II. Indications

  1. Dangerous and uncontrolled Violent Behavior

III. General

  1. Never use for convenience
  2. Never restrain in prone position (case reports of asphyxia)
  3. Never place weight on patient's back while prone
  4. Run like a Resuscitation code
  5. Command cooperation
    1. Explain to the patient the need for restraints
  6. Document justification and frequent Vital Signs

IV. Technique

  1. Remove jewelry, ties, weapons
  2. Patient should be positioned supine (not prone)
  3. May place oxygen mask over the patient's face to prevent spitting
  4. Apply by at least 5 assistants
    1. One assistant to secure patient's head
    2. One assistant per limb
      1. Tie each leg to the opposite side of the gurney (if not disallowed by facility policy)
  5. Restraint materials: Five point restraints
    1. Leather restraints are usually necessary
    2. Soft restraints may be adequate for elderly
    3. Figure-of-four arm lock may allow IV placement or IM Chemical Restraint injection
  6. Patient stays in seclusion room while restrained

V. Management: Monitoring

  1. Physical Restraints require 1:1 observation (staff is with them 100% of the time)
  2. Medical provider must order the Physical Restraints and must see the patient within 1 hour of order
    1. Physical Restraints may not be ordered as needed
  3. Reevaluation by provider
    1. Children <9 years: Every 1 hour
    2. Children 9-18 years: Every 2 hours
    3. Adults: Every 4 hours

VI. Precautions

  1. Physical Restraints are a bridge to other management (typically transient use for 30-60 minutes)
  2. Typically used to obtain IM access to deliver Sedative (e.g. Ketamine, Benzodiazepines, Haloperidol, Olanzapine)
  3. Prolonged use of Physical Restraints risks life threatening complications for the patient (e.g. Rhabdomyolysis)
  4. Remove the Physical Restraints once sedation or other effective measures are implemented
  5. Deaths have occurred in physically restrained children
  6. Do not partially restrain
    1. Risk of patient still getting out of bed, falling or Choking

VIII. Complications: Staff

  1. Eye Injury
  2. Musculoskeletal Injury (strains and sprains)
  3. Scratches
  4. Needlestick Injury
  5. Blody Fluid Exposure

IX. References

  1. Mason, Mallon and Colwell in Herbert (2018) EM:Rap 18(10): 11-2

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