induced.
 Even those with a Psychotic origin often haveEven those with a Psychotic origin often have
illicit drugs on board.illicit drugs on board.
 This makes for trouble, increased SZ risk, andThis makes for trouble, increased SZ risk, and
need forneed for prompt predictable restraint with aprompt predictable restraint with a
minimum of adverse reactions.minimum of adverse reactions.
 Benzo’s best fit the bill.Benzo’s best fit the bill.

45. Downside of benzo’sDownside of benzo’s
 More respiratory complicationsMore respiratory complications
 Sedation may be excessiveSedation may be excessive
 Sedation tends to last longer than otherSedation tends to last longer than other
class of drugsclass of drugs
 Limits neuro assessmentLimits neuro assessment
 This is especially true when alcohol is aThis is especially true when alcohol is a
factorfactor

47. ValiumValium
 DiazepamDiazepam
 Old FaithfulOld Faithful
 Dose: 2-5 mg IV, 5 mg IMDose: 2-5 mg IV, 5 mg IM
 Duration 1- 4 hoursDuration 1- 4 hours
 Repeat PRN up to 10 mgRepeat PRN up to 10 mg
 Slow absorption IMSlow absorption IM
 Lasts a long time. (too long?)Lasts a long time. (too long?)
 Works well for SZWorks well for SZ
 11stst
line for cocaine and meth (and presumablyline for cocaine and meth (and presumably
MDMA)MDMA)

48. VersedVersed
 MidazolamMidazolam
 Dose: 0.5-2.5 mg IV, 5 mg IMDose: 0.5-2.5 mg IV, 5 mg IM
 Max of 5 mgMax of 5 mg
 Duration 30 – 60 minutesDuration 30 – 60 minutes
 Absorbed Quickly IM (5-10 minutes)Absorbed Quickly IM (5-10 minutes)
 Short actingShort acting
 Works well for SZWorks well for SZ
 Amnesic effectsAmnesic effects
 hypotensionhypotension

49. AtivanAtivan
 LorazepamLorazepam
 Dose: 1-4 mg IV or IMDose: 1-4 mg IV or IM
 Max of 4mgMax of 4mg
 Slow actingSlow acting

50. XanaxXanax
 AlprazolamAlprazolam
 Not suited for EMS/ED useNot suited for EMS/ED use
 Used orally in mental health facilitiesUsed orally in mental health facilities
 Is a benzo and may potentiates otherIs a benzo and may potentiates other
benzosbenzos

52. Tranquilizers / Neuropletic agentsTranquilizers / Neuropletic agents
 ButrophenonesButrophenones
HaldolHaldol
InapsineInapsine
 PhenothiazinesPhenothiazines
ThorazineThorazine
 Anti HistaminesAnti Histamines
PhenerganPhenergan
BenadrylBenadryl

53. HaldolHaldol
 Butyrophone type of drug. Inhibits AlphaButyrophone type of drug. Inhibits Alpha
adrenergic and dopamine receptorsadrenergic and dopamine receptors
 Combine with Benadryl 25-50 mgCombine with Benadryl 25-50 mg
 2-5 mg IV or IM, Repeat up to 10 mg2-5 mg IV or IM, Repeat up to 10 mg
 Slower onset (15 -30 minutes).Slower onset (15 -30 minutes).
 Half life close to 24 hours.Half life close to 24 hours.
 Contraindicated in Meth and MDMAContraindicated in Meth and MDMA
 Can have EPS, decreased SZ threshold, andCan have EPS, decreased SZ threshold, and
anti-cholinergic effects.anti-cholinergic effects.

54. InapsineInapsine
 DroperidolDroperidol
 Butyrophone type of drug. Inhibits Alpha adrenergic andButyrophone type of drug. Inhibits Alpha adrenergic and
dopamine receptors.dopamine receptors.
 Commony used as an anti-emetic and as a chemicalCommony used as an anti-emetic and as a chemical
restraintrestraint
 2.5-5 mg IV/IM2.5-5 mg IV/IM
 FDA “Black Boxed” for reports of refractory Torsades deFDA “Black Boxed” for reports of refractory Torsades de
Points.Points. EKG use MandatoryEKG use Mandatory, 12 lead preferred., 12 lead preferred.
 Can have EPSCan have EPS
 Consider combining with Benadryl 25-50 mgConsider combining with Benadryl 25-50 mg
 Metabolized through liver. Excreted through urine andMetabolized through liver. Excreted through urine and
feces.feces.

55. ThorazineThorazine
 ChlorpromazineChlorpromazine
 Phenothiazine, Antagonizes DopaminePhenothiazine, Antagonizes Dopamine
receptorsreceptors
 Metabolized through liver. ExcretedMetabolized through liver. Excreted
through urine and feces.through urine and feces.
 Dose 25-50 mg IM q 1-4 hours PRNDose 25-50 mg IM q 1-4 hours PRN
 Also rarely used as an anti-emeticAlso rarely used as an anti-emetic

56. PhenerganPhenergan
 PromethazinePromethazine
 Phenothiazine, non selective anti-histamine. CommonlyPhenothiazine, non selective anti-histamine. Commonly
used as an anti emetic.used as an anti emetic.
 Used extensively in 50’s and 60’s foe sedation in mentalUsed extensively in 50’s and 60’s foe sedation in mental
institutions.institutions.
 12.5-25 mg IV/IM, repeat up to 50 mg.12.5-25 mg IV/IM, repeat up to 50 mg.
 Local phlebitis/irritation, Watch concentration whenLocal phlebitis/irritation, Watch concentration when
giving IV!giving IV!
 Can have EPSCan have EPS
 Consider combining with Benadryl 25-50 mgConsider combining with Benadryl 25-50 mg
 Metabolized through liver. Excreted through urine andMetabolized through liver. Excreted through urine and
feces.feces.

57. BenadrylBenadryl
 DiphenhydramineDiphenhydramine
 Non selective antihistamineNon selective antihistamine
 25-50 mg IV/IM/PO q 4-6 hours prn25-50 mg IV/IM/PO q 4-6 hours prn
 Max 300 mg/dayMax 300 mg/day
 Use caution with asthmatics with activeUse caution with asthmatics with active
wheezing or SOB.wheezing or SOB.

58. ParalyticsParalytics
 Generally speaking, Paralytics are NOTGenerally speaking, Paralytics are NOT
used for simple restraint.used for simple restraint.
Cant intubate/cant ventilate situationCant intubate/cant ventilate situation
Malignant HyperthermiaMalignant Hyperthermia
 May be used in a combative pt who meetsMay be used in a combative pt who meets
other criteria for RSI.other criteria for RSI.
Always used with sedativesAlways used with sedatives

59. Six Good Reasons to AvoidSix Good Reasons to Avoid
Phenothiazines andPhenothiazines and
ButyrophenonesButyrophenones
 Lower seizure thresholdLower seizure threshold
 Interfere with heat dissipationInterfere with heat dissipation
 Exacerbate tachycardiaExacerbate tachycardia
 Produce hypotensionProduce hypotension
 Increase heat production (movementIncrease heat production (movement
disorders)disorders)
 Not cross-tolerant with ethanol and otherNot cross-tolerant with ethanol and other
sedative hypnoticssedative hypnotics

61. Restraint Pitfalls: Life ThreatsRestraint Pitfalls: Life Threats
Causing Further Harm:Causing Further Harm:
 Agitated DeliriumAgitated Delirium
 HypoxiaHypoxia
 HyperthermiaHyperthermia
 H+ Ions (acidosis)H+ Ions (acidosis)
Volume depletionVolume depletion
RhabdomyolysisRhabdomyolysis
SeizuresSeizures
Positional AsphyxiaPositional Asphyxia

62. Comments On HyperthermiaComments On Hyperthermia
 Elevated temp is often caused by exertionElevated temp is often caused by exertion
and/or drug use.and/or drug use.
 Occasionally we increase heat retentionOccasionally we increase heat retention
by use of improper restraint devices.by use of improper restraint devices.
Body BagsBody Bags
Reeves SleveReeves Sleve
 Elevated Temp by itself is a risk factor forElevated Temp by itself is a risk factor for
pt death.pt death.

63. HyperthermiaHyperthermia
Struggling increases catecholamine releaseStruggling increases catecholamine release
which can exacerbate stimulant drugwhich can exacerbate stimulant drug
effectseffects
Prolonged struggling or chasing increasesProlonged struggling or chasing increases
heat productionheat production
Hyperthermia is one of the bestHyperthermia is one of the best
prognosticators for lethal eventsprognosticators for lethal events

64. Agitated Delirium and HeatAgitated Delirium and Heat

65. KEY POINTKEY POINT
 NEXT TO CHEMICAL SEDATION,NEXT TO CHEMICAL SEDATION,
ADDRESSING HEAT ISSUES IS AADDRESSING HEAT ISSUES IS A
CORNER STONE TREATMENTCORNER STONE TREATMENT
 PROMOTE HEAT DISSIPATIONPROMOTE HEAT DISSIPATION
THROUGH :THROUGH :
CONDUCTIONCONDUCTION
CONVECTIONCONVECTION
RADIATIONRADIATION
DECREASED ACTIVITYDECREASED ACTIVITY

66. Agitated DeliriumAgitated Delirium
 AKA: Excited deliriumAKA: Excited delirium
 An excited, often confused and combative stateAn excited, often confused and combative state
that made up of one or more of the following:that made up of one or more of the following:
 Use of stimulants (coke, meth, MDMA, PCP),Use of stimulants (coke, meth, MDMA, PCP),
 Chronic use may be as much of a factor as acute toxicityChronic use may be as much of a factor as acute toxicity
 Increased exertion and O2 demand (Increased exertion and O2 demand (Oxygen DeficitOxygen Deficit))
 IncreasedIncreased Heat ProductionHeat Production
 Sympathetic response (fight or flight)Sympathetic response (fight or flight)
 Cardiac damage both from chronic and acute factorsCardiac damage both from chronic and acute factors
 Greatly increases risk of “in custody death”,Greatly increases risk of “in custody death”,
especially when combined with improperespecially when combined with improper
restraint.restraint.

67. Rhabdomyolysis and AgitatedRhabdomyolysis and Agitated
DeliriumDelirium
 Believed to be a progression of Agitated Delirium, exacerbated andBelieved to be a progression of Agitated Delirium, exacerbated and
complicated by improper restraint, as well as a risk in restraint.complicated by improper restraint, as well as a risk in restraint.
 Breakdown of muscle releasing contents (Myoglobin and Potassium) ofBreakdown of muscle releasing contents (Myoglobin and Potassium) of
muscle fibers into blood stream.muscle fibers into blood stream.
 Three primary methods of morbidity:Three primary methods of morbidity:
 Kidney Failure (pre renal obstructive)Kidney Failure (pre renal obstructive)
 Fluid Shift from vascular space to surviving muscle, leading to relative volumeFluid Shift from vascular space to surviving muscle, leading to relative volume
depletion and possibly shock.depletion and possibly shock.
 HyperkalemiaHyperkalemia
 Multiple causes, today we are concerned about:Multiple causes, today we are concerned about:
 HeatHeat
 TraumaTrauma
 Prolonged SZProlonged SZ
 Severe ExertionSevere Exertion
 Drug useDrug use
 Any condition that damages skeletal muscleAny condition that damages skeletal muscle
Note: It may or may not result in visible myoglobinuria, ( red or brown urine. )Note: It may or may not result in visible myoglobinuria, ( red or brown urine. )

68. RunningRunning

69. FightingFighting

70. DrugsDrugs

71. Tx of RhabdoTx of Rhabdo
 Prevention! V.O.M.I.T., Cooling, etcPrevention! V.O.M.I.T., Cooling, etc
 HydrationHydration
 Fluids titrated to urine output 300 cc/hourFluids titrated to urine output 300 cc/hour
 Watch for CHFWatch for CHF
 Alkalinization of urineAlkalinization of urine
 Bicarb based on urine and plasma PHBicarb based on urine and plasma PH
 DiureticsDiuretics
 Lasix 40-120 intialy, with maint of 200 mg over 2-4 hoursLasix 40-120 intialy, with maint of 200 mg over 2-4 hours
 ManitolManitol
 Electrolyte correctionElectrolyte correction
 Insulin and glucose for hyper-K, Ca only in crisisInsulin and glucose for hyper-K, Ca only in crisis
 DialysisDialysis
 Supportive therapySupportive therapy

72. Agitated Delirium, Heat Issues, and RhabdoAgitated Delirium, Heat Issues, and Rhabdo
(Treatment)(Treatment)
Rapid CoolingRapid Cooling
Volume resuscitationVolume resuscitation
SedationSedation

73. Agitated Delirium
(Pitfalls)
 Improper physical restraint
 Exacerbating instead of halting the syndrome.
 Use of Beta adrenergic antagonists (Brevibloc)
 FAILURE to increase oxygenation
 FAILURE to facilitate ventilation
 FAILURE to give fluids
 FAILURE to mitigate heat and to Aggressively Cool
 FAILURE to minimize noxious stimuli
 FAILURE to aggressively monitor.
 These are the same pitfalls with cocaine, MDMA, and
Meth OD’s

74. Positional AsphyxiaPositional Asphyxia
 AKA; Sudden in custody death syndrome,AKA; Sudden in custody death syndrome,
Restraint Asphyxia, Mechanical AsphyxiaRestraint Asphyxia, Mechanical Asphyxia
 Often preceded by some agitated deliriumOften preceded by some agitated delirium
 Inhibition of the “Mechanical Bellows” ofInhibition of the “Mechanical Bellows” of
the chest.the chest.
 Rapid progression to code blue in under 2Rapid progression to code blue in under 2
minutes has been reported.minutes has been reported.

75. Photo © 1997 Bioguardian Systems, Inc.

76. Positional AsphyxiaPositional Asphyxia
 PA is defined as anytime the position of the bodyPA is defined as anytime the position of the body
interferes with respiration, resulting in respiratoryinterferes with respiration, resulting in respiratory
failure and death from suffocation.failure and death from suffocation.
 Often Positional Asphyxia could be preventedOften Positional Asphyxia could be prevented
just by turning the pt on his side.just by turning the pt on his side.
 There are many creative variations on theseThere are many creative variations on these
methods, including the “scoop sandwich” andmethods, including the “scoop sandwich” and
inappropriate use of devices such as theinappropriate use of devices such as the
“Reeves Sleeve” or KED.“Reeves Sleeve” or KED.
 All of these methods IMPAIR RESPIRATIONAll of these methods IMPAIR RESPIRATION
and put the patientand put the patient
(and you) at risk.(and you) at risk.

77. Restraint Associated AsphyxiaRestraint Associated Asphyxia
 Restraint asphyxia is a subset ofRestraint asphyxia is a subset of
“Positional Asphyxia”“Positional Asphyxia”
 Restraint Asphyxia is PA caused byRestraint Asphyxia is PA caused by
improper restraint techniques.improper restraint techniques.
 Manual Forceful Prone restraint,Manual Forceful Prone restraint,
Mechanical Forceful Prone Restraint,Mechanical Forceful Prone Restraint,
Prone Hobble restraintProne Hobble restraint

78. Mechanical Forceful ProneMechanical Forceful Prone
RestraintRestraint
 Mechanical Forceful-Prone-RestraintMechanical Forceful-Prone-Restraint
can be defined as placing a patient face-downcan be defined as placing a patient face-down
upon an ambulance wheeled stretcher, and thenupon an ambulance wheeled stretcher, and then
using restraint straps to compress the patient’susing restraint straps to compress the patient’s
chest and upper legs to the stretcher, preventingchest and upper legs to the stretcher, preventing
him from moving his body parts up and off ofhim from moving his body parts up and off of
that surface (out of a prone position).that surface (out of a prone position).
 ““Physical” and “Mechanical” forceful-prone-Physical” and “Mechanical” forceful-prone-
restraint are relatively the same things: forcefulrestraint are relatively the same things: forceful
compression of an individual while in a pronecompression of an individual while in a prone
position, maintaining that compression, andposition, maintaining that compression, and
preventing movement out of the prone positionpreventing movement out of the prone position

79. Basic Premise of PositionalBasic Premise of Positional
AsphyxiaAsphyxia
 Pt is already O2 hungry at cellular level due toPt is already O2 hungry at cellular level due to
agitated delirium, stimulant use, and exertionagitated delirium, stimulant use, and exertion
 Pt likely has early (or late stages) of heartPt likely has early (or late stages) of heart
damagedamage
 Pt may even be acidotic.Pt may even be acidotic.
 We then restrain improperly them when they areWe then restrain improperly them when they are
already compromised, making them morealready compromised, making them more
hypoxic (and likely struggle more) resulting in ahypoxic (and likely struggle more) resulting in a
rapid progression from screaming to cardiacrapid progression from screaming to cardiac
arrestarrest

80. Mechanical Forceful ProneMechanical Forceful Prone
RestraintRestraint
Photo Courtesy of Charlie D. Miller.

81. Hobble restraintHobble restraint
Photo Courtesy of Charlie D. Miller.

82. Effective respirationEffective respiration
Photo Courtesy of Charlie D. Miller.

83. Effective respirationEffective respiration
Photo Courtesy of Charlie D. Miller.

84. Effective respirationEffective respiration
Photo Courtesy of Charlie D. Miller.

85. Effective respirationEffective respiration
Photo Courtesy of Charlie D. Miller.

86. Effective respirationEffective respiration
 Essentially, whether forcefully-prone-restrained and/or hobbleEssentially, whether forcefully-prone-restrained and/or hobble
restrained, an individual must lift his entire body off of the surface herestrained, an individual must lift his entire body off of the surface he
is pronely placed upon – against physical pressure or restraintis pronely placed upon – against physical pressure or restraint
devices – usingdevices – using only his abdominal musclesonly his abdominal muscles, simply to take in or let, simply to take in or let
out a little bit of breath.out a little bit of breath.
 The forcefully-prone-restrained and/or hobble restrained individualThe forcefully-prone-restrained and/or hobble restrained individual
cannot breathe in, and can’t breathe out, in anything remotelycannot breathe in, and can’t breathe out, in anything remotely
resembling an adequate or effective manner.resembling an adequate or effective manner.
 When placed in forceful-prone-restraint and/or hobble restraints, theWhen placed in forceful-prone-restraint and/or hobble restraints, the
muscular act of breathing suddenly requires a greatly increasedmuscular act of breathing suddenly requires a greatly increased
physical effort – a greatly increased energy-expenditure. Yet, thisphysical effort – a greatly increased energy-expenditure. Yet, this
great effort/energy-expenditure achieves (at best) only the tiniestgreat effort/energy-expenditure achieves (at best) only the tiniest
volume of breath.volume of breath.

87. Cycle of deathCycle of death

88. Restraint AsphyxiaRestraint Asphyxia
 Prevention is the KeyPrevention is the Key
 The most effective (and important)The most effective (and important)
measure is to first turn the patient on hismeasure is to first turn the patient on his
side.side.
 By correctly restraining a pt, your job isBy correctly restraining a pt, your job is
easier, the patient is safer.easier, the patient is safer.
 Aggressive ABC, monitoring is a must.Aggressive ABC, monitoring is a must.

89. Correct restraintCorrect restraint
Photo Courtesy of Charlie D. Miller.

90. Correct restraintCorrect restraint
Photo Courtesy of Charlie D. Miller.

91. Mitigate the risk!Mitigate the risk!
 CONTROL THE SITUATIONCONTROL THE SITUATION
 Travel in packsTravel in packs
 V.O.M.I.T. and Temp.V.O.M.I.T. and Temp.
 Promote heat dissipation, Active coolingPromote heat dissipation, Active cooling
 Promote respirationPromote respiration
 Good sedation, Use Benzo’sGood sedation, Use Benzo’s
 Supply O2 (Blow by if pt wont tolerate NC or mask)Supply O2 (Blow by if pt wont tolerate NC or mask)
 Fluid ResuscitationFluid Resuscitation
 Watch your pt position, Never Prone! No Hobbles.Watch your pt position, Never Prone! No Hobbles.
 Be prepared for the crash.Be prepared for the crash.

93. Questions??Questions??

94. Special ThanksSpecial Thanks
 Charlie D. Miller, Paramedic, RestraintCharlie D. Miller, Paramedic, Restraint
ExpertExpert
 Check out her Web Page at:Check out her Web Page at:
http://www.charlydmiller.com/http://www.charlydmiller.com/
 Email at:Email at:
c-d-miller@neb.rr.comc-d-miller@neb.rr.com

95. The LiteratureThe Literature
 O’Halloran RL, Newman LV. RestraintO’Halloran RL, Newman LV. Restraint
asphyxiation in excited delirium.asphyxiation in excited delirium. Am JAm J
Forensic med PathForensic med Path. 1993;14(4):289-295. 1993;14(4):289-295

96. The LiteratureThe Literature
 Findings:Findings:
 11 cases of sudden death of men restrained in prone11 cases of sudden death of men restrained in prone
position by police officers.position by police officers.
 9 were hogtied, 1 was tied to hospital gurney, and 19 were hogtied, 1 was tied to hospital gurney, and 1
was manually held prone.was manually held prone.
 All were in excited delirious state (3 were psychotic, 8All were in excited delirious state (3 were psychotic, 8
from drugs [6 cocaine, 1 methamphetamine, 1 LSD])from drugs [6 cocaine, 1 methamphetamine, 1 LSD])
 2 were shocked with stun guns2 were shocked with stun guns

97. The LiteratureThe Literature
 Findings:Findings:
 Sudden death of people in a state of agitated delirium duringSudden death of people in a state of agitated delirium during
prone restraint appears not to be uncommon.prone restraint appears not to be uncommon.
 Mechanism of death is sudden, fatal cardiac dysrhythmia orMechanism of death is sudden, fatal cardiac dysrhythmia or
respiratory arrestrespiratory arrest
 Factors:Factors:
 Psychiatric or drug-induced state causes catecholamine stress onPsychiatric or drug-induced state causes catecholamine stress on
the heartthe heart
 Hyperactivity coupled with struggling with PD and against restraintsHyperactivity coupled with struggling with PD and against restraints
contributes to increases in oxygen demandscontributes to increases in oxygen demands
 Hogtied position clearly impairs breathing in situations of highHogtied position clearly impairs breathing in situations of high
oxygen demand by impairing chest wall and diaphragmaticoxygen demand by impairing chest wall and diaphragmatic
movementmovement

98. The LiteratureThe Literature
 Stratton SJ, Rogers C, Green K. SuddenStratton SJ, Rogers C, Green K. Sudden
death in individuals in hobble restraintsdeath in individuals in hobble restraints
during paramedic transport.during paramedic transport. Ann EmergAnn Emerg
Med.Med. 1995;25:710-7121995;25:710-712

99. The LiteratureThe Literature
 Findings:Findings:
2 cases of unexpected death in restrained,2 cases of unexpected death in restrained,
agitated individuals being transported by ALSagitated individuals being transported by ALS
ambulance.ambulance.
Both patients placed in hobble restraints byBoth patients placed in hobble restraints by
law enforcement.law enforcement.

100. The LiteratureThe Literature
 Case 1Case 1
 35 y/o agitated, combative man found rolling in the street.35 y/o agitated, combative man found rolling in the street.
 Arrested and handcuffed with hands behind back.Arrested and handcuffed with hands behind back.
 Remained uncontrollable and placed in hobble restraints.Remained uncontrollable and placed in hobble restraints.
 Placed in prone position on stretcher and transported with cardiacPlaced in prone position on stretcher and transported with cardiac
monitor attached.monitor attached.
 During transport, pulse dropped from 135 to 60, then increased to 102,During transport, pulse dropped from 135 to 60, then increased to 102,
and then developed asystole.and then developed asystole.
 Restraints removed, resuscitation attempted and failed.Restraints removed, resuscitation attempted and failed.
 Autopsy negative other than antecubital needle marks.Autopsy negative other than antecubital needle marks.
 TOX: + amphetamine and methamphetamineTOX: + amphetamine and methamphetamine
 Death: Methamphetamine intoxication and restrained maneuvers forDeath: Methamphetamine intoxication and restrained maneuvers for
bizarre behavior.bizarre behavior.

101. The LiteratureThe Literature
 Case 2Case 2
 30 y/o male who was riding his bicycle in and out of traffic30 y/o male who was riding his bicycle in and out of traffic
 Stopped and arrested by police.Stopped and arrested by police.
 Fought police and placed into hobble restraints after other methods ofFought police and placed into hobble restraints after other methods of
restraint failed.restraint failed.
 EMS summoned and patient placed in prone position.EMS summoned and patient placed in prone position.
 Initially combative and paramedics unable to obtain vital signs.Initially combative and paramedics unable to obtain vital signs.
 Within 6 minutes, patient became unresponsive.Within 6 minutes, patient became unresponsive.
 Restraints removed and resuscitation attempted and failed.Restraints removed and resuscitation attempted and failed.
 Autopsy revealed pulmonary edema and congestion, otherwiseAutopsy revealed pulmonary edema and congestion, otherwise
negative.negative.
 TOX: ETOH=0.100 + cocaine, + methamphetamineTOX: ETOH=0.100 + cocaine, + methamphetamine
 Death: Positional asphyxia during restraint for agitated deliriumDeath: Positional asphyxia during restraint for agitated delirium

102. The LiteratureThe Literature
 Findings:Findings:
 Patients should be placed in supine or lateral positionPatients should be placed in supine or lateral position
rather than prone.rather than prone.
 If hobble restraints are used, allow slack forIf hobble restraints are used, allow slack for
ventilatory movement of the chest wall.ventilatory movement of the chest wall.
 Patient must be monitored closely.Patient must be monitored closely.
 EMS crew must have capability to immediatelyEMS crew must have capability to immediately
release the restraints and provide ALS.release the restraints and provide ALS.

103. The LiteratureThe Literature
 Roeggla M, Wagner A, Mueliner M, et al.Roeggla M, Wagner A, Mueliner M, et al.
Cardiorespiratory consequences to hobbleCardiorespiratory consequences to hobble
restraint.restraint. Wien Klin WorchenschrWien Klin Worchenschr..
1997;109:359-361.1997;109:359-361.

104. The LiteratureThe Literature
 Findings:Findings:
 Study of 6 healthy volunteers restrained with hobble restraints inStudy of 6 healthy volunteers restrained with hobble restraints in
upright and prone positions.upright and prone positions.
 During hobble restraint in the prone position they found FVCDuring hobble restraint in the prone position they found FVC
dropped by 40%, end-tidal COdropped by 40%, end-tidal CO22 increased by 15%, and theincreased by 15%, and the
cardiac output increased by 37%.cardiac output increased by 37%.
 Hobble restraints in the prone position leads to a dramaticHobble restraints in the prone position leads to a dramatic
impairment of hemodynamics and respirationimpairment of hemodynamics and respiration
 Upright position and frequent control of vital parameters areUpright position and frequent control of vital parameters are
necessary to prevent possibly fatal outcome in persons in hobblenecessary to prevent possibly fatal outcome in persons in hobble
restraintsrestraints

105. The LiteratureThe Literature
 Chan TC, Vilke GM, Neuman T, ClausenChan TC, Vilke GM, Neuman T, Clausen
JL. Restraint position and positionalJL. Restraint position and positional
asphyxia.asphyxia. Ann Emerg MedAnn Emerg Med. 1997;30:578-. 1997;30:578-
586586

106. The LiteratureThe Literature
 Findings:Findings:
 Experimental cross-over trial of healthy volunteers placed inExperimental cross-over trial of healthy volunteers placed in
“hobble” or “hogtie” restraints.“hobble” or “hogtie” restraints.
 15 healthy men (ages 18-40) underwent drug screening and15 healthy men (ages 18-40) underwent drug screening and
pulmonary function testing.pulmonary function testing.
 11stst
Phase: Exercised for 4 minutes and underwent PFT sitting,Phase: Exercised for 4 minutes and underwent PFT sitting,
supine, prone and restraint positions.supine, prone and restraint positions.
 22ndnd
Phase: Subjects underwent 2 exercise and 2 rest periodsPhase: Subjects underwent 2 exercise and 2 rest periods
(seated for first rest period and restrained for second).(seated for first rest period and restrained for second).

107. The LiteratureThe Literature
 Findings:Findings:
 ABGs, pulse and oximetry measured throughout.ABGs, pulse and oximetry measured throughout.
 Subjects placed in restraint exhibited a reduced pulmonarySubjects placed in restraint exhibited a reduced pulmonary
function pattern by PFT, but no evidence of hypoxia orfunction pattern by PFT, but no evidence of hypoxia or
hypercapnia was found.hypercapnia was found.
 Restraint position, by itself, was not associated with anyRestraint position, by itself, was not associated with any
clinically-relevant changes in respiratory or ventilatory functionclinically-relevant changes in respiratory or ventilatory function
(decrease of 13%)(decrease of 13%)
 There is no evidence to suggest that hypoventilatory respiratoryThere is no evidence to suggest that hypoventilatory respiratory
failure or asphyxiation occurs as a direct result of body restraintfailure or asphyxiation occurs as a direct result of body restraint
position in healthy, awake, non-intoxicated individuals.position in healthy, awake, non-intoxicated individuals.

108. The LiteratureThe Literature
 Chan TC, Vilke GM, Neuman T.Chan TC, Vilke GM, Neuman T.
Reexamination of custody restraintReexamination of custody restraint
position and positional asphyxia.position and positional asphyxia. Am JAm J
Forensic Med Path.Forensic Med Path. 1998;19(3):201-2051998;19(3):201-205

109. The LiteratureThe Literature
 Findings:Findings:
 Collective review of literature on restraint and positionalCollective review of literature on restraint and positional
asphyxia.asphyxia.
 Factors other than body positioning appear to be more importantFactors other than body positioning appear to be more important
determinants for sudden, unexpected deaths in individuals in thedeterminants for sudden, unexpected deaths in individuals in the
hogtie custody restraint position.hogtie custody restraint position.
 Factors include: illicit drug use, physiologic stress, hyperactivity,Factors include: illicit drug use, physiologic stress, hyperactivity,
hyperthermia, catechol hyperstimulation, and trauma fromhyperthermia, catechol hyperstimulation, and trauma from
struggle.struggle.

110. The LiteratureThe Literature
 Ross DL. Factors associated with excitedRoss DL. Factors associated with excited
delirium deaths in police custody.delirium deaths in police custody. ModMod
PatholPathol. 1998;11(11):1127-1137. 1998;11(11):1127-1137

111. The LiteratureThe Literature
 Findings:Findings:
Review of 61 cases of excited delirium whereReview of 61 cases of excited delirium where
patient died in police custody.patient died in police custody.

112. PsychologicalPsychological PhysiologicPhysiologic PhysicalPhysical
ParanoidParanoid TachycardiaTachycardia HypervigilenceHypervigilence
HallucinationsHallucinations HyperthermiaHyperthermia Extreme StrengthExtreme Strength
GrandiosityGrandiosity HypertensionHypertension Incoherent speechIncoherent speech
Extreme agitationExtreme agitation Foaming of theFoaming of the
mouthmouth
ShoutingShouting
FearFear MydriasisMydriasis Violent behaviorViolent behavior
FornicationFornication Cardiac arrestCardiac arrest Bizarre behaviorBizarre behavior
Thought disorderThought disorder SeizuresSeizures Kicking/ThrashingKicking/Thrashing
DysphoricDysphoric PulmonaryPulmonary
congestioncongestion
Running/HidingRunning/Hiding
Chest painChest pain Threat to self/othersThreat to self/others
Profuse sweatingProfuse sweating AggressionAggression
High pain thresholdHigh pain threshold

113. The LiteratureThe Literature
 Findings:Findings:
 Most common aggravating factor was abuse of cocaine andMost common aggravating factor was abuse of cocaine and
cocaine/alcohol.cocaine/alcohol.
 Restraint equipment that controls a violent patient’s legsRestraint equipment that controls a violent patient’s legs
independent of the wrists, such as a leg wrapping strap device,independent of the wrists, such as a leg wrapping strap device,
which allows the subject to be in an upright and seated positionwhich allows the subject to be in an upright and seated position
at the scene and during transport should be used.at the scene and during transport should be used.
 The hogtie system should only be used judiciously and inThe hogtie system should only be used judiciously and in
situations when there is no alternative. The patient should besituations when there is no alternative. The patient should be
placed upright or rolled on his side quickly after restraint andplaced upright or rolled on his side quickly after restraint and
vital signs monitored.vital signs monitored.

114. The LiteratureThe Literature
 Hick JL, Smith SW, Lynch MT. MetabolicHick JL, Smith SW, Lynch MT. Metabolic
acidosis in restraint-associated cardiacacidosis in restraint-associated cardiac
arrest: a case series.arrest: a case series. Acad Emerg MedAcad Emerg Med..
1999;6:239-243.1999;6:239-243.

115. The LiteratureThe Literature
 Findings:Findings:
 Review of 5 cases (4 fatal) where cardiovascularReview of 5 cases (4 fatal) where cardiovascular
collapse occurred in ED patients who were strugglingcollapse occurred in ED patients who were struggling
despite maximum restraint techniques.despite maximum restraint techniques.
 All were intoxicated (cocaine, benzoyleconineAll were intoxicated (cocaine, benzoyleconine
[cocaine metabolite])[cocaine metabolite])
 Profound metabolic acidosis was associated withProfound metabolic acidosis was associated with
cardiovascular collapse following exertion in acardiovascular collapse following exertion in a
restrained position (pH ranges: 6.25-6.81)restrained position (pH ranges: 6.25-6.81)

116. The LiteratureThe Literature
 Findings:Findings:
 Avoiding the hobble restraint position andAvoiding the hobble restraint position and
emphasizing side rather than prone positioning myemphasizing side rather than prone positioning my
eliminate some of the problems that contribute to theeliminate some of the problems that contribute to the
deaths.deaths.
 Early EMS involvement may help to prevent in-Early EMS involvement may help to prevent in-
custody deaths through use of chemical restraints andcustody deaths through use of chemical restraints and
bicarbonate therapy.bicarbonate therapy.

117. The LiteratureThe Literature
 Pollanen MS, Chiasson DA, Cairns JT,Pollanen MS, Chiasson DA, Cairns JT,
Young JC. Unexpected death related toYoung JC. Unexpected death related to
restraint for excited delirium: arestraint for excited delirium: a
retrospective study of deaths in policeretrospective study of deaths in police
custody.custody. CMAJCMAJ. 1998;158:1603-7.. 1998;158:1603-7.

118. The LiteratureThe Literature
 Findings:Findings:
 Review of 21 Canadian cases of unexpected death inReview of 21 Canadian cases of unexpected death in
persons with excited delirium.persons with excited delirium.
 Deaths were all associated with restraint either withDeaths were all associated with restraint either with
the person in the prone position or subject to pressurethe person in the prone position or subject to pressure
on the neck.on the neck.
 All lapsed into tranquility shortly after beingAll lapsed into tranquility shortly after being
restrained.restrained.

119. The LiteratureThe Literature
 Findings:Findings:
 58% had psychiatric disorder58% had psychiatric disorder
 38% had cocaine-induced psychosis38% had cocaine-induced psychosis
 Restraint may contribute to the death of people inRestraint may contribute to the death of people in
states of excited delirium.states of excited delirium.
 Law enforcement personnel should bear in mind theLaw enforcement personnel should bear in mind the
potential for the unexpected death of people inpotential for the unexpected death of people in
excited states of delirium who are restrained prone orexcited states of delirium who are restrained prone or
with a neck hold.with a neck hold.

120. The LiteratureThe Literature
 Schmidt P, Snowden T. The effects ofSchmidt P, Snowden T. The effects of
positional restraint on heart rate andpositional restraint on heart rate and
oxygen saturation.oxygen saturation. J Emerg MedJ Emerg Med..
1999;17(5):777-782.1999;17(5):777-782.

121. The LiteratureThe Literature
 Findings:Findings:
 18 healthy subjects (ages 21-42 years) were studied.18 healthy subjects (ages 21-42 years) were studied.
 Resting heart rates and SpOResting heart rates and SpO22 was measured.was measured.
 Randomly assigned to seated unrestrained or hogtiedRandomly assigned to seated unrestrained or hogtied
position, with protocols switched after 15 minutesposition, with protocols switched after 15 minutes
rest.rest.
 Phase 1: Each exercised until their heart rate was >Phase 1: Each exercised until their heart rate was >
120 (124-150).120 (124-150).

122. The LiteratureThe Literature
 Findings:Findings:
 Phase 2: Students paired with other student within 5 pounds ofPhase 2: Students paired with other student within 5 pounds of
body weight and ran simulated police chase course.body weight and ran simulated police chase course.
 Exercise intensity was high (pulse rates 175-212). At the end ofExercise intensity was high (pulse rates 175-212). At the end of
the chase, the chaser was placed in the seated position and thethe chase, the chaser was placed in the seated position and the
chased was placed in the hogtied position.chased was placed in the hogtied position.
 The chased subject then struggled for 30 seconds and SpOThe chased subject then struggled for 30 seconds and SpO22
measured. Roles reversed and process repeated.measured. Roles reversed and process repeated.

123. The LiteratureThe Literature
 Findings:Findings:
Findings refute the premise that positionalFindings refute the premise that positional
restraint alone produces physiological stressrestraint alone produces physiological stress
that places healthy persons at risk for suddenthat places healthy persons at risk for sudden
death.death.
Cocaine appears to be a common element inCocaine appears to be a common element in
positional restraint deaths.positional restraint deaths.
High levels of dopamine from cocaine may beHigh levels of dopamine from cocaine may be
a factor.a factor.

124. The LiteratureThe Literature
 Stratton SJ, Rogers C, Brockett K,Stratton SJ, Rogers C, Brockett K,
Gruzinski G. Factors associated withGruzinski G. Factors associated with
sudden death of individuals requiringsudden death of individuals requiring
restraint for excited delirium.restraint for excited delirium. Am J EmergAm J Emerg
MedMed. 2001;19:187-191.. 2001;19:187-191.

125. The LiteratureThe Literature
 Findings:Findings:
 Retrospective review of the LA County EMS and LARetrospective review of the LA County EMS and LA
Coroner’s records from 1992-1998.Coroner’s records from 1992-1998.
 216 cases of excited delirium located.216 cases of excited delirium located.
 18 deaths reported18 deaths reported
 20 cases of excited delirium witnessed by EMS20 cases of excited delirium witnessed by EMS
personnel.personnel.
 All had been hobble restrained.All had been hobble restrained.
 81% prone81% prone
 9% lateral9% lateral
 10% undetermined10% undetermined

126. The LiteratureThe Literature
 Findings:Findings:
 Multiple factors associated with sudden death while restrainedMultiple factors associated with sudden death while restrained
for excited delirium.for excited delirium.
 Excited delirium (100%)Excited delirium (100%)
 Hobble restraint (100%)Hobble restraint (100%)
 Prone position (100%)Prone position (100%)
 Forceful struggle against restraint (100%)Forceful struggle against restraint (100%)
 Positive stimulant use (78%)Positive stimulant use (78%)
 Autopsy evidence of chronic disease (56%)Autopsy evidence of chronic disease (56%)
 Obesity (56%)Obesity (56%)

127. The LiteratureThe Literature
 The data do not support or refute theThe data do not support or refute the
prone position while hobble restraint wasprone position while hobble restraint was
independently associated with suddenindependently associated with sudden
death.death.

128. The LiteratureThe Literature
 Position appears not to be significant factor inPosition appears not to be significant factor in
healthy patients.healthy patients.
 Patients with excited delirium at markedlyPatients with excited delirium at markedly
increased risk for restraint asphyxia.increased risk for restraint asphyxia.
 Stimulants contribute to problem of restraintStimulants contribute to problem of restraint
asphyxia.asphyxia.
 Prone position is best avoided.Prone position is best avoided.
 Hobble restraints are best avoided.Hobble restraints are best avoided.
 Chronic alcoholism or alcohol intoxication putsChronic alcoholism or alcohol intoxication puts
patients at risk for positional asphyxia.patients at risk for positional asphyxia.

129. The LiteratureThe Literature
 Cardiac dysrhythmias may be a causative factor.Cardiac dysrhythmias may be a causative factor.
 Metabolic acidosis may play a major role inMetabolic acidosis may play a major role in
deaths and is possibly preventable.deaths and is possibly preventable.
 Restraint asphyxia appears multi-factorial.Restraint asphyxia appears multi-factorial.
 Beware when the restrained patient becomesBeware when the restrained patient becomes
tranquil.tranquil.
 Often, deaths happen regardless of careOften, deaths happen regardless of care
rendered.rendered.