managing the violent patient in the transition from prehospital care to the emergency department jim...
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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 MedicineUniformed Services University of the Health SciencesClinical Professor of Emergency MedicineGeorge Washington UniversityBethesda, Maryland, U.S.A.
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
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
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 ideationInjuries in a residenceAddress where prior violent events reportedPatients with prior psychiatric problems
Initial On-Scene Management of Potentially Violent SituationsEMS 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 sightRemove potential weapons from scene
ƒ Caution if handling will alter evidence needed by police
Options to Consider in Disposition of Violent Patients Arrest & restraint by police, then transport by policeƒ To jailƒ To medical facility
Police assist in restraint, then transport in EMS vehicle to medical facilityƒ With or without police in EMS vehicle
If police unwilling to assist in restraint, should call physician medical command to talk to police directly
Sequence of Events Needed to Physically Restrain a Violent Patient
Collect at least 5 strong personnelDesignate one person in chargePreposition belts & wraps & backboard or scoop stretcher on litter
Body fluid precautionsOne 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
Initial Considerations Once the Patient is Physically RestrainedSearch clothes for weapons or meds & remove
Quickly check for hypoxia, hypoglycemia, hyperthermia, and treat if identified
Precautions against aspirationƒ Suction should be ready
Keep stretcher close to ground levelDecide if > 1 person needed in back of ambulance for safety
Personal Protective Measures for Prehospital PersonnelBody armor / bullet-proof vests
ƒ Protect also well against stabs and blunt chest trauma from MVC's
Weaponsƒ 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
Restraint Considerations on the Ambulance StretcherCervical collar if any possible neck traumaLegs or ankles should not be crossedAdditional 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
Use of On-Line Physician Medical Command to Assist in Managing Violent Patients
Should contact medical command if :ƒ Patient refusing care but not competentƒ EMS personnel need more help from policeƒ Proper disposition of patient is unclear to EMS personnel
ƒ Use of medications for chemical restraint is needed
Use of Chemical RestraintsChoices include :
ƒ Narcotics (morphine)ƒ Benzodiazepines (midazolam, diazepam)–Advantage of these is that they can be reversed by naloxone or flumazenil
ƒ Haloperidolƒ Neuromuscular blockers–Require endotacheal intubation & adavanced training
Use of any agent requires close monitoring
Considerations in Use of Haloperidol for Chemical RestraintOften 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 reactionsƒ Treat with 25 mg diphenhydramine IV
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 agitationAdvantage 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
Considerations in Use of Narcotics as Chemical RestraintsCommonly cause respiratory depression & / or hypotension
Also may cause nausea / emesisUseful if concurrent pain from injury contributing to patient's combativeness
Morphine dose is 1 to 5 mg IM or IV, & repeat as needed
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
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 frequentlyDon't leave patient unobserved
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