Management of the violent patient

Physical restraint within the prehospital Emergency Medical Care Environment: A scoping review

Background

Psychomotor agitation and aggressive behaviour (AAB) have the potential to occur in any healthcare setting, including those in which Emergency Medical Services (EMS) operate. This scoping review aimed to examine the available literature on physical restraint of patients within the prehospital setting and to identify guidelines and their effectiveness, safety to patients and health care practitioners and strategies relating to physical restraint when used by EMS.

Methods

We performed our scoping review using the methodological framework described by Arksey and O'Malley augmented by that of Sucharew and Macaluso. Several steps guided the review process: identification of the research question, eligibility criteria, information sources (CINAHL, Medline, Cochrane and Scopus), search, selection and data collection, ethical approval, collation, summarizing and reporting on the results.

Results

The population of interest, in this scoping review was prehospital physically restrained patients, however, there was a reduced research focus on this population in comparison to the larger emergency department.

Conclusion

The limitation of informed consent from incapacitated patients may relate to the lack of prospective real-world research from previous and future studies. Future research should focus on patient management, adverse events, practitioner risk, policy, and education within the prehospital setting.

Adverse events following emergent prehospital sedation of patients with behavioral emergencies: A retrospective cohort study

BACKGROUND

Patients presenting to emergency medical services (EMS) with behavioral emergencies may require emergent sedation to facilitate care, but concerns about sedation-related adverse events (AEs) exist. This study aimed to describe the frequency of AEs following emergent prehospital sedation with three types of sedative agents: ketamine, benzodiazepines and antipsychotics.

METHODS

This retrospective cohort study included patients ≥ 15 years who presented to 1031U.S. EMS agencies in calendar year 2019 with behavioral emergencies necessitating emergent prehospital sedation. Serious AEs (SAE) included cardiac arrest, invasive airway placement, and severe oxygen desaturation (<75%). Less-serious AEs included positive pressure ventilation, any oxygen desaturation (<90%), oropharyngeal or nasopharyngeal airway placement, and suctioning. The need for additional sedation was also assessed.

FINDINGS

Of 7973 patients, 1996 received ketamine; 4137 received a benzodiazepine; 1532 received an antipsychotic agent; and 308 received an indeterminant agent. Cardiac arrest occurred in 11 patients (0·1%) and any SAE occurred in 165 patients (2·1%). Invasive airway placement was more frequent with ketamine (40, 2·0%) compared with benzodiazepines (17, 0·4%) or antipsychotics (3, 0·2%). Oxygen desaturation below 75% also occurred more frequently with ketamine (51, 2·6%) than with benzodiazepines (52, 1·3%) or antipsychotics (14, 0·9%). Patients sedated with ketamine were less likely to require additional sedation. Propensity-matching to minimize potential confounding between patient condition, sedative choice and AEs did not meaningfully alter the results.

INTERPRETATION

Although SAEs were rare among patients receiving emergent prehospital sedation, prehospital clinicians should remain mindful of the potential risks and monitor patients closely.

FUNDING

None.

Retrospective Study of Midazolam Protocol for Prehospital Behavioral Emergencies

Introduction

Agitated patients in the prehospital setting pose challenges for both patient care and emergency medical services (EMS) provider safety. Midazolam is frequently used to control agitation in the emergency department setting; however, limited data exist in the prehospital setting. We describe our experience treating patients with midazolam for behavioral emergencies in a large urban EMS system. We hypothesized that using midazolam for acute agitation leads to improved clinical conditions without causing significant clinical deterioration.

Methods

We performed a retrospective review of EMS patient care reports following implementation of a behavioral emergencies protocol in a large urban EMS system from February 2014–June 2016. For acute agitation, paramedics administered midazolam 1 milligram (mg) intravenous (IV), 5 mg intramuscular (IM), or 5 mg intranasal (IN). Results were analyzed using descriptive statistics, Levene’s test for assessing variance among study groups, and t-test to evaluate effectiveness based on route.

Results

In total, midazolam was administered 294 times to 257 patients. Median age was 30 (interquartile range 24–42) years, and 66.5% were male. Doses administered were 1 mg (7.1%) and 5 mg (92.9%). Routes were IM (52.0%), IN (40.8%), and IV (7.1%). A second dose was administered to 37 patients. In the majority of administrations, midazolam improved the patient’s condition (73.5%) with infrequent adverse events (3.4%). There was no significant difference between the effectiveness of IM and IN midazolam (71.0% vs 75.4%; p = 0.24).

Conclusion

A midazolam protocol for prehospital agitation was associated with reduced agitation and a low rate of adverse events.

Iranian pre-hospital emergency care nurses' strategies to manage workplace violence: A descriptive qualitative study

AIM

To explore the experiences of Iranian nurses working in pre-hospital emergency care services and the strategies used to manage of workplace violence.

BACKGROUND

Pre-hospital emergency nurses are subject to workplace violence; however, little research addresses their experiences, particularly related to their strategies in dealing with workplace violence.

METHODS

A descriptive qualitative study that involved nineteen male nurses who were working in pre-hospital services collected data using semi-structured interviews and analysed it using qualitative content analysis.

RESULTS

Data analysis yielded four descriptive categories including no reaction to violence (tolerance and acceptance as common workplace conflicts), situational management (patient and scene management), confrontation (direct and indirect) and escaping the scene. Patient management was the dominant strategy used and had the best outcomes related to both patient and personnel safety.

CONCLUSION

This study showed that pre-hospital nurses use different strategies to manage violence and patient management was a common and useful strategy for managing workplace violence. However, the pre-hospital nurses have little training, insufficient support and are poorly prepared to manage workplace violence.

IMPLICATIONS FOR NURSING MANAGEMENT

The development of context-based guidelines, continuing education, better-equipped ambulances that include medical and defence equipment, as well as better coordination of the police force in ambulance operations, can help to reduce workplace violence.

Prehospital resuscitation of a man with excited delirium and cardiopulmonary arrest

Features consistent with the syndrome known as excited delirium (ExDS) have been associated with law enforcement restraint-related death. The pathophysiology and exact causative factors of restraint-related death associated with ExDS remain unclear. We present a case of successful field resuscitation of a man with ExDS who experienced cardiopulmonary arrest while being restrained by law enforcement officers. Despite the presence of a severe lactic acidosis on emergency department admission, the patient recovered following prehospital treatment with advanced cardiac life support measures and intravenous sodium bicarbonate, likely in part due to early recognition of the disease process.

Workplace Violence: A Survey of Nationally Registered Emergency Medical Services Professionals

Previous studies on violence against prehospital personnel have mainly reported on “verbal” and “physical” violence. This study explored how provider demographic and work-related characteristics were associated with five different forms of workplace violence (being cursed or threatened; being punched, slapped, or scratched; being spat upon; being stabbed/stabbing attempt; and being shot/shooting attempt). A cohort of nationally registered United States Emergency Medical Services professionals was surveyed to determine the experience of each of these types of patient initiated violence by these providers and their partners. Multivariable logistic regression analyses indicated gender was significantly associated with both being cursed/threatened and being stabbed or experiencing a stabbing attempt (odds ratio (OR) = 0.65, CI = 0.44–0.96; OR = 0.27, CI = 0.09–0.75, resp.). Level of EMT practice was significantly associated with being cursed/threatened, being spat upon, and being punched, slapped, or scratched (OR = 0.17, CI = 0.11–0.27; OR = 0.30, CI = 0.21–0.43; OR = 0.31, CI = 0.22–0.44, resp.). Both community size and experience were significantly associated with all the types of violence investigated. EMS workplace violence research is at its infancy; thus this study adds to a limited but growing body of knowledge.

Issues in the management of acute agitation: how much current guidelines consider safety?

Agitated behavior constitutes up to 10% of emergency psychiatric interventions. Pharmacological tranquilization is often used as a valid treatment for agitation but a strong evidence base does not underpin it. Available literature shows different recommendations, supported by research data, theoretical considerations, or clinical experience. Rapid tranquilization (RT) is mainly based on parenteral drug treatment and the few existing guidelines on this topic, when suggesting the use of first generation antipsychotics and benzodiazepines, include drugs with questionable tolerability profile such as chlorpromazine, haloperidol, midazolam, and lorazepam. In order to systematically evaluate safety concerns related to the adoption of such guidelines, we reviewed them independently from principal diagnosis while examining tolerability data for suggested treatments. There is a growing evidence about safety profile of second generation antipsychotics for RT but further controlled studies providing definitive data in this area are urgently needed.

Consequences of workplace violence directed at nurses

The consequences of workplace violence (WPV) are far-reaching, and impact on the nurse, the perpetrator and the organization. However, the authors were unable to identify any research in the literature on nurses' perceptions of the consequences of WPV in non-teaching hospital settings. This study therefore aimed to examine nurses' perspectives of the consequences of WPV, to identify ways to reduce the impact of these incidents. A descriptive, exploratory approach was adopted to collect qualitative survey and interview data from nurses working in several areas of one West Australian non-teaching hospital in 2006. Three themes emerged from the data: nurse, perpetrator and organizational consequences. The sub-themes included nurses accepting that WPV is part of their job; physical and emotional effects; not feeling competent; avoiding patients; organizational costs of WPV; adverse effects of restraint; and disruption to patient care. Participants experienced several negative consequences as a result of WPV. Recommendations for improving the safety of hospitals for staff and patients are made in light of the findings.

Taser Use in Restraint-Related Deaths

OBJECTIVE

The Taser is an electric weapon capable of releasing significant amounts of electricity in rapid pulses, causing uncontrollable muscle contraction. Use of this weapon has dramatically increased over the past decade, and it is now commonly used by law enforcement officers nationwide. Emergency medical services providers are, likewise, seeing more patients who have recently been subjected to application of a Taser. We examined the autopsy reports of patients who died after application of a Taser in an attempt to identify high-risk interactions.

METHODS

This is a case series of Taser-related deaths. Fatalities occurring over four years beginning in January 2001 were identified through an Internet search, and autopsy reports were requested. Reports were analyzed for patient demographics, preexisting cardiac disease, toxicology, evidence of excited delirium, restraint techniques used, and listed cause of death.

RESULTS

Of 75 cases identified, 37 (49.3%) had autopsy reports available for review. All cases involved men, with ages ranging from 18 to 50 years. Cardiovascular disease was found in 54.1%. Illegal substance use was found on toxicology screening for 78.4%; within that group, 86.2% were found to have been using stimulants. A diagnosis of excited delirium was given for 75.7% of the cases. Use of a Taser was considered a potential or contributory cause of death in 27%.

CONCLUSIONS

This is the largest review of Taser-related fatalities reported in the medical literature. The findings are consistent with prior studies, suggesting a high frequency of restraint-related and excited delirium-related fatalities.

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

OBJECTIVE

We hypothesized that the assaults on EMS personnel by patients requiring restraints can be correlated with demographic information, patient condition, and other scene information such as presence the of law enforcement.

METHODS

The study was a one-year cross-sectional study of paramedic restraint use and assault on EMS personnel in an urban area. A data collection form was completed by EMS for each patient placed in restraints. Study outcome variable was "Assault on EMS personnel." Predictor variables included demographic and EMS call information, patient condition, law-enforcement related variables, and the paramedic's perception of the need for chemical restraints. To compare predictor and outcome variables, a multivariable model with odds ratios and 95% confidence intervals was used.

RESULTS

The study included 271 restrained patients over a 12-month period from April 2002 to April 2003. Seventy-seven (28%) cases were positive for assaults on EMS personnel. Multivariable analysis including 8 variables, indicated the following 6 variables were associated with assault on EMS personnel: time of day between midnight and 6 am (OR = 4.4, 95% CI = 1.6-12.7); female patient (OR for males 0.6, 95% CI = 0.3-1.0); violent patient (OR = 10.1, 95%CI = 2.3-48.2); patient injured under supervision (OR = 3.9, 95% CI = 1.1-13.8); arrested patient (OR = 4.4, 95% CI = 1.1-18.5); and perceived need for chemical restraint (OR = 2.1, 95% CI = 1.2-3.9).

CONCLUSION

Multiple factors are correlated with assaults on EMS personnel by patients requiring restraints. By specifically targeting patients exhibiting these factors, EMS providers can help prevent injury to themselves. Patients not exhibiting these factors may be less dangerous.

Physiology and pathology of TASER electronic control devices

TASER ECDs (electronic control device) are small, battery powered, handheld devices. They deliver short duration, low energy pulses to stimulate motor neurons, causing transient paralysis. While the experience is painful, proper use of the device is rarely associated with significant side effects in spite of 1070 human worldwide exposures daily. In fact, there have been more than 780,000 training exposures and 630,000 field uses (total of over 1.4 million human uses) without any credible evidence of a resulting cardiac arrhythmia. In this article we describe the mechanisms by which the device operates, and review possible morbidities.

Impact of a restraint training module on paramedic students' likelihood to use restraint techniques

OBJECTIVES

The purpose of this study was to evaluate a restraint training module for paramedic students. The hypotheses were that the effect of an hour-long restraint training module on paramedic students would (1) improve their understanding of concepts about patient restraints and (2) change their likelihood to use restraint techniques on patients in emergency situations.

METHODS

This was a cross-sectional study. A five-person panel of highly experienced emergency medical services (EMS) personnel compiled an hour-long restraint training module based on a compiled list of important concepts. A pretest and posttest were designed to contain the following two parts: (1) a knowledge quiz consisting of ten content-based questions and (2) a questionnaire on the likelihood to use restraint techniques in emergency situations, consisting of a five-question validated scale (Video Assessment of Propensity to use Emergency Restraints Scale [VAPERS]).

RESULTS

Thirty-four paramedic students at our training institution participated. We found that the paramedic students had a significant increase in their knowledge of the content shown (66% vs. 85%, p<0.05). There was no significant overall difference between pretest scores on the VAPERS (56+/-17 on a 0-100 scale) and posttest scores (57+/-16 on a 0-100 scale).

CONCLUSIONS

Paramedic students had improved understanding of important restraint concepts following a training module. The training module did not significantly change overall likelihood to use restraint techniques.

The combative multitrauma patient: a protocol for prehospital management

OBJECTIVE

To describe the management of the combative trauma patient in the prehospital setting, and to suggest a protocol for management.

METHODS

A retrospective, prehospital case series conducted in Israel among military medical teams over the course of nearly 2 years, between January 2000 and October 2002. We collected a case series of patients who became combative following traumatic injury. Following data collection, we summoned an expert panel and developed a protocol for physicians and paramedics upon encountering a combative trauma patient.

RESULTS

Available data were found for 11 patients and these were included in the analysis. Most victims included in this study were injured under military or geographical circumstances mandating a long time interval from injury to definitive care, namely 114 min (range 38-225 min). Five patients received intravenous ketamine, in three of which it was coadministered with midazolam. Sedation with ketamine given alone, or combined with other drugs, was effective in all five cases. In no case did a patient become more agitated after administration. No adverse effects were recorded by the prehospital caregivers.

CONCLUSIONS

In this article, an algorithmic approach to the treatment of the patient's agitation is outlined, using ketamine as the principal sedating agent, either alone or combined with midazolam. The combination of both drugs is suggested for the effective sedation of adult prehospital combative patient population.