Physical and chemical restraints
Victoria A. Coburn, MD, Mark B. Mycyk, MD
Physical restraint Chemical restraint Violence Safety Sedation
Combative and violent patients are commonly encountered in the emergency depart-ment These patients may be brought in by concerned family members, referredto the ED by other health professionals, or transported by police or emergencymedical services (EMS) personnel for causing a public disturbance. These patientspose significant diagnostic and management challenges to the physicians, nurses,technicians, and other staff members who are trying to care for them. A combativepatient’s behavior can have numerous causes, including but not limited to psychiatricillness, substance abuse and withdrawal, traumatic injury, and metabolic distur-bances. Emergency physicians are expected to manage an agitated patient’sbehavior safely, determine if a medical or traumatic cause is a contributor to the agita-tion, and arrange for appropriate disposition.To differentiate between an organic anda functional cause for agitated or violent behavior, it is imperative to obtain a historyand perform a complete physical examination on these patients, and, in some cases,order laboratory work and radiologic imaging. Unfortunately, agitated or violentbehavior is itself an obstacle to that medical workup and puts the individual patientand all caregivers at risk of injury. When de-escalation strategies are ineffective ingetting a violent patient to cooperate, the use of physical and chemical restraintsneeds to be considered. Once the decision is made to use restraints, it is importantto follow hospital policy on patient monitoring and documentation. Hospital policieson restraints should be derived from the Joint Commission’s Restraint and SeclusionStandards because the use of restraints is tracked by the Joint Commission.
Violence is prevalent in our society. According to the Centers for Disease Control andPrevention (CDC)’s National Institute for Occupational Safety and Health (NIOSH),nonfatal assaults occur in 8.3 per 10,000 health care workers yearly, whereas therate of nonfatal assaults in private sector industries is 2 per 10,000.Of all health
Department of Emergency Medicine, Boston University School of Medicine, Boston MedicalCenter, 1 Boston Medical Center Place, Dowling 1 South, Boston, MA 02118, USA* Corresponding author.
E-mail address: (M.B. Mycyk).
Emerg Med Clin N Am 27 (2009) 655–667doi:10.1016/j.emc.2009.07.003
0733-8627/09/$ – see front matter ª 2009 Elsevier Inc. All rights reserved.
care areas examined, violence has been found to be more prevalent in EDs, waitingrooms, psychiatric wards, and geriatrics units. The ED environment, with high stress,fragmented communication, long waiting times, overcrowding, staff shortages, finan-cial issues, and confusion, can provoke violence in predisposed individuals. Surpris-ingly, 50% of health care workers will be victims of physical violence during theirStudies suggest that working in an ED, with more than 50,000 patient visitsper year and an average waiting time longer than 2 hours, puts health care workersat higher risk of injury from violent
It is helpful for the emergency physician to be familiar with the characteristics thatpredispose patients to violent or aggressive behavior in the ED. Positive predictorsof potential violent behavior are male gender, having a prior history of violence, arrivingin the custody of the police, being a victim of violence, and having a history of alcoholor drug Psychiatric illness (especially schizophrenia, personality disorders,mania, and psychotic depression) has also been identified as a significant risk forviolent behavior in the
Schizophrenics can experience command auditory hallucinations instructing them
to perform violent acts or have delusions that others are trying to harm them. Thesepatients may be noncompliant with their medications, nonresponsive to treatment,or be using alcohol or drugs, which can lead to violent behavior.Certain person-ality disorders, such as borderline and antisocial, are more prone to violent behaviorbecause these patients have little remorse for their actions on staff. Patients withmania can also exhibit periods of violence and aggression during episodes ofemotional lability.
Agitation can have an organic cause. The differential diagnosis is broad and
includes delirium, dementia, traumatic brain injury, neurological disease, metabolicdisturbance, infection, vascular or circulatory issues, renal or hepatic insufficiency,and endocrine dysfunction.Intoxication or withdrawal from alcohol or any otherrecreational drug can lead to out-of-control behavior. Even with sedative abuse(alcohol, benzodiazepines) some patients may experience a ‘‘paradoxical disinhibi-tion’’ (an increase in impulsivity due to a decrease in the frontal self-regulatory func-tion).It is important for the physician to differentiate between functional andorganic causes for a patient’s aggressive behavior and carefully rule out organiccauses even in patients with a history of psychiatric illness or substance abuse prob-lems. One must never assume out-of-control behavior is solely caused by psychiatricillness; all patients should have their blood glucose level checked on arrival and furtherdiagnostic testing, such as serum and urine tests, cranial computer tomographic scan,and lumbar puncture, should be considered as clinically indicated. First time out-of-control behavior has a higher incidence of organic cause in patients older than 40years with no known psychiatric history, patients with disorientation or hallucinations,and patients with abnormal vital signs.
RECOGNIZING AND DE-ESCALATING THE VIOLENT PATIENT
EMS personnel are at a high risk of encountering violent patients: 14% of calls areprecipitated by a violent act and violence occurs during 5% of their overall trans-When EMS is transporting a violent patient to a hospital, ideally a call shouldbe made to alert ED staff to prepare and mobilize appropriate resources.
Violence is not usually the initial response of a patient in the ED but is the result of
increasing tension and frustration. In addition to the risks mentioned earlier, certain
cues from the patient can predict the possibility of violent behavior. If these cues arenoticed, a situation can be diffused before it escalates and gets out of control. The 3phases of violence should be understood to initiate de-escalation before harm occursor restraint procedures are used.
Patients in this early phase are often loud, have pressured speech, and exhibit bodymovements the only purpose of which seems to be to expend energy: pacing, clench-ing fists, and constantly changing position on the stretcher). Because such featuresare frequently seen in anxious ED patients who do not have a propensity for violence,these cues are often ignored by staff and those prone to violence unfortunately esca-late beyond this phase. To avoid progression to increasingly aggressive behavior,many of these patients could be appeased by simply being acknowledged by staff.Establishing a rapport with the patient goes a long way. Patients should be treatedwith courtesy, respect, and empathy. Offering food and drink or warm blankets canbe useful in establishing trust and rapport because it appeals to the most basic humanPhysicians should relay their concern for patients and assure them that theyare in a safe environment.
In the second phase, patients are verbally abusive, using inappropriately profanelanguage. Their behavior is irrational. Feeling that one is losing control of the situationis usually the underlying cause. Limits need to be set for patients in this phase withsome choices offered. Limits should be simple, clear, enforceable, and consistent;the patient needs to know the consequences of choosing not to stay within theselimits. Staff must be calm and professional but firm when interacting with patients. Itis important to avoid countertransference. These patients can be difficult and causethe staff to become angry. If aggression continues or escalates, isolating the patientshould be Seclusion can be helpful because extraneous stimulation inpatients with hallucinations, paranoia, or agitation can intensify the Seclu-sion should not be used for patients needing continuous monitoring, such as suicidalor overdosed patients.
In the third phase, patients exhibit completely irrational and out-of-control behaviorwith threatening language or violent acts toward themselves, other patients, or staff.
Verbal management techniques are ineffective with patients in this phase, so physicaland chemical restraints are warranted. The decision to use restraints is never an easyone; it is important to remember that restraints for patients in this phase are meant forthe safety of the patient, staff, and others, not for punishment.The Joint Commissionstresses that restraints should only be used as a last resort when less restrictive inter-ventions are
Physical restraints should be considered when previous efforts to establish rapportand trust, to set limits, and to inform a patient of the consequences of not cooperatinghave failed. The decision to order physical restraints is difficult because complicationscan occur and their use can be perceived as coercion or punishment instead of a lastresort to ensure Indications for restraining a patient include (1) preventingharm to oneself, (2) preventing harm to other patients, (3) preventing harm to
caregivers and other staff, and (4) preventing serious disruption or damage to the envi-ronment.Restraints can be helpful in allowing the physician to perform a medicallyindicated examination in a patient with altered mental status or when indicated medi-cations need to be safely administered. Although restraining patients can be risky,appropriate use when needed may be less risky than not preventing the patient’sout-of-control behavior, which can lead to delayed treatment of the patient or injuryto the ED staff. Restraints should never be used for staff convenience.
Every institution should have a detailed protocol for the use of restraints.This
protocol should identify the members of a restraint team and how to activate theteam. All members of the restraint team should be appropriately trained and familiarwith the restraining procedure. The team should have at least five members, includinga designated leader who explains the process to the patient in clear language. Thisshow of force alone can sometimes prompt better behavior from an aggressivepatient. If possible, to prevent lawsuits, at least one member of the team should bea woman, especially when a woman is to be restrained. Before entering a patient’sroom and initiating the restraining procedure, all personal belongings that couldpotentially be used as a weapon or cause injury should be removed, including suchapparently benign objects as necklaces, lanyards with IDs, stethoscopes aroundthe neck, neckties, or hanging
During the restraining procedure, the team leader maintains the safety of the
patient’s head while each of the other members takes control of a preassignedextremity. Each extremity should be controlled at the major joint (elbow, knee) andthe restraint should be tied to the frame of the bed, not the handrails. All restraintpositions carry certain risks, and careful monitoring of the restrained patient is essen-tial. If aspiration is a risk, the patient should be restrained on the side, otherwiserestraint in the supine position may facilitate the medical examination and be morecomfortable for the patient. Sentinel event tracking by the Joint Commission indi-cates that restraining patients on their side reduces adverse restraint events.Re-straining a patient in the prone position predisposes them to Ifa patient is to be restrained in the prone position, the airway must remain unob-structed at all times and the expansion of the lungs must not be restricted by exces-sive pressure on the patient’s back.Restraining patients in the supine positionpredisposes them to aspiration. If a patient is to be restrained in the supine position,the head must be free to rotate to the side and, when possible, the head of the bedmust be elevated.If four-point restraints are used, the arms should be restrained sothat one arm is up and one down. This position makes it difficult for the patient togenerate enough force to overturn the stretcher. If two-point restraints are used,the contralateral arm and leg should be restrained. If additional restraint is needed,a sheet can be placed around the chest and tied to the stretcher, taking care thatthe sheet is not so tight that it prevents adequate chest
Soft restraints can be used in semicooperative patients, but for patients who are
combative and trying to escape, leather restraints are preferred. Soft restraints cantighten and cause circulatory compromise as a patient struggles, whereas leatherrestraints rarely compromise distal circulation but are more difficult to cut and removein an emergency.While restrained, patients should be under continuous observationand close monitoring. Change in position is important to prevent rhabdomyolysis,pressure sores, and paresthesias.
The treating physician should not be involved in the actual restraint process to
preserve the doctor-patient relationship. However, a member of the medical teamshould be present during the restraining process to monitor the patient. The restraintprocedure requires careful documentation by the physician and the nurse.Physician
documentation should cite that verbal techniques failed to calm the patient, thespecific indication for the restraining procedure, the time the restraints were applied,the time-limited duration of the restraining procedure, the planned medical workup ortreatment, and the patient’s decision-making capacity. Nursing documentation shouldinclude frequent assessment of the patient’s vital signs, general condition, andpersonal needs. Formal reassessment should occur every 15 minutes for signs ofinjury associated with application of restraints, measurement of vital signs, nutritionand hydration status, circulation, and range-of-motion of extremities, hygiene andelimination, physical and psychological status, patient comfort, and readiness fordiscontinuation of restraint. The patient must be reassessed by a physician at theend of predefined time limits. When clinically appropriate, restraints should beremoved one at a time in 5-minute intervals until two are left. If the patient remainscooperative, the last two can be removed.
The Joint Commission provides up-to-date guidelines and standards for restraints
and seclusion on their website.These include:
(1) A physician or licensed practitioner must see and evaluate the patient within 1
(2) Seclusion or restraint can only be used when clinically justified and after consid-
eration of alternative treatment options.
(3) Seclusion and restraints must have time-limited orders: 4 hours for adults (older
than 17 years), 2 hours for adolescents (9–17 years), 1 hour for patients youngerthan 9 years.
(4) Patients must have continuous monitoring with periodic evaluation with the
intent to discontinue intervention at the earliest possible time.
(5) A face-to-face reevaluation must be performed before each renewal of initial
(6) Clinical leadership (ie, the medical director) must be notified after 12 hours of
continuous seclusion or restraint and every 24 hours thereafter.
(7) With the patient’s informed consent, family should be notified promptly when
seclusion or restraint is initiated.
(8) Debriefing with patient and staff should be performed after intervention has been
Emergency physicians should be familiar with the risks associated with the use of
physical restraints. In a survey covering a 10-year period from 50 states, 142 patientdeaths occurred while in restraints, although many of these occurred outside of theED The Joint Commission lists patient injury or death under restraint asone of the top 10 sentinel events in the ED.There are many issues that can be thesource or cause of patient injury or death. These issues include miscommunicationamong staff or between staff and patient, procedural noncompliance, inadequatepatient assessment, and restraint of a patient in a room not under continuous obser-vation by staff. During Joint Commission inspections, failure to document and prac-tice safe use of restraints is one of the leading
Abrasions and bruising are the most common complications.Positional asphyxia
has been reported to occur if the patient is restrained in the prone or hobble posi-tion.Death can also occur if the restraints are not applied properly or the patientis not carefully Factors related to excited delirium, including acute intox-ication, withdrawal, and untreated psychosis, are more likely to contribute to suddendeath.Protracted struggling against restraints can lead to hyperthermia, increasedsympathetic tone with vasoconstriction, and lactic acid release from prolonged
isotonic muscle contractions leading to metabolic acidosis. Cardiovascular collapsefrom this metabolic acidosis has been found in many restraint-associated Any complications from the restraining procedure need to be documented fully.
Studies have evaluated various methods to improve compliance with the federal
requirements listed earlier. A recent innovation is the use of computerized forcingfunctions that signal when a restraint order is expiring. One study locked physiciansout from their computer system if a restraint order was not renewed or discontinuedat a predetermined time. That same study demonstrated that the overall time patientsspent in restraints decreased when the number of appropriately documented restraintorders per patient increased.There is concern that physicians may be less likely touse physical restraints in settings with computerized forcing functions, and insteaduse more pharmacological restraints or other informal restraint methods that do notrequire an order, or completely bypass the computerized order entry system.Care-ful, consistent, thorough, and standardized documentation , whether done on paper orin a computerized fashion, minimizes the risk of miscommunication, adverse events,and other complications from physical restraints.
Chemical or pharmaceutical restraints, called ‘‘rapid tranquilization’’ in older literature,should also be considered in conjunction with or in place of physical restraints. Phys-ical restraints can be counterproductive because struggling against restraints mayprevent obtaining a history or completing a thorough physical examination.Chem-ical restraints can help gain better control of the agitated patient and allow evaluationand treatment. Complications associated with struggling against physical restraints,such as hyperthermia, dehydration, rhabdomyolysis, or lactic acidosis, can all be mini-mized with the early use of chemical
Because so many patients with violent behavior in the ED have an underlying psychi-atric illness, antipsychotic (neuroleptic) medications, either alone or with benzodiaz-epines, have been used most commonly in the ED setting. Antipsychotics havea high therapeutic index and a lack of addictive potential. This class of medicationhas a high affinity for the dopamine-2 receptor. Contraindications to these medica-tions include an allergy to the class, Parkinson disease, and anticholinergic drugintoxication.
Haloperidol (Haldol), a butyrophenone antipsychotic, is easily given intramuscularly
(IM) at doses of 2.5 to 10 mg. Repeat doses can be given at 30- to 60-minute intervals,but the desired effect is usually obtained within three doses. The half-life of haloperidolis 10 to 19 hours. Intravenous (IV) administration has not been approved by the US Foodand Drug Administration (FDA), but it has been frequently given via this route. Extrapy-ramidal syndrome (EPS) is a potential side effect of haloperidol and, in rare cases, hasbeen reported to occur days after administration, even after only one dose. Signs of EPSinclude akathisia and acute dystonia (torticollis, opisthotonos, or oculogyric crisis).
Occurrence of EPS is easily treated with diphenhydramine (Benadryl) or benztropineHaloperidol can be safely given in the same syringe as lorazepam, thusfacilitating administration, hastening onset of sedation, and resulting in fewer EPSepisodes than when haloperidol is given Numerous studies have also shownthe benefit of using haloperidol to treat aggressive methamphetamine-intoxicatedpatients.Quickly sedating patients with methamphetamine intoxication is
particularly important because so many are at risk for rhabdomyolysis, hypertensivecrisis, cardiac ischemia, and cardiac dysrhythmias. It has been suggested that haloper-idol’s dopaminergic antagonism and antimuscarinic properties are neuroprotective inmethamphetamine
Droperidol (Inapsine), also a butyrophenone, used to be one of the most commonly
used chemical sedatives in EDs. Routine use has significantly diminished since theFDA issued a black box warning in 2001 about droperidol because of a potentialrisk for prolongation of the QT interval and resultant torsades de pointes in highdoses (QT prolongation has been caused by haloperidol at doses greater than 50mg IV, but it has no FDA black box Studies have demonstrated that dro-peridol results in faster control of the patient, shorter duration of effect (half-life 5 2hours), more consistent sedation, and a smaller incidence of EPS when comparedwith haloperidol, so its use in the ED setting seems ideal.Today, if a clinicianprefers to use droperidol, a pretreatment electrocardiogram should be obtained,but in the agitated, combative patient, doing so is obviously quite a challenge andthe infrequent use of droperidol not surprising. Continued cardiac monitoring afteradministration is also recommended.
Neuroleptic malignant syndrome (NMS) is an idiosyncratic adverse effect that can
occurs in 1% of patients receiving antipsychotics. NMS is recognized by autonomicinstability, hyperthermia, altered mental status, and muscle rigidity. Creatine phospho-kinase levels may be elevated.Treatment is supportive, with aggressive coolingmeasures and cessation of all neuroleptics. In some cases dantrolene is indicatedfor treatment of extreme muscle rigidity.
Second generation antipsychotic medications, more commonly called ‘‘atypical
antipsychotics,’’ are newer agents common in outpatient psychiatry and recentlyincorporated into the ED setting for the treatment of violent Risperidone,olanzapine, and ziprasidone are the most commonly used atypical antipsychotics inthe ED. Atypical antipsychotics inhibit dopamine-2 and serotonin receptors andthus provide more tranquilization and less sedation. An important benefit of theseatypical antipsychotics is the lower incidence of EPS from the serotonergic activity.
Risperidone (Risperdal) may be given IM or orally by elixir or a recently available dis-
integrating tablet. Studies have shown risperidone to be as effective as IM haloperidoland less sedating than in the acute treatment of Convincing an out-of-control patient to take risperidone orally can be challenging, but onset is rapid withthe orally dissolving tablets, so this option is safer and potentially more convenientfor nursing staff.
Olanzapine (Zyprexa), available IM or in orally dissolving tablets, has been found to
be comparable in efficacy to either lorazepam or haloperidol in many well-controlledstudies assessing its use for the treatment of agitated elderly patients with Alzheimerdisease, bipolar patients with mania, and schizophrenic patients in acute agita-tion.Occurrence of dystonia and akathisia are less common than with haloper-Mild hypotension is a common side effect and olanzapine has significantanticholinergic properties, which could exacerbate an agitated patient who overdosedon an anticholinergic agent such as diphenhydramine or jimsonweed.
Ziprasidone (Geodon) has been approved by the FDA for the treatment of acute
agitation in patients with schizophrenia and bipolar patients with mania. Studieshave shown IM ziprasidone to be superior to haloperidol and occurrence of EPSless common.The peak plasma concentration of the IM formulation is achievedin 30 to 45 minutes (8 hours for oral formulation). Importantly, ziprasidone was foundto prolong the QTc by 20 milliseconds and therefore is not indicted for patients withpre-existing QTc
Lorazepam (Ativan) is one of the more frequently used benzodiazepines for the treat-ment of agitation in the ED setting. It is a favorable medication because of its rapidonset, lack of active metabolites, effectiveness in patients intoxicated with a sympa-thomimetic agent such as cocaine, and availability in oral, IM, and IV formulations. Ofall the benzodiazepines, it is the one most reliably absorbed when administered IM, soit is especially useful in the agitated patient without IV access.It has a half-life of10 to 20 hours. It is also particularly useful in patients with alcohol dependence orcirrhosis because its inactivation is preserved in the setting of liver disease.Mostcommon side effects include sedation, confusion, nausea, and ataxia. Patientsmust be closely monitored for respiratory depression. It is a class D agent in preg-nancy and should also be avoiding in lactating women. As mentioned earlier, studiesby Battaglia and have shown that the sedative effect from the combina-tion of lorazepam and haloperidol is superior to higher doses of either medicationalone. In addition, occurrence of EPS is less common in those given lorazepam andhaloperidol together compared with those given haloperidol
Midazolam (Versed) is a water-soluble short-acting benzodiazepine that can be
administered IM or IV, has a rapid time to onset (18 minutes) and a time to arousalof 30 to 120 minutes (average 82 minutes). When administered IV, midazolam mayresult in significant hypotension, whereas IM it has little effect on the cardiopulmonaryOne study revealed that midazolam had similar efficacy to haloperidol or lor-azepam but was superior to both in that time to arousal was significantly lower.Ashorter time to arousal is a useful quality in the ED in that it allows these patients’ eval-uations to be completed more rapidly, allowing for faster determination of the appro-priate disposition of the patient ).
For some patients, seclusion can be an alternative to restraint by allowing for somefreedom of movement. However, even limited freedom of movement can bedangerous, especially for large adolescents and adults who can harm themselvesand others with their strength, agitation, and free use of their extremities. Psycholog-ical harm can also be caused if the patient feels isolated or has a sense of Rooms used for seclusion need to be safe, calm, and ideally have two exits. Wallsneed to be indestructible and solid. Furniture needs to be heavy and immovable.
The color of the room needs to be calming and there needs to be windows withunbreakable glass to allow for monitoring. No free-standing objects should be in theroom. Clear exits and panic buttons should also be Continuous observationis required.
Hospital staff can be victims of assault before a violence management team can beactivated and the patient restrained. As noted earlier, 50% of health care workerswill be a victim of work-place violence during their career.A few recommendationscan help minimize personal injury when facing a potentially violent patient. Do notface the patient head on; keep a sideward stance and try to keep a buffer zone ofat least four body widths from the patient. Have your arms ready for self-protection.
Try to appear calm and avoid sudden movements. Minimize direct eye contact andtry to deflect any kicks or punches. If bitten, do not pull away but instead push intothe patient and use the other hand to close their nares, causing them to reflexivelyopen their mouth. Avoid arguing and do not lie, bargain, or make promises. Try to
Table 1Comparison of antipsychotics and benzodiazepines
useful in elderly,bipolar andschizophrenicpatients
effect with IM;hypotension withIV; short time toarousal
Abbreviations: CHF, congestive heart failure; ESRD, end-stage renal disease.
Data from Lexi-comp/Up to Date.Available at:
control the natural instinct to shout which inadvertently reciprocates the violence.Do not reach for any weapon the patient may be holding.
PREVENTATIVE MEASURES AND PREPARATION FOR THE COMBATIVE PATIENT
Various environmental, administrative, and behavioral preventative measures can beimplemented to help make the ED a safer environment.
Certain environmental designs can strategically minimize violence in hospitals.
Monitoring systems such as metal detectors and security cameras have been foundto discourage aggressive behavior in the ED and other industries. Waiting roomsshould be designed to accommodate and assist visitors and patients who mayhave a delay in service. The triage area, waiting rooms, and reception areas shouldhave heavy furniture that cannot be lifted and used as weapons; glass should be shat-terproof or bulletproof; nursing stations should be enclosed because nurses are oftenthe first target of violence.Uniformed security available 24 hours a day is one of thebest ways to increase the safety of a department and hospital. Alarm systems andother ways of emergency signaling should be in place in all EDs. A panic button inpatient rooms and hallways can be helpful. A verbal alarm system to get the attentionof other staff, such as a code like ‘‘Dr. Armstrong to room 8,’’ is another effective wayto mobilize appropriate staff without upsetting other
Administrative controls to help reduce patient violence include designing staffing
patterns to minimize patient waiting times and to prevent staff from working alone. Re-stricting the movement of the public throughout the hospital or various sections of theED by card-controlled ID access has also been recommended.
Behavioral prevention strategies include continually educating and training all staff
to recognize and manage violent events and assaults, resolve conflicts when dealingwith patients, and maintain situational awareness. Patient searches are important toexclude weapons from the ED: studies have revealed that up to 10% of patients pre-senting to the ED carry some type of weapon. Searches can be performed either byhaving a policy that all patients undress and change into a gown or having a signposted that all individuals entering the ED will be searched for
The violent patient may be considered for discharge if the patient is cooperative,demonstrates no evidence of intoxication, organic problems have been adequatelyexcluded as the cause of a patient’s agitation, other medical and psychiatric problemshave been addressed, mental status is normal, and vitals signs are normal. Violentpatients who elope before their evaluation is completed pose a significant risk to them-selves and to others. Elopements can also be a legal risk to health care providers, solocal authorities should be notified in such cases.
As EDs continue to become more crowded, safely managing violent or aggressivepatients will continue to be challenging. Appropriately trained personnel, adherenceto protocol, careful attention to documentation, and good common sense will mini-mize complications and ensure safe use of physical or chemical restraints whenindicated.
1. Lavoie FW, Carter GL, Danzi DF, et al. Emergency department violence in United
States teaching hospitals. Ann Emerg Med 1988;17(11):1227–33.
2. Martel M, Sterzinger A, Miner J, et al. Management of acute undifferentiated
agitation in the emergency department: a randomized double-blind trial of dro-peridol, ziprasidone, and midazolam. Acad Emerg Med 2005;12(12):1167–72.
3. The Joint Commission. Available at: . Accessed April 2,
4. CDC. Department of Health and Human Services. Centers for Disease Control
and Prevention. National Institute for Occupational Safety and Health. Availableat: . Accessed March 15, 2009.
5. Mahoney BS. The extent, nature and response to victimization of emergency
nurses in PA. J Emerg Nurs 1991;17(5):282–91.
6. McAneney CM, Shaw KN. Violence in the pediatric emergency department. Ann
7. Citrome L, Volavka J. Violent patients in the emergency setting. Psychiatr Clin
8. Tardiff K. Diagnosis and management of violent patients. In: Michels R, Cavener JD,
Cooper AM, et al, editors. Psychiatry, vol. 3. Philadelphia: Lippincott-Raven; 1997.
9. Regier DA, Farmer ME, Rae DS, et al. Comorbidity of mental disorders with
alcohol and other drug abuse. Results from the Epidemiologic Catchment Area(ECA) Study. JAMA 1990;264(19):2511–8.
10. Swanson JW. Mental disorder, substance abuse and community violence: an
epidemiological approach. In: Monahan J, Steadman HJ, editors. Violence andmental disorder: developments in risk assessment. Chicago (IL): University ofChicago Press; 1994. p. 101–36.
11. American Psychiatric Association. Practice guidelines for the treatment of
patients with delirium. Am J Psychiatry 1999;156(5 Suppl):1–20.
12. Martel M, Miner J, Fringer R, et al. Discontinuation of droperidol for the control of
acutely agitated out-of-hospital patients. Prehosp Emerg Care 2005;9(1):44–8.
13. Mock EF, Wrenn KD, Wright SW, et al. Prospective field study of violence in EMS
calls. Ann Emerg Med 1998;32(1):33–6.
14. Nonviolent crisis intervention workbook. Brookfield (WI): National Crisis Preven-
15. Isaacs E. The Violent patient. In: Adams JG, Nadel E, DeBlieux P, et al, editors.
Emergency medicine. 1st edition. Philadelphia: Saunders Elsevier; 2008. p.
16. Hill S, Petit J. The violent patient. Emerg Med Clin North Am 2000;18(2):301–15.
17. Annas GJ. The last resort–the use of physical restraints in medical emergencies.
N Engl J Med 1999;341(18):1408–12.
18. Rice MM, More GP. Management of the violent patient: therapeutic and legal
considerations. Emerg Med Clin North Am 1991;9(1):13–30.
19. Kuhn W. Violence in the emergency department: managing aggressive patients
in a high-stress environment. Postgrad Med 1999;105(1):143–8.
20. Hick JL, Smith SW, Lynch MT. Metabolic acidosis in restraint associated cardiac
arrest: a case series. Acad Emerg Med 1999;6(3):239–43.
21. Lavoie FW. Consent, involuntary treatment and the use of force in an urban emer-
gency department. Ann Emerg Med 1992;21(1):25–32.
22. Kozub ML, Skidmore R. Seclusion and restraint: understanding recent changes.
J Psychosoc Nurs Ment Health Serv 2001;39(3):24–31.
23. Zun LS. A prospective study of the complication rate of the use of patient restraint
in the emergency department. J Emerg Med 2003;24(2):119–24.
24. Chan TC, Vilke GM, Neuman T, et al. Restraint position and positional asphyxia.
25. Griffey RT, Wittels K, Gilboy N, et al. Use of computerized forcing function
improves performance in ordering restraints. Ann Emerg Med 2009;53(4):469–76.
26. Bisantz A, Wears R. Forcing functions: the need for restraint. Ann Emerg Med
27. Diaz JE. Chemical restraint. J Emerg Med 2000;19(3):289–91.
28. Currier GW, Trenton A. Pharmacologic treatment of psychotic agitation. CNS
29. Battaglia J, Moss S, Rush J, et al. Haloperidol, lorazepam or both for psychotic
agitation? A multicenter, prospective, double blind, emergency departmentstudy. Am J Emerg Med 1997;15(4):335–40.
30. Kuribara H. Early post treatment with haloperidol retards induction of metham-
phetamine sensitization in mice. Eur J Pharmacol 1994;256(3):295–9.
31. Kuribara H. Inhibition of methamphetamine sensitization by post methamphet-
amine treatment with SCH 23390 or haloperidol. Psychopharmacology 1995;199(1):34–8.
32. Kao LW, Kirk MA, Evers SJ, et al. Droperidol, QT prolongation and sudden death:
what is the evidence? Ann Emerg Med 2003;41(4):546–58.
33. Chase PB, Biros MH. A retrospective review of the use and safety of droperidol in
a large, high-risk, inner-city emergency department patient population. AcadEmerg Med 2002;9(12):1402–10.
34. Knott J, Taylor D, Castle D. Randomized clinical trial comparing intravenous mid-
azolam and droperidol for sedation of the acutely agitated patient in the emer-gency department. Ann Emerg Med 2006;47(1):61–7.
35. Dubin WR, Weiss KJ. Emergency psychiatry. In: Michels R, Caverner JD,
Cooper AM, et al, editors, Psychiatry, vol. 2. Philadelphia: Lippincott-Raven;1997. p. 1–15.
36. Rund DA, Ewing JD, Mitzel K, et al. The use of intramuscular benzodiazepines
and antipsychotic agents in the treatment of acute agitation or violence in theemergency department. J Emerg Med 2006;31(3):317–24.
37. Currier GW, Simpson GM. Risperidone liquid concentrate and oral lorazepam
versus intramuscular haloperidol and intramuscular lorazepam for treatment ofpsychotic agitation. J Clin Psychiatry 2001;62(3):153–7.
38. Meehan KM, Wang H, David SR, et al. Comparison of rapidly acting intramus-
cular olanzapine, lorazepam and placebo: a double blind randomized study inacutely agitated patients with dementia. Neuropsychopharmacology 2002;26(4):494–504.
39. Meehan K, Zhang F, David S, et al. A double blind, randomized comparison of the
efficacy and safety of intramuscular injections of olanzapine, lorazepam orplacebo in treating acutely agitated patients diagnosed with bipolar mania.
J Clin Psychopharmacol 2001;21(4):389–97.
40. Breier A, Meehan K, Birkett M, et al. A double blind, placebo controlled dose
response comparison of intramuscular olanzapine and haloperidol in the treat-ment of acute agitation in schizophrenia. Arch Gen Psychiatry 2002;59(5):441–8.
41. Wright P, Birkett M, David SR, et al. Double blind, placebo controlled comparison
of intramuscular olanzapine and intramuscular haloperidol in the treatment ofacute agitation in schizophrenia. Am J Psychiatry 2001;158(7):1149–51.
42. Brook S, Lucey JV, Gunn KP. Intramuscular ziprasidone compared with intramus-
cular haloperidol in the treatment of acute psychosis. J Clin Psychiatry 2000;61(12):933–41.
43. Brook S. Intramuscular ziprasidone: Moving beyond the conventional in the treat-
ment of acute agitation in schizophrenia. J Clin Psychiatry 2003;64(suppl 19):13–8.
44. Bellnier TJ. Continuum of care: stabilizing the acutely agitated patient. Am J
Health Syst Pharm 2002;59(17 Suppl 5):S12–8.
45. Goodnick PJ. Ziprasidone: Profile on safety. Expert Opin Pharmacother 2001;
46. Salzman C. Use of benzodiazepines to control disruptive behavior in inpatients.
J Clin Psychiatry 1988;49(Suppl 12):13–5.
47. Greenblatt DJ, Divoll M, Harmatz JS, et al. Pharmacokinetic comparison of sublin-
gual lorazepam with intravenous, intramuscular and oral lorazepam. J Pharm Sci1982;71(2):248–52.
48. Greenblatt DJ, Shader RI, Franke K, et al. Pharmacokinetics and bioavailability of
intravenous, intramuscular and oral lorazepam in humans. J Pharm Sci 1979;68(1):57–63.
49. Tesar GE. The agitated patient, part II: pharmacologic treatment. Hosp Commu-
50. Gerecke M. Chemical structure and properties of midazolam compared with
other benzodiazepines. Br J Clin Pharmacol 1983;16(Supp 1):11S–6S.
51. Nobay F, Simon B, Levitt A, et al. A prospective double-blind, randomized trial of
midazolam versus haloperidol versus lorazepam in the chemical restraint ofviolent and severely agitated patients. Acad Emerg Med 2004;11(7):744–9.
52. LexiComp/Up-To-Date. Available at: .
53. Masters KJ, Bellonci C, Bernet W, et al. Practice parameter for the prevention and
management of aggressive behavior in child and adolescent psychiatric institu-tions with special reference to seclusion and restraint. J Am Acad Child AdolescPsychiatry 2002;41(2):4S–25S.
54. Rankins RC, Hendey GW. Effect of a security system on violent incidents and
hidden weapons in the emergency department. Ann Emerg Med 1999;33(6):676–9.
55. Fernandes CMB, Raboud JM, Christenson JM, et al. The effect of an education
program on violence in the emergency department. Ann Emerg Med 2002;39(1):47–55.
56. Blanchard JC, Curtis KM. Violence in the emergency department. Emerg Med
57. Here’s how to prevent assaults on staff. ED Manag 2001;13(6):66–9.
58. Mattox EA, Wright SW, Bracikowski AC. Metal detectors in the pediatric emer-
gency department: patron attitudes and national prevalence. Pediatr EmergCare 2000;16(3):163–5.
Department of Family Medicine George Provincial Hospital January 2009 Guidelines for patients needing Urology services in the Eden – Karoo districts It is important to take note that there is no state Urologist in the Southern Cape – Karoo districts. Family Medicine serves as a buffer for this service, but patients needing surgical procedures beyond the 10 minor Urology proce
Antimicrobial Susceptibility of Monoculture Biofilms of aClinical Isolate of Enterococcus faecalis Anne E. Williamson, DDS, MS, Jared W. Cardon, DDS, and David R. Drake, MS, PhD AbstractThe purpose of this study was to create a monoculturebiofilm of a clinical isolate of Enterococcus faecalis andThe primary etiology of persistent periapical pathosis has been attributed to viablebacteria remain