restraint and the street medic 2009

Restraint and Restraint and the Street the Street

MedicMedic

Steve ColeSteve Cole

One Cool DudeOne Cool Dude

Revision InfoRevision Info

Disclosures:Disclosures:No Commercial AffiliationNo Commercial AffiliationNo Paid Product EndorsementsNo Paid Product Endorsements

Revised 08-09Revised 08-09For more information, contact For more information, contact

Steve ColeSteve Cole

Not that kind of restraint!Not that kind of restraint!

Not that!Not that!

Not that either!Not that either!

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 Verbal Verbal and Non Verbal Physical RestraintsPhysical Restraints Chemical RestraintsChemical Restraints Improper RestraintsImproper Restraints

What are the risks?What are the risks?

BackgroundBackground

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 limitphysical mobility of a patient.

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.

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

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."

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 resourcesMore Scene HazardsMore Scene HazardsLimited diagnostic equipment to rule out non Limited 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 to If we restrain a pt, we must be prepared to

assume TOTAL CONTROL.assume TOTAL CONTROL.

Who can we restrain?Who can we restrain?

Any person we can assume a “duty to act” with Any 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.

Some people need to be restrained Some people need to be restrained for their own safetyfor their own safety

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

Why not?Why not?

Taking actions that lead to the death of a Taking actions that lead to the death of a person because they were rude, person because they were rude, belligerent and aggressive is a belligerent and aggressive is a questionable action. questionable action.

Restraint is Restraint is notnot a 1 a 1stst line of action unless line of action unless the person is an the person is an eminenteminent danger to danger to themselves or others.themselves or others.

Remember:Remember:

Scene Management is vital to insure that Scene 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 itemsAssign personnel to body partsAssign personnel to body partsDon’t get angryDon’t get angry Its not a rodeo!Its not a rodeo!

How do we restrain?How do we restrain?

VerbalVerbal Non VerbalNon Verbal Physical Physical ChemicalChemical

Important Concept!Important Concept!

When is Enough; When is Enough; Enough?Enough? Pt calms downPt calms down Pt stops struggling Pt stops struggling Enough help on hand for Enough help on hand for

handle further outburstshandle further outbursts Further violence is Further violence is

prevented prevented Environment is safe.Environment is safe. Total Control is assured.Total Control is assured.

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.

Verbal and Non VerbalVerbal and Non Verbal

Initial MethodInitial Method De-escalation toolDe-escalation tool FirmFirm ForcefulForceful FairFair Body Language Body Language NumbersNumbers How's this body

language?

Physical RestraintsPhysical Restraints

Control the SituationControl the Situation

Do not attempt to restrain an agitated Do not attempt to restrain an agitated patient until you have them thoroughly patient 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 to Rapidly controls the patient in order to minimize the risk of patient traumaminimize the risk of patient trauma

“…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.”

Physical RestraintPhysical Restraint

Proper restraint requires at least five to Proper 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 and One person manages the head and airwayairway

C.C. One person coordinates the activityOne person coordinates the activity

D.D. Universal precautions should be Universal precautions should be utilized at all timesutilized at all times

Physical RestraintPhysical Restraint

One hand just One hand just proximal and proximal and one one hand just distal to the hand just distal to the joint joint

Immobilize both Immobilize both elbows and knees in elbows and knees in extension extension

Restricts movementRestricts movement. .

Team leader secures the patient’s head by grasping the Team leader secures the patient’s head by grasping the forehead with one hand and securing the chin with the forehead 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!

Check each limb for discoloration and any compromise of pulse and Check 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.

Correct restraintCorrect restraint

Photo Courtesy of Charlie D. Miller.

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 BE Pt’s respiratory excursion MUST NOT BE COMPROMISED.COMPROMISED.

O2 and SAO2 should be in place. ECG O2 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. (no ABC’s should be easily monitored. (no

pillow cases)pillow cases)

Improper restraint positionsImproper restraint positions

ProneProneSandwichedSandwichedHobbledHobbledBody bagsBody bagsPapoosesPapooses

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

Chemical RestraintsChemical Restraints

Basic Premise of Chemical Basic Premise of Chemical RestraintsRestraints

Chemical restraints are an adjunct to Chemical restraints are an adjunct to physical restraint.physical restraint.

Chemical restraints are used to Chemical restraints are used to increase pt safety, and to facilitate increase pt safety, and to facilitate medical care, when physical restraint medical care, when physical restraint alone increases pt risk.alone increases pt risk.

Struggle against physical restraints Struggle against physical restraints may lead to fatal eventsmay lead to fatal events

Advantages of chemical Advantages of chemical restraintsrestraints

Control violent behavior and patient Control violent behavior and patient agitation agitation

May reduce need for physical restraints May reduce need for physical restraints Decreases Exertional demands of ptDecreases Exertional demands of ptAllows basic assessments and proceduresAllows basic assessments and proceduresAllow examination and performance of Allow examination and performance of

radiographic imaging at ERradiographic imaging at ER

Disadvantages of chemical Disadvantages of chemical restraintsrestraints

Respiratory DepressionRespiratory DepressionLoss of GagLoss of GagOccasional paradoxical reaction results in Occasional paradoxical reaction results in

increased agitation increased agitation Increase effect of other CNS depressantsIncrease effect of other CNS depressantsLimit mental status assessment and Limit mental status assessment and

neurologic examination during sedationneurologic examination during sedation

A good general rule:A good general rule:

When the pt cannot be safely or properly When the pt cannot be safely or properly restrained using physical means alone, then restrained using physical means alone, then chemical restraints is a viable option.chemical restraints is a viable option.

In some hospital settings, chemical restraint is In some hospital settings, chemical restraint is sometimes used alone. However for EMS, if they sometimes used alone. However for EMS, if they need chemical restraints, then some form of need 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 and The exact degree is dependant on situation and

clinical needsclinical needs

AgentsAgents

BenzodiazepinesBenzodiazepinesTranquilizers / neuropletic agentsTranquilizers / neuropletic agents

Phenothiazines and ButyrophenonesPhenothiazines and Butyrophenones AntihistaminesAntihistamines

Other notesOther notes

May call OLMC to exceed max dosageMay call OLMC to exceed max dosageAllow for longer elimination and retention Allow for longer elimination and retention

periods in elderly, and those with periods in elderly, and those with liver/kidney disfunctionliver/kidney disfunction

Use lower initial doses when alcohol is Use lower initial doses when alcohol is involvedinvolved

Benzo’sBenzo’s

In the prehospital setting, Benzodiazapines are In 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 often Prehospital 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 have Even those with a Psychotic origin often have illicit drugs on board. illicit drugs on board.

This makes for trouble, increased SZ risk, and This makes for trouble, increased SZ risk, and need for need for prompt predictable restraint with a prompt predictable restraint with a minimum of adverse reactions.minimum of adverse reactions.

Benzo’s best fit the bill.Benzo’s best fit the bill.

Downside of benzo’sDownside of benzo’s

More respiratory complicationsMore respiratory complicationsSedation may be excessiveSedation may be excessiveSedation tends to last longer than other Sedation tends to last longer than other

class of drugsclass of drugsLimits neuro assessmentLimits neuro assessmentThis is especially true when alcohol is a This is especially true when alcohol is a

factorfactor

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 presumably line for cocaine and meth (and presumably

MDMA)MDMA)

VersedVersed

Midazolam Midazolam Dose: 0.5-2.5 mg IV, 5 mg IMDose: 0.5-2.5 mg IV, 5 mg IM Max of 5 mg Max 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

AtivanAtivan

LorazepamLorazepamDose: 1-4 mg IV or IMDose: 1-4 mg IV or IMMax of 4mgMax of 4mgSlow actingSlow acting

XanaxXanax

AlprazolamAlprazolamNot suited for EMS/ED useNot suited for EMS/ED useUsed orally in mental health facilitiesUsed orally in mental health facilities Is a benzo and may potentiates other Is a benzo and may potentiates other

benzosbenzos

Tranquilizers / Neuropletic agentsTranquilizers / Neuropletic agents

ButrophenonesButrophenonesHaldol Haldol InapsineInapsine

PhenothiazinesPhenothiazinesThorazineThorazine

Anti HistaminesAnti HistaminesPhenerganPhenerganBenadrylBenadryl

HaldolHaldol

Butyrophone type of drug. Inhibits Alpha Butyrophone 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, and Can have EPS, decreased SZ threshold, and

anti-cholinergic effects.anti-cholinergic effects.

InapsineInapsine DroperidolDroperidol Butyrophone type of drug. Inhibits Alpha adrenergic and Butyrophone type of drug. Inhibits Alpha adrenergic and

dopamine receptors.dopamine receptors. Commony used as an anti-emetic and as a chemical Commony 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 de FDA “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 and Metabolized through liver. Excreted through urine and

feces.feces.

ThorazineThorazine

ChlorpromazineChlorpromazinePhenothiazine, Antagonizes Dopamine Phenothiazine, Antagonizes Dopamine

receptorsreceptorsMetabolized through liver. Excreted Metabolized 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 PRNAlso rarely used as an anti-emeticAlso rarely used as an anti-emetic

PhenerganPhenergan PromethazinePromethazine Phenothiazine, non selective anti-histamine. Commonly Phenothiazine, 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 mental Used 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 when Local 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 and Metabolized through liver. Excreted through urine and

feces.feces.

BenadrylBenadryl

DiphenhydramineDiphenhydramineNon selective antihistamineNon selective antihistamine25-50 mg IV/IM/PO q 4-6 hours prn25-50 mg IV/IM/PO q 4-6 hours prnMax 300 mg/dayMax 300 mg/dayUse caution with asthmatics with active Use caution with asthmatics with active

wheezing or SOB. wheezing or SOB.

ParalyticsParalytics

Generally speaking, Paralytics are NOT Generally speaking, Paralytics are NOT used for simple restraint.used for simple restraint.Cant intubate/cant ventilate situationCant intubate/cant ventilate situationMalignant HyperthermiaMalignant Hyperthermia

May be used in a combative pt who meets May be used in a combative pt who meets other criteria for RSI.other criteria for RSI.Always used with sedativesAlways used with sedatives

Six Good Reasons to Avoid Six Good Reasons to Avoid Phenothiazines and Phenothiazines and

ButyrophenonesButyrophenonesLower seizure thresholdLower seizure threshold Interfere with heat dissipationInterfere with heat dissipationExacerbate tachycardiaExacerbate tachycardiaProduce hypotensionProduce hypotension Increase heat production (movement Increase heat production (movement

disorders)disorders)Not cross-tolerant with ethanol and other Not cross-tolerant with ethanol and other

sedative hypnoticssedative hypnotics

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

Comments On HyperthermiaComments On Hyperthermia

Elevated temp is often caused by exertion Elevated temp is often caused by exertion and/or drug use.and/or drug use.

Occasionally we increase heat retention Occasionally we increase heat retention by use of improper restraint devices.by use of improper restraint devices.Body BagsBody BagsReeves SleveReeves Sleve

Elevated Temp by itself is a risk factor for Elevated Temp by itself is a risk factor for pt death.pt death.

HyperthermiaHyperthermiaStruggling increases catecholamine release Struggling increases catecholamine release

which can exacerbate stimulant drug which can exacerbate stimulant drug effectseffects

Prolonged struggling or chasing increases Prolonged struggling or chasing increases heat productionheat production

Hyperthermia is one of the best Hyperthermia is one of the best prognosticators for lethal eventsprognosticators for lethal events

Agitated Delirium and HeatAgitated Delirium and Heat

KEY POINTKEY POINTNEXT TO CHEMICAL SEDATION, NEXT TO CHEMICAL SEDATION,

ADDRESSING HEAT ISSUES IS A ADDRESSING HEAT ISSUES IS A CORNER STONE TREATMENTCORNER STONE TREATMENT

PROMOTE HEAT DISSIPATION PROMOTE HEAT DISSIPATION THROUGH :THROUGH :CONDUCTIONCONDUCTIONCONVECTIONCONVECTIONRADIATIONRADIATIONDECREASED ACTIVITYDECREASED ACTIVITY

Agitated DeliriumAgitated Delirium AKA: Excited deliriumAKA: Excited delirium An excited, often confused and combative state An 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)) Increased Increased 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 improper especially when combined with improper restraint.restraint.

Rhabdomyolysis and Agitated Rhabdomyolysis and Agitated DeliriumDelirium

Believed to be a progression of Agitated Delirium, exacerbated and Believed 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) of Breakdown 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 volume Fluid 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. )

RunningRunning

FightingFighting

DrugsDrugs

Tx of RhabdoTx of Rhabdo Prevention! V.O.M.I.T., Cooling, etcPrevention! V.O.M.I.T., Cooling, etc Hydration Hydration

Fluids titrated to urine output 300 cc/hourFluids titrated to urine output 300 cc/hour Watch for CHFWatch for CHF

Alkalinization of urine Alkalinization 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 correction Electrolyte correction Insulin and glucose for hyper-K, Ca only in crisisInsulin and glucose for hyper-K, Ca only in crisis

Dialysis Dialysis Supportive therapy Supportive therapy

Agitated Delirium, Heat Issues, and Rhabdo Agitated Delirium, Heat Issues, and Rhabdo (Treatment) (Treatment)

Rapid CoolingRapid Cooling

Volume resuscitationVolume resuscitation

SedationSedation

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

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 delirium Often preceded by some agitated delirium Inhibition of the “Mechanical Bellows” of Inhibition of the “Mechanical Bellows” of

the chest.the chest. Rapid progression to code blue in under 2 Rapid progression to code blue in under 2

minutes has been reported.minutes has been reported.

Positional AsphyxiaPositional Asphyxia PA is defined as anytime the position of the body PA is defined as anytime the position of the body

interferes with respiration, resulting in respiratory interferes with respiration, resulting in respiratory failure and death from suffocation.failure and death from suffocation.

Often Positional Asphyxia could be prevented Often 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 these There are many creative variations on these methods, including the “scoop sandwich” and methods, including the “scoop sandwich” and inappropriate use of devices such as the inappropriate use of devices such as the “Reeves Sleeve” or KED.“Reeves Sleeve” or KED.

All of these methods IMPAIR RESPIRATION All of these methods IMPAIR RESPIRATION and put the patientand put the patient(and you) at risk.(and you) at risk.

Restraint Associated AsphyxiaRestraint Associated Asphyxia

Restraint asphyxia is a subset of Restraint asphyxia is a subset of “Positional Asphyxia”“Positional Asphyxia”

Restraint Asphyxia is PA caused by Restraint 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

Mechanical Forceful Prone Mechanical Forceful Prone RestraintRestraint

Mechanical Forceful-Prone-RestraintMechanical Forceful-Prone-Restraintcan be defined as placing a patient face-down can be defined as placing a patient face-down upon an ambulance wheeled stretcher, and then upon an ambulance wheeled stretcher, and then using restraint straps to compress the patient’s using restraint straps to compress the patient’s chest and upper legs to the stretcher, preventing chest and upper legs to the stretcher, preventing him from moving his body parts up and off of that him from moving his body parts up and off of that surface (out of a prone position). surface (out of a prone position).

““Physical” and “Mechanical” forceful-prone-Physical” and “Mechanical” forceful-prone-restraint are relatively the same things: forceful restraint are relatively the same things: forceful compression of an individual while in a prone compression of an individual while in a prone position, maintaining that compression, and position, maintaining that compression, and preventing movement out of the prone positionpreventing movement out of the prone position

Basic Premise of Positional Basic Premise of Positional AsphyxiaAsphyxia

Pt is already O2 hungry at cellular level due to Pt 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 heart Pt 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 are We then restrain improperly them when they are

already compromised, making them more already compromised, making them more hypoxic (and likely struggle more) resulting in a hypoxic (and likely struggle more) resulting in a rapid progression from screaming to cardiac rapid progression from screaming to cardiac arrestarrest

Mechanical Forceful Prone Mechanical Forceful Prone RestraintRestraint


Hobble restraintHobble restraint


Effective respirationEffective respiration


Effective respirationEffective respiration Essentially, whether forcefully-prone-restrained and/or hobble Essentially, whether forcefully-prone-restrained and/or hobble

restrained, an individual must lift his entire body off of the surface he restrained, an individual must lift his entire body off of the surface he is pronely placed upon – against physical pressure or restraint is pronely placed upon – against physical pressure or restraint devices – using devices – 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 individual The forcefully-prone-restrained and/or hobble restrained individual cannot breathe in, and can’t breathe out, in anything remotely cannot 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, the When placed in forceful-prone-restraint and/or hobble restraints, the muscular act of breathing suddenly requires a greatly increased muscular act of breathing suddenly requires a greatly increased physical effort – a greatly increased energy-expenditure. Yet, this physical effort – a greatly increased energy-expenditure. Yet, this great effort/energy-expenditure achieves (at best) only the tiniest great effort/energy-expenditure achieves (at best) only the tiniest volume of breath.volume of breath.

Cycle of deathCycle of death

Restraint Asphyxia Restraint Asphyxia

Prevention is the KeyPrevention is the KeyThe most effective (and important) The most effective (and important)

measure is to first turn the patient on his measure is to first turn the patient on his side.side.

By correctly restraining a pt, your job is By 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.

Correct restraintCorrect restraint


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 respiration Promote respiration Good sedation, Use Benzo’s Good 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 Resuscitation Fluid 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.

Questions??Questions??

Special ThanksSpecial Thanks

Charlie D. Miller, Paramedic, Restraint Charlie D. Miller, Paramedic, Restraint Expert Expert

Check out her Web Page at:Check out her Web Page at:http://www.charlydmiller.com/http://www.charlydmiller.com/

Email at: Email at: [email protected] [email protected]

The LiteratureThe Literature

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


Findings:Findings: 11 cases of sudden death of men restrained in prone 11 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 1 9 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, 8 All 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

The LiteratureThe Literature Findings:Findings:

Sudden death of people in a state of agitated delirium during Sudden 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 or Mechanism of death is sudden, fatal cardiac dysrhythmia or respiratory arrestrespiratory arrest

Factors:Factors: Psychiatric or drug-induced state causes catecholamine stress on Psychiatric or drug-induced state causes catecholamine stress on

the heartthe heart Hyperactivity coupled with struggling with PD and against restraints Hyperactivity 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 high Hogtied position clearly impairs breathing in situations of high

oxygen demand by impairing chest wall and diaphragmatic oxygen demand by impairing chest wall and diaphragmatic movementmovement


Stratton SJ, Rogers C, Green K. Sudden Stratton SJ, Rogers C, Green K. Sudden death in individuals in hobble restraints death in individuals in hobble restraints during paramedic transport. during paramedic transport. Ann Emerg Ann Emerg Med.Med. 1995;25:710-712 1995;25:710-712


Findings:Findings:2 cases of unexpected death in restrained, 2 cases of unexpected death in restrained,

agitated individuals being transported by ALS agitated individuals being transported by ALS ambulance.ambulance.

Both patients placed in hobble restraints by Both patients placed in hobble restraints by law enforcement. law enforcement.

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 cardiac Placed 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 for Death: Methamphetamine intoxication and restrained maneuvers for

bizarre behavior.bizarre behavior.

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 of Fought 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, otherwise Autopsy 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


Findings:Findings: Patients should be placed in supine or lateral position Patients should be placed in supine or lateral position

rather than prone.rather than prone. If hobble restraints are used, allow slack for If 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 immediately EMS crew must have capability to immediately

release the restraints and provide ALS.release the restraints and provide ALS.


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


Study of 6 healthy volunteers restrained with hobble restraints in Study 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 FVC During hobble restraint in the prone position they found FVC dropped by 40%, end-tidal COdropped by 40%, end-tidal CO2 2 increased by 15%, and the increased by 15%, and the cardiac output increased by 37%.cardiac output increased by 37%.

Hobble restraints in the prone position leads to a dramatic Hobble 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 are Upright position and frequent control of vital parameters are necessary to prevent possibly fatal outcome in persons in hobble necessary to prevent possibly fatal outcome in persons in hobble restraintsrestraints


Chan TC, Vilke GM, Neuman T, Clausen Chan TC, Vilke GM, Neuman T, Clausen JL. Restraint position and positional JL. Restraint position and positional asphyxia. asphyxia. Ann Emerg MedAnn Emerg Med. 1997;30:578-. 1997;30:578-586586


Experimental cross-over trial of healthy volunteers placed in Experimental 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 and 15 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 periods Phase: 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).


ABGs, pulse and oximetry measured throughout.ABGs, pulse and oximetry measured throughout. Subjects placed in restraint exhibited a reduced pulmonary Subjects placed in restraint exhibited a reduced pulmonary

function pattern by PFT, but no evidence of hypoxia or function pattern by PFT, but no evidence of hypoxia or hypercapnia was found.hypercapnia was found.

Restraint position, by itself, was not associated with any Restraint position, by itself, was not associated with any clinically-relevant changes in respiratory or ventilatory function clinically-relevant changes in respiratory or ventilatory function (decrease of 13%)(decrease of 13%)

There is no evidence to suggest that hypoventilatory respiratory There is no evidence to suggest that hypoventilatory respiratory failure or asphyxiation occurs as a direct result of body restraint failure or asphyxiation occurs as a direct result of body restraint position in healthy, awake, non-intoxicated individuals.position in healthy, awake, non-intoxicated individuals.


Chan TC, Vilke GM, Neuman T. Chan TC, Vilke GM, Neuman T. Reexamination of custody restraint Reexamination of custody restraint position and positional asphyxia. position and positional asphyxia. Am J Am J Forensic Med Path.Forensic Med Path. 1998;19(3):201-205 1998;19(3):201-205


Findings:Findings: Collective review of literature on restraint and positional Collective review of literature on restraint and positional

asphyxia.asphyxia. Factors other than body positioning appear to be more important Factors other than body positioning appear to be more important

determinants for sudden, unexpected deaths in individuals in the determinants 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 from hyperthermia, catechol hyperstimulation, and trauma from struggle.struggle.


Ross DL. Factors associated with excited Ross DL. Factors associated with excited delirium deaths in police custody. delirium deaths in police custody. Mod Mod PatholPathol. 1998;11(11):1127-1137. 1998;11(11):1127-1137


Findings:Findings:Review of 61 cases of excited delirium where Review of 61 cases of excited delirium where

patient died in police custody.patient died in police custody.

PsychologicalPsychological PhysiologicPhysiologic PhysicalPhysical

ParanoidParanoid TachycardiaTachycardia HypervigilenceHypervigilence

HallucinationsHallucinations HyperthermiaHyperthermia Extreme StrengthExtreme Strength

GrandiosityGrandiosity HypertensionHypertension Incoherent speechIncoherent speech

Extreme agitationExtreme agitation Foaming of the Foaming of the mouthmouth

ShoutingShouting

FearFear MydriasisMydriasis Violent behaviorViolent behavior

FornicationFornication Cardiac arrestCardiac arrest Bizarre behaviorBizarre behavior

Thought disorderThought disorder SeizuresSeizures Kicking/ThrashingKicking/Thrashing

DysphoricDysphoric Pulmonary Pulmonary congestioncongestion

Running/HidingRunning/Hiding

Chest painChest pain Threat to self/othersThreat to self/others

Profuse sweatingProfuse sweating AggressionAggression

High pain thresholdHigh pain threshold


Most common aggravating factor was abuse of cocaine and Most common aggravating factor was abuse of cocaine and cocaine/alcohol.cocaine/alcohol.

Restraint equipment that controls a violent patient’s legs Restraint 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 position which 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 in The hogtie system should only be used judiciously and in situations when there is no alternative. The patient should be situations when there is no alternative. The patient should be placed upright or rolled on his side quickly after restraint and placed upright or rolled on his side quickly after restraint and vital signs monitored.vital signs monitored.


Hick JL, Smith SW, Lynch MT. Metabolic Hick JL, Smith SW, Lynch MT. Metabolic acidosis in restraint-associated cardiac acidosis 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.


Review of 5 cases (4 fatal) where cardiovascular Review of 5 cases (4 fatal) where cardiovascular collapse occurred in ED patients who were struggling collapse occurred in ED patients who were struggling despite maximum restraint techniques.despite maximum restraint techniques.

All were intoxicated (cocaine, benzoyleconine All were intoxicated (cocaine, benzoyleconine [cocaine metabolite])[cocaine metabolite])

Profound metabolic acidosis was associated with Profound metabolic acidosis was associated with cardiovascular collapse following exertion in a cardiovascular collapse following exertion in a restrained position (pH ranges: 6.25-6.81)restrained position (pH ranges: 6.25-6.81)


Findings:Findings: Avoiding the hobble restraint position and Avoiding the hobble restraint position and

emphasizing side rather than prone positioning my emphasizing side rather than prone positioning my eliminate some of the problems that contribute to the eliminate 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 and custody deaths through use of chemical restraints and bicarbonate therapy.bicarbonate therapy.


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


Findings:Findings: Review of 21 Canadian cases of unexpected death in Review of 21 Canadian cases of unexpected death in

persons with excited delirium.persons with excited delirium. Deaths were all associated with restraint either with Deaths were all associated with restraint either with

the person in the prone position or subject to pressure the person in the prone position or subject to pressure on the neck.on the neck.

All lapsed into tranquility shortly after being All lapsed into tranquility shortly after being restrained.restrained.


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 in Restraint may contribute to the death of people in

states of excited delirium.states of excited delirium. Law enforcement personnel should bear in mind the Law enforcement personnel should bear in mind the

potential for the unexpected death of people in potential for the unexpected death of people in excited states of delirium who are restrained prone or excited states of delirium who are restrained prone or with a neck hold.with a neck hold.


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


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 SpO2 2 was measured.was measured. Randomly assigned to seated unrestrained or hogtied Randomly assigned to seated unrestrained or hogtied

position, with protocols switched after 15 minutes rest.position, with protocols switched after 15 minutes 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).


Findings:Findings: Phase 2: Students paired with other student within 5 pounds of Phase 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 of Exercise intensity was high (pulse rates 175-212). At the end of

the chase, the chaser was placed in the seated position and the the 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 SpO2 2

measured. Roles reversed and process repeated.measured. Roles reversed and process repeated.


Findings:Findings:Findings refute the premise that positional Findings refute the premise that positional

restraint alone produces physiological stress restraint alone produces physiological stress that places healthy persons at risk for sudden that places healthy persons at risk for sudden death.death.

Cocaine appears to be a common element in Cocaine appears to be a common element in positional restraint deaths.positional restraint deaths.

High levels of dopamine from cocaine may be High levels of dopamine from cocaine may be a factor.a factor.


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


Retrospective review of the LA County EMS and LA Retrospective 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 EMS 20 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


Findings:Findings: Multiple factors associated with sudden death while restrained Multiple 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%)


The data do not support or refute the The data do not support or refute the prone position while hobble restraint was prone position while hobble restraint was independently associated with sudden independently associated with sudden death.death.

The LiteratureThe Literature Position appears not to be significant factor in Position appears not to be significant factor in

healthy patients.healthy patients. Patients with excited delirium at markedly Patients with excited delirium at markedly

increased risk for restraint asphyxia.increased risk for restraint asphyxia. Stimulants contribute to problem of restraint Stimulants 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 puts Chronic alcoholism or alcohol intoxication puts

patients at risk for positional asphyxia.patients at risk for positional asphyxia.


Cardiac dysrhythmias may be a causative factor.Cardiac dysrhythmias may be a causative factor. Metabolic acidosis may play a major role in Metabolic 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 becomes Beware when the restrained patient becomes

tranquil.tranquil. Often, deaths happen regardless of care Often, deaths happen regardless of care

rendered.rendered.

restraint and the street medic 2009

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