Most emergency physicians think of agitation as relatively simple to treat, with sedation being the most common course of action. However, sedating even just a few agitated patients in precious ED beds can increase waiting times for the entire ED. Further complicating matters is that all agitation is not the same. Use of restraints is sometimes necessary, but decisions to use them are often made without thinking of the ramifications.
“Use of restraints is sometimes necessary, but decisions to use them are often made without thinking of the ramifications.”
The key advantages to restraining agitated patients are that it protects staff from violence from patients and facilitates intramuscular (IM) delivery of calming medications. On the other hand, improperly applied restraints may injure patients. In addition, most injuries to staff probably occur during the restraint process. Physicians should be mindful that restraints don’t allow patients to participate fully in their care.
Appropriate Use of Restraints Among Agitated Patients
Restraints should be applied either in the upper extremities only or on the upper and lower extremities with minimal force,which usually requires assistance from others in the ED. Every attempt should be made to avoid standing or sitting on patients during application. If weight force is needed, it should be applied as briefly as possible with careful monitoring of ventilatory status. Although many physicians wish to stand aside during the forceful takedown of patients, physician presence during takedowns may reassure staff and patients that these procedures will be done as gently as possible. Emergency physicians, however, should only partake in takedowns if they’ve been trained to do so.
In most cases, medication and restraint procedures are used against patients’ wishes. Patient wishes should be overridden only if it’s clearly in their best interests or when patients lack the ability to make decisions. Importantly, clinicians’ reasons for doing so should be clearly noted in patient charts.
Restraints & Chemical Sedation in the ED
Whether to restrain patients who have not been given calming medications is somewhat controversial. Several factors come into play, including patient willingness to take medication, the degree of agitation, the perceived risk of violence, and the availability of trained personnel to assist in restraining processes. Once the decision is made to treat patients involuntarily with IM medications and restraint, it’s important to develop and follow plans for successful execution.
Most emergency physicians believe that agitated patients who need to be restrained should also be treated with calming medications. Ethically, leaving patients in restraints without administering these medications is problematic. Although patients sometimes may need to be physically restrained in order to receive medication, physical restraint almost always should be accompanied by medication use.
Readings & Resources (click to view)
Vilke GM, Wilson MP. Agitation: what every emergency physician should know. Emerg Med Rep. 2009;30:233-244.
Wilson MP, Pepper D, Currier GW, Holloman Jr. GH, Feifel D. The psychopharmacology of agitation: consensus statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup. West J Emerg Med. 2012;13:26-34.
Currier GW, Allen MH. Physical and chemical restraint in the psychiatric emergency service. Psychiatr Serv. 2000;52:717-719.
Lavoie FW. Consent, involuntary treatment, and the use of force in an urban emergency department. Ann Emerg Med. 1992;21:25-32.
Tueth MJ. Management of behavioral emergencies. Amer J Emerg Med. 1995;13:344-350.
Park KS, Korn CS, Henderson SO. Agitated delirium and sudden death: Two case reports. Prehosp Emerg Care. 2001;5:214-216.
Vilke GM, Chan TC. Agitated delirium and sudden death. Prehosp Emerg Care. 2002;6:259.