M Anagement of the v Iolent P Atient

Abstract

Emergency medical services (EMS) providers must often manage violent or combative patients. The data regarding violence against EMS personnel are poor, but according to studies conducted thus far, between 0.8% and 5.0% of incidents to which EMS personnel respond involve violence or the threat of violence. Physical or chemical restraint is usually the only option available to emergency care providers to control violent patients. Physical restraint, however, can lead to sudden death in otherwise healthy patients, possibly as a result of positional asphyxia, severe acidosis, or a patient's excited delirium. Chemical restraint has traditionally consisted of either neuroleptics or benzodiazepines, but those drugs also have drawbacks. Haloperidol and droperidol, the neuroleptics most frequently used for restraint, can cause serious side effects such as extrapyramidal symptoms or QTc (QT interval corrected for heart rate) prolongation. The Food and Drug Administration recently issued a black box warning regarding the use of droperidol, because the QTc prolongation associated with the drug has led to fatal torsades de pointes in some patients. Benzodiazepines are also associated with adverse effects, such as sedation and respiratory depression, especially when the drugs are mixed with alcohol. The atypical antipsychotics, a new option that may be available soon, are less likely to cause such effects and therefore may be preferred over the neuroleptics. Liquid and injectable formulations of various atypical antipsychotics are currently in clinical trials. Because few options are currently available to EMS personnel for managing violent patients outside of the hospital, more research regarding violence against emergency care providers is necessary.

Relationship of Restraint Use, Patient Injury, andAssaults on Ems Personnel

“…Studies have suggested that between 0.8% and 5.0% of all incidents to which EMS personnel respond involve violence or the threat of violence. 31 The frequency of assault directed against EMS personnel in our study was much higher (27%) because we sampled only restrained patients. There were still few injuries (12/271; 4%) and all were minor (2 required medical treatment, none resulted in lost work).…”

Prehospital resuscitation of a man with excited delirium and cardiopulmonary arrest

“…Prehospital use of sedatives and antipsychotics, which may be of benefit in patients with ExDS, is increasing but has not been prospectively studied. 1,6,8,9 Other care recommendations that may improve survival include a focus on minimizing the amount of and time in restrictive restraint while still ensuring that field personnel remain safe and early mobilization of advanced life support practitioners. Perhaps most importantly, education for both law enforcement officers and emergency medical services personnel, as occurs in our system, may help protect both patients and providers.…”

Physiology and pathology of TASER® electronic control devices

“…[55][56][57][58][59][60] Since the ECD causes moderate muscle contractions it is natural to consider the possibility that an ECD application might exacerbate this acidosis. Animal studies with unventilated anesthetized swine do report pH changes.…”