Medic 24 is dispatched to assist the local sheriff’s department on an unknown medical emergency at a convenience store. As the crew approaches the scene, they see several police cars and a fairly large crowd of people. Once providers have checked with law enforcement to ensure the scene is safe, Steve, an EMT, carefully parks the ambulance while Rita, a paramedic, grabs the airway bag and defibrillator.„

As they walk toward the store, six sheriff’s deputies exit the store carrying a large, handcuffed man. The man is yelling, spitting and attempting to bite the officers. A seventh deputy opens the back doors of the ambulance, and the man is deposited onto the stretcher in the prone position. The deputies handcuff the patient to the stretcher while Rita watches from a short distance. Steve obtains scene details from other law enforcement personnel.

It seems the patient, known only as ˙Big John,Ó went into the convenience store and began behaving in a bizarre fashionƒshouting, singing ˙Amazing GraceÓ and throwing sodas from the cooler to the floor. After frightening the clerk and several customers, Big John proceeded to urinate all over the candy aisle. The sheriff’s department was called, and two deputies arrived within minutes. They attempted to take Big John outside to the parking lot, but he resisted. A scuffle ensued, and Big John was struck several times by deputies with a telescoping baton. Finally, additional officers arrived, wrestled him to the ground and subdued him. Big John continued to resist.

Once in the ambulance, Rita carefully places a surgical mask over Big John’s face to keep him from spitting. The deputies say they will follow the ambulance to the hospital. Rita attempts an assessment. The patient is 6‘ 6″ tall and weighs nearly 400 lbs. He has a protuberant abdomen and multiple homemade tattoos on both arms. Rita attempts to listen to his chest, but he struggles. She tries to attach the pulse oximeter, but he keeps removing the probe. Rita resigns herself to the fact that she’s not going to be able to assess the patient.

The crew departs for the local emergency department (ED). Big John remains highly agitated and constantly fights the handcuffs. However, about five minutes from the hospital, he quits and becomes quiet. Rita reassesses him and finds him to be pulseless and apneic. She yells to Steve, ˙He’s arrested.Ó

When Steve stops the ambulance, Rita opens the back door but doesn’t see a deputy. Steve summons the fire department for assistance. Steve and Rita are able to move Big John to a somewhat supine position despite the handcuffs being behind him. The fire department arrives within two minutes and assists. CPR is started and Big John is delivered to„Holy„Family„Hospital. There, ED personnel continue CPR and ACLS, but Big John is later pronounced dead.

The next shift, Steve and Rita learn the county coroner had found that Big John had died of restraint asphyxia. The patient had been high on cocaine and methamphetamine, as well as intoxicated. The local district attorney refers the case to the grand jury, and the providers are suspended by both their„EMS agency and the state pending the legal outcome.

After three weeks, the grand jury doesn’t return indictments against the pair or any involved law enforcement personnel, and Steve and Rita are allowed to return to work. Because of the incident, the„EMS agency, in conjunction with local law enforcement agencies, revises its policies and procedures in regard to patient restraint and transport of combative patients. Although Steve and Rita return to work, the costsƒof decreased service, legal fees, damaged reputations and, above all, a patient’s lifeƒwere significant.

This case illustrates why the management of agitated and combative patients has become a hot topic in„EMS. Considerable emotion surrounds this difficult aspect of prehospital care and creates an incentive for enforcing best practices.

WhatIs Restraint?
Restraintis the use of a physical/mechanical device or chemical agent to involuntarily restrain a patient’s movement in order to protect the patient or others from harm. Several restraining devices are in use today, the most common of which are the metal handcuffs routinely used by law enforcement personnel. The medical use of restraints has historically included the use of hard or leather arm and leg apparatus and such devices as straitjackets.

Some patients cannot be safely restrained with simple devices. Thus, law enforcement personnel have used a restraint maneuver calledhog-tying. Hog-tying involves placing the person in a prone position, securing their hands and feet together behind their back and then tying their hands to their feet. This maneuver is also calledhobble restraint. Several deaths have been reported in people undergoing hog-tying, and these cases were subsequently studied in order to determine the actual cause of death and hopefully prevent future deaths.

Cases of Restraint Asphyxia
Several incidents in the 1980s and early ’90s encouraged researchers to look at the issues surrounding deaths of patients who had been arrested or restrained. One early study found that many patients die as a result of physical positioning, especially when associated with alcohol intoxication. In the study, researchers evaluated the deaths of 30 adults who apparently died of positional or postural asphyxia over a nine-year period in the 1980s in Broward and Dade counties in„Florida.

The researchers found that chronic alcoholism and alcohol intoxication (average ethanol level 0.24 g/dL) were factors in 75% of the cases. The victims had an average age of 50.6 years, and no gender or racial differences were found when compared with the diversity of the medical examiner population. Further, the victims were commonly found in a restrictive position (hyperflexion of the head and neck). Two deaths involved the use of restraint vests. The authors subsequently described the criteria for determining whether the deaths were due to positional asphyxia.

Researchers in the„Seattle area noted similarities between three cases of positional asphyxia that occurred during law enforcement transport in the early ’90s. The first case was of a 28-year-old man who had a history of psychiatric illness. On the day of his death, he assaulted and threatened to kill his wife. Police were summoned and a violent confrontation ensued. The subject choked one police officer until an officer struck the subject with a nightstick. The man then ran from the police and became trapped in some bushes. Additional police arrived, and he was subdued, placed face-down on the ground and hog-tied. The subject was then placed face-down in the back seat of a patrol car. After a five- to seven-minute ride to the ED (for treatment of his nightstick wounds), he was found pulseless and apneic. Resuscitation was attempted but unsuccessful. The autopsy was negative except for minor injuries sustained in the struggle. Death was attributed to positional asphyxia.

The second case in„Seattle involved a man who was drinking beer and got into a fight with some friends. The 28-year-old patient attempted to flee from police, and a struggle ensued. He was struck several times with nightsticks. Several additional officers arrived, and he was restrained face-down.

The man continued to struggle and asked for air. He was hog-tied and placed prone in the backseat of the patrol car. While en route, he fell to the floorboard and remained in a prone position. The transporting officer noticed that the prisoner’s breath became ˙gurgly.Ó The officer then called paramedics, who arrived and found the patient unresponsive. Resuscitation was attempted but unsuccessful. Autopsy findings supported the officers’ report of the event. The toxicology screen was positive for alcohol, LSD and THC (marijuana). Death was attributed to positional asphyxia.

The third case in the study was of a 34-year-old man with a long psychiatric history who was behaving bizarrely. After police were summoned and arrived, the victim became quite agitated. A scuffle took place, and the victim was subdued. He was hog-tied and placed on his side on the rear floorboard of the patrol car. The officer reported no problems during transport but noted the victim became ˙quiet.Ó When they arrived at the jail, the victim was dead. The autopsy failed to demonstrate any significant findings. Death was attributed to positional asphyxia.

Another study published in 1995 described two patients in hobble restraints who suffered rapid asystolic arrest and died during paramedic transports. The first patient was a 35-year-old, agitated, combative man found rolling in the street. He was arrested, his hands handcuffed behind his back. Despite this, he remained uncontrollable and was placed in hobble restraints.

Paramedics were summoned, and the patient was placed in a prone position on the stretcherƒstill in hobble restraints. Paramedics placed him on a cardiac monitor. During transport his pulse dropped from 136 to 60, increased to 102, and then deteriorated to asystole within a minute. The restraints were removed, and resuscitation was attempted but unsuccessful. At autopsy, the patient was found to have methamphetamine and amphetamine in his system. The coroner ruled that his death was due to methamphetamine intoxication and restraint maneuvers.

The second patient was a 30-year-old man who was riding his bicycle erratically in and out of traffic. Police arrested and handcuffed him. The man began to spit and kick at police officers, and he was placed in hobble restraints when other restraint measures failed.„EMS was summoned for transport. He was placed prone on the stretcher and continued to struggle. Within six minutes, he became unresponsive. Restraints were released, and resuscitation was attempted but unsuccessful. At autopsy the patient was found to have ethanol, cocaine and various cocaine derivatives, methamphetamine and amphetamine in his system. Cause of death was positional asphyxia secondary to restraint for excited delirium.

Another study investigated factors associated with restraint asphyxia in 11 patients with excited delirium. Three of the victims were psychotic; the others suffered from drug intoxication. The 11 victims were males who ranged in age from 14Ï44 years. All exhibited wild, threatening or bizarre behavior, and it took several people to restrain them. All struggled against the restraints initially and later were noted to be unresponsive or dead. All were restrained in the prone position, nine of whom were hog-tied.

Causes of Asphyxia
The literature clearly illustrates that patients with excited delirium are at risk for sudden death while in the prone position. So, is the problem the prone positioning, the hobble restraint, the excited delirium or a combination of the three?

Several studies have attempted to clarify this issue. A German study reported significant impairment of cardiac output and respiration in six male volunteers who were placed in hobble restraints in a prone position. But two other studies with larger numbers of subjects came to different conclusions.

In a„San Diego study, researchers sought to determine whether hobble restraints result in clinically relevant respiratory depression. They studied 15 healthy men (ages 18Ï40) who had normal respiratory function and a negative drug screen. Subjects underwent a four-minute exercise period and then rested in a seated position while their pulse, oxygen saturation and arterial blood gasses were measured. The subjects later repeated the exercise but were placed in a prone, restraint position and hog-tied with the same monitoring.„

The researchers found that the restraint position resulted in restricted pulmonary function, but did not result in clincally relevant changes in oxygenation or ventilation.„

These conclusions were similar to findings of a study published in 1999. Researchers measured the heart rates and oxygen saturations of 18 healthy volunteers who were seated and unrestrained. They had the subjects exercise and then hog-tied them afterward. No statistical difference was found between the seated versus hog-tied heart rates and oxygen saturations.

The subjects then simulated a pursuit and struggle scenario, and they were placed in the maximal restraint position. Again, no statistically significant change was noted in the heart rates or oxygen saturations at rest or in maximum restraints. They concluded that use of the hog-tie restraint did not result in clinically significant changes in heart rate or oxygen saturation.

In another San Diego study, researchers concluded that factors other than body positioning appear to be more important determinants for sudden death in patients restrained in the hog-tie position.These include illicit drug use (especially stimulants and hallucinogenics), physiologic stress, hyperactivity, hyperthermia, increased sympathetic nervous system stimulation from epinephrine and norepinephrine (catechol hyperstimulation) and trauma from struggle.

Researchers in„Minnesota found that restrictive positioning of combative patients resulted in significant acidosis (pH 6.25Ï6.81) in their review of five patients, four of whom died. They also found that restraint may impede appropriate respiratory compensation for the acidosis. They suggested buffer therapy with sodium bicarbonate might be of benefit in these patients.

A criminal justice study also evaluated factors associated with excited delirium deaths in police custody. Researchers reviewed 61 cases and found that the subject fought with and was restrained by the police in all cases. Death usually occurred on scene or during transport. In the majority of cases, both cocaine toxicity and physical restraint contributed to death.

Canadian researchers also reviewed 21 cases of unexpected death related to restraint for excited delirium. They found that in 86% of deaths, the patient was in the prone position, and 14% of deaths were associated with neck holds. Of the 21 total cases, excited delirium was caused by psychiatric disorders in 57% of the cases and 38% had cocaine-induced delirium. All 21 lapsed into tranquility shortly after being restrained.

Researchers in„Los Angeles reviewed factors associated with 18 sudden deaths in individuals treated by„EMS who required restraint for excited delirium. They found the following factors associated with death in 100% of cases:„

ÎExcited delirium;

ÎHog-tie restraint;

ÎProne position; and

Î Forceful struggle against restraint.

These and other factors are shown in„Figure 1.

Clearly, patients who have these factors are at increased risk of death.

Restraint in Modern„EMS
Despite the current scientific evidence, considerable confusion remains regarding the issue of patient restraint in prehospital care. In fact, the 1995 DOT EMT curriculum still recommends placing patients in the prone position for restraint.Thus,„EMS system leaders should take the lead and proactively establish or consider revisiting protocols that address the issue of patient restraint by prehospital providers. These protocols must be based upon the relevant medical literature and recommendations of organizations such as the National Association of EMS Physicians (NAEMSP).

Further, it’s essential that all local law enforcement and mental health agencies be involved in the development of restraint protocols. Each person on scene with an agitated patient who requires restraint must know what their roles are as well as the roles of other responding public safety personnel. Clearly identified roles and responsibilities will help avoid problemsƒlike in a case study in which„EMS personnel were unable to remove the handcuffs from a patient with a deteriorating medical condition because they didn’t have the key.

In addition to system preparation,„EMS personnel should carefully plan any restraint maneuvers to be applied in the field. This planning includes ensuring that an adequate number of personnel is on scene, that restraint devices are readily available, and that all involved personnel precisely know what their role in the restraint process will be. These steps minimize the likelihood of the patient or rescuers being harmed in the process.

The Restraint Process
EMSpersonnel have three modalities available for patient restraint: verbal defusing, physical restraint and chemical restraint. Every patient will be different, and the technique chosen must tailored for the patient in question.

Verbal defusing:Some agitated patients may be lucid enough to respond favorably to verbal defusing techniques. If you elect to first try this method, select a team member to approach the patient and begin dialogue. It’s important that the team member always have an open path for retreat should the patient become a physical threat.

When performing verbal defusing, approach the patient only with their permission. Use a calm voice and show concern. Never encroach upon the patient’s ˙personal spaceÓ because this might cause heightened agitation. If possible, remain at the patient’s eye level but specifically avoid eye contact.

EMS personnel who wear badges should remove these prior to approaching the patient to avoid confusion with a law enforcement officer. Also, don’t have objects, such as a stethoscope, hanging around your neck because a patient might grab this and attempt to choke you.

Allow the patient to talk. If necessary, wait for them to respond. If they’re delusional, don’t point out their irrational behavior because this may agitate them. Gain their confidence, and then ask them to voluntarily comply with your requests.

Above all, always assure them that you’re their advocate, mean them no harm and only want to get them the help they need. Not all patients are candidates for verbal defusing because their level of agitation may prevent them from understanding your motives.

Physical restraint:Unfortunately, some patients must be physically restrained to prevent them from hurting themselves or others. The process of physical restraint should never be approached lightly. Patients in excited delirium can be amazingly strong and pose a clear and present danger to emergency personnel and others on scene.

If the decision is made to physically restrain a patient, a minimum of five people should be availableƒone for each extremity and one for the head. A team leader must direct the process. Applying physical restraint can place emergency personnel at increased risk of exposure to blood and other potentially infectious materials. So all involved personnel must don appropriate body substance isolation measures.

You should approach the patient as a team and surround the patient at a safe distance. The team leader should talk with the patient and continue any verbal defusing techniques, which should somewhat distract the patient from the actions of the other rescuers.

Upon a previously agreed signal, all should simultaneously approach the patient and secure their pre-assigned body appendage. The patient should be safely brought to the ground as directed by the team leader. During the initial restraint maneuver, it is permissible to restrain the patient in the prone position. It decreases the patient’s visual stimulation and limits the patient’s ability to kick and punch effectively. It’s important not to restrict the patient’s airway or respiratory function during prone positioning. However, once the team has control of the patient, the team should immediately turn the patient to a supine position while maintaining control.

The team should move the supine patient to the ambulance stretcher or a backboard. There, the extremities should be secured to the backboard or stretcher with commercial soft restraints or roller bandages (e.g., Kling or Kerlix). Ideally, one arm should be placed at the patient’s side and the other above their head. Once the patient is positioned on the stretcher, place the lower strap tightly across the knees and the upper strap tightly across the chest (but loose enough to allow respiratory movement.) If the patient is biting, you can place a rigid cervical collar as long as it doesn’t compromise the patient’s airway. This may restrict the range of motion of the neck and decrease the potential for the patient inflicting a bite. If the patient is spitting, apply a loose surgical mask to protect emergency personnel from the saliva.

Once restrained, the patient should be moved to a protected environment, such as the back of the ambulance, to minimize sensory stimulation.„EMS personnel should place the patient on all appropriate monitors, if possible, including the ECG and pulse oximeter. It’s important to remember that several medical conditions, such as hypoglycemia, hypoxia, and nervous system illness or injury, can result in agitation.„EMS personnel must look for and correct treatable causes of the patient’s agitation before simply assuming it to be the result of mental illness and/or substance abuse.

After restraint, continue verbal defusing techniques. If the patient keeps struggling against the restraints, consider administering a medication to lessen their agitation (as discussed later). Continuously monitor the patient’s condition during care, including pulses distal to the restraint devices.

Hard-restraint devices, such as commercial leather restraints, should be avoided unless all involved personnel are trained and competent in their use and the patient is carefully monitored during care.„EMS personnel should never use law enforcement restraints, including handcuffs, stun guns, pepper spray, mace, telescoping batons or even metal flashlights.

If law enforcement personnel place handcuffs on a patient prior to EMS transport, it’s essential that the law enforcement officer accompany the subject in the patient compartment at all times, including transport, and have the key to immediately remove the handcuffs should the patient deteriorate. This issue should be addressed during protocol development to avoid on scene disagreement between„EMS personnel and law enforcement.

Above all, patients should never be hog-tied or maintained in a prone position. As a rule, restraints placed in the field should remain in place until the patient is delivered to the ED except for cases when the patient’s medical condition deteriorates necessitating medical intervention.

Chemical restraint:The use of sedatives is an important and often overlooked aspect of prehospital patient restraint. Many of these patients have extreme sympathetic stimulation as a result of mental illness or use of stimulants. Continued struggle during restraint has been shown to be a significant risk factor in deaths due to restraint asphyxia. In these cases, it may be prudent to administer a sedative to lessen the patient’s agitation.

The two medication types most frequently used for chemical restraint are antipsychotics and benzodiazepines. Often, a combination of the two are used. The goal of pharmacological therapy is to lessen the patient’s agitation without inducing amnesia or unconsciousness.

The two types of antipsychotics used for chemical restraint are the butyrophenones (haloperidol/Haldol and droperidol/Inapsine) and the atypical agents (ziprasidone/Geodon). Although all of these are effective, the FDA has issued a ˙black boxÓ warning for droperidol because it has been demonstrated to prolong the QT interval in certain patients and cause dysrhythmias. Haloperidol and ziprasidone may also increase the QT interval but don’t have the ˙black boxÓ warning at this time. The FDA recommends that a 12-lead ECG be obtained before administering droperidol. Because 12-lead monitoring is often impossible in an agitated patient, haloperidol and ziprasidone may be the preferred antipsychotic agents. All of these agents can be administered IM or IV.

Benzodiazepines are potent sedatives and are effective in chemical restraint. Diazepam, lorazepam and midazolam can all be administered IM or IV. Also, olanazepine is supplied in a fast-dissolving wafer that can be administered orally with rapid release of the drug. Because it must be given orally, it often takes longer to provide the desired effects and also places„EMS personnel at risk for bite injuries. However, patients who are somewhat lucid may agree to an oral agent as opposed to an agent administered with a needle.

The actual administration of a chemical agent to an agitated patient places providers at increased risk for injuries, including needlesticks. If the decision is made to administer a medication before the patient is completely restrained, the patient must be approached and restrained before the medication is administered. In severe cases, providers may need to administer the medication through the patient’s clothingƒa necessary risk for the patient’s safety.

Patient restraint poses a particular risk for„EMS personnel and the patient. Each„EMS system must have policies and procedures in place that address these risks. In addition, these policies and procedures must be developed in conjunction with other agencies that may be involved, such as law enforcement.

The literature has clearly demonstrated that deaths due to restraint asphyxia are multi- factorial. No single factor appears responsible for these deaths. Thus,„EMS personnel should carefully evaluate patients with excited delirium and assume an increased risk of restraint asphyxia. Simply placing a patient in the supine position doesn’t ensure that they won’t die. It’s important to remember the risk factors associated with restraint asphyxia include excited delirium, substance abuse (particularly stimulants), prone position, hog-tie restraints, continued struggle against restraints and obesity.

In addition, many cases of agitation may be due to treatable medical conditions, including hypoglycemia, hypoxia and central nervous system problems. It’s essential to always look for these before simply assuming a patient’s agitation is due to psychosis or substance abuse. And finally, beware the restrained patient who suddenly lapses into tranquilityƒthis is often a precursor to death.

Bryan E. Bledsoe, DO, FACEP, EMT-P, is an emergency physician and EMS author from Midlothian, Texas. He completed his residency training at Scott and White Hospital in Temple, Texas.„

David Phillips, BS, EMT-P, is a paramedic and president/CEO of Central Texas Regional EMS.

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