Chemical Restraint?

[Dustdevil]

I'm hoping for a restraint protocol involving Succinylcholine, or perhaps Adenosine drip? Anyone got anything like that?

Exactly. Go big or go home. That's why I RSI all of my psych patients. You never know when they're going to go nutzoid on you. Prevention is the best medicine.

[croaker260]

Ahhhhh.....the better part of the B52.. A lot closer to my comfort zone....Do you know how long this protocol has been implemented??

Any training about Excited Delerium or Cocaine Induced Delerium included?? VERY curious :-k

We have training on Excited Delerium/Agitated Delerium, I can provide you the PPT if you like.

ANyway, our protocols are here:

http://www.adaweb.net/departments/paramedics/swo2006.asp

Our specific protocol is here:

SECTION: M-14

PROTOCOL TITLE: Behavioral Emergencies and Combative Patients

REVISED: 15 April 2006

GENERAL COMMENTS: Behavioral emergencies and combative patients are some

of the most pitfall filled patients EMS personnel will encounter. Many of these patients

will have multiple underlying pathologies, including illicit drug use, which will pose

many challenges to overcome. Patient care should be focused with preventing/mitigating

hyperthermia, agitated delirium, positional asphyxia, hypoxia, and physical self-harm.

BLS SPECIFIC CARE: See adult General Medical Care Protocol M-1

- Assess for medical causes for altered LOC/violent behavior.

- Involve law enforcement as early as possible.

- Restraints may be used for patient and/or rescuer safety.

• Do not restrain prone if possible. 4 point restraints are

recommended

Observe and prevent positional asphyxia. Monitor airway and

respirations closely. If restrained, do not release restraints until at

the hospital unless required for essential patient care

- Do not leave patient unattended.

- Allow for adequate heat dissipation.

ILS SPECIFIC CARE: See adult General Medical Care Protocol M-1

- IV access (to a max of three attempts) only if needed due to severity of underlying

injury or illness, otherwise defer until arrival of ALS providers.

- Assess BG to rule out hypoglycemic episode.

ALS SPECIFIC CARE: See adult General Medical Care Protocol M-1

Sedation

- Diazepam (Valium)

• IV: 2-5 mg every 5-10 min PRN.

IM: 5-10 mg repeated once in 20 minutes PRN.

Max of 20 mg.

- Midazolam (Versed)

- Haloperidol (Haldol)

• IV/IM: 2.0-5.0 mg IVP PRN to a max of 10 mg.

Strongly consider co-administration of Benadryl.

Caution with Hyperthermia, seizure risks, and Hyperdynamic drug

use.

Adjunctive medications: These medications are given for their potentiation of other

drugs effects or for the prevention/treatment of certain side effects (nausea, EPS, etc)

of drugs used in sedation.

- Phenergan (Promethazine)

• IV: 6.25-12.5 mg IVP diluted.

IM: 12.5-50 mg

- Benadryl (Diphenhydramine)

PHYSICIAN PEARLS:

ALS Providers may decrease the dosage, or prolong the administration intervals of any

medication with sedative properties when doing so would decrease adverse effects and

still likely obtain the clinical goal.

Cautions with using medications to restrain a patient:

• Respiratory depression.

Loss of gag reflex.

Occasional paradoxical reaction results in increased agitation.

Increase effect of other CNS depressants.

Limit mental status assessment and neurologic examination during sedation.

Among the most difficult tasks is determining the etiologies of combative patients and

treating accordingly.

• Psychiatric (functional)

• Non-psychiatric (organic)

– Medical (CVA, Hypoglycemia, Increased ICP, Meningitis etc )

– Toxicologic

• Approximately two thirds have non-psychiatric (organic) etiology.

[tinman694]

We still only have the old fashioned method...handcuffs.

[Medic26]

Maybe I am a little different but if someone is that violent that they need to be restrained, they can take the ride in handcuffs in the police cruiser. Why put me and my partner in harms way when there are fella's out there that get paid and trained to do it.

Just my humble 2 cents worth.

[Just Plain Ruff]

most law enforcement agencies where I'm from will not transport a violent psych patient to the hospital. They call us. We restrain them with leathers and transport.

We usually tell them if they are violent enough to be restrained then there will be a cop in the ambulance with us and another one driving behind us.

Is your safety in jeopardy on these calls hell yeah

do you transport anyway well yeah

[croaker260]

Maybe I am a little different but if someone is that violent that they need to be restrained, they can take the ride in handcuffs in the police cruiser. Why put me and my partner in harms way when there are fella's out there that get paid and trained to do it.

Just my humble 2 cents worth.

Because the physiologic stress (heat, cardiac, metabolic and toxicologic) in these situations can be fatal in some of these patients. and the police cruiser on the way to the jail or the ER is the LAST place we want these patients to code...and the only ones who feel stronger about that is the cops themselves.

Interesting enough I said SOME and not MOST or ALL..there is enough research that we can approach this from a point of view of assessing "co-morbid" factors, just like we do when we use the ones we use for determining if a patient needs to go to a trauma center.

Not 100% positive or negative for inclusion or exclusion, but a good place to start.

[ccmedoc]

Maybe I am a little different but if someone is that violent that they need to be restrained, they can take the ride in handcuffs in the police cruiser. Why put me and my partner in harms way when there are fella's out there that get paid and trained to do it

If you've ever had a case of a positional asphyxia during transport, the popo get a very leary when taking combative patients to the ED without medical clearance..

Because the physiologic stress (heat, cardiac, metabolic and toxicologic) in these situations can be fatal in some of these patients. and the police cruiser on the way to the jail or the ER is the LAST place we want these patients to code...and the only ones who feel stronger about that is the cops themselves.

Interesting enough I said SOME and not MOST or ALL..there is enough research that we can approach this from a point of view of assessing "co-morbid" factors, just like we do when we use the ones we use for determining if a patient needs to go to a trauma center.

Not 100% positive or negative for inclusion or exclusion, but a good place to start.

Of the research I have found on the subject, and it is sparse, it would appear that after a certain point, there is little that can be done for these patients due to these physiologic factors such as acidosis..There was an alarming number of deaths occurring in ALS presence, hence the need for quick assessment, intervention and appropriate transport(ie, positioning of patient). I think field sedation protocols are a start, but I am glad to see increasing education about the factors involved and proper assessment of these patients..

[croaker260]

Of the research I have found on the subject, and it is sparse, it would appear that after a certain point, there is little that can be done for these patients due to these physiologic factors such as acidosis..There was an alarming number of deaths occurring in ALS presence, hence the need for quick assessment, intervention and appropriate transport(ie, positioning of patient). I think field sedation protocols are a start, but I am glad to see increasing education about the factors involved and proper assessment of these patients..

I would ammend that to say there is very little we can do (as in the prognosis is very poor) for patients who code (even witnessed arrest)...that said, there is plenty we can do before cardiac arrest that may avert it...hence the need for PROPER chemical restraint and proper restraint period, as well as mitigation strategies targeting the co-morbid factors.

[croaker260]

Actually on re reading your post, we are saying pretty much the same thing....My bad.

[kevkei]

There have been great points made about excited delerium and I think it is inumbent upon people to have a better knowledge and understanding of what it is, how to identify it and how to treat it.

...hence the need for PROPER chemical restraint and proper restraint period, as well as mitigation strategies targeting the co-morbid factors.

Excellent comment, although it should be expanded upon that the 'proper' restraint or agent of choice should be benzodiazepines. Other hypnotics or sedatives (Haldol, etc) don't mitigate the massive sympathetic response that these patients are experiencing.

It is also a good point about these patients, we need to initiate prompt and aggressive intervention as you are right, they get to a point of no return. Once this happens, it's too late.