The beat

EMS Edmonton / North Zone
MEDICAL REFERENCE
REF-3038.0
APRIL 1, 2009
PHYSICAL RESTRAINTS

There may be times in the field where patient restraint is a consideration or even a necessity. The safety of EMS
personnel is factor when dealing with these patients. Refer to Psychiatric / Violent (MCG-1104.0).
Verbal, physical and chemical restraints provide effective ways of restraining patients who are a threat to
themselves or require medical treatment for a condition associated with combative or agitated behavior (hypoxia,
hypoglycemia, alcohol or drug intoxication, stroke, brain trauma). Restraint procedures can expose EMS
providers to blood, spit, urine or feces, making appropriate BSI a must.
VERBAL DEESCALATION

Honest and straightforward verbal exchange, in a friendly tone, may be all that is needed when dealing with
agitated or aggressive behavior. Avoid direct contact and encroachment upon the patient’s personal space as this
may provoke or escalate stress and anxiety. Attempt to have equally open escape routes for both the EMS
personnel and the patient. Verbal intervention sometimes diffuses the situation and may avoid the need for
additional restraints.
PHYSICAL RESTRAINTS

When physically restraining a patient, take every effort to avoid injuring the patient. Ideally, a minimum of five
people should be present to safely apply physical restraints to a violent patient (one for each limb and one for the
head). Four point soft restraints are preferred over two point restraints. Do not transport the patient in the prone
position. If possible, securing the patient to a spine board will eliminate the need to remove the restraints when
moving the patient to the hospital bed. A loosely fitted mask or a non-rebreather will help protect EMS from
spitting.
Soft restraints may still cause injury, therefore it is important to perform and document neurovascular
assessments of the extremities that are restrained to assure adequate circulation. A patient who has undergone
physical restraint should not be allowed to continue to struggle against the restraints. This may lead to severe
acidosis, hyperkalemia, rhabdomyolysis or a fatal dysrhythmia (Refer to Excited Delirium REF-3016.5). The use
of chemical restraints should be considered if the patient continues to struggle.
Special consideration should be given to applying physical restraints prior to narcan administration in the narcotic
overdose patient.
CHEMICAL RESTRAINTS

The goal of chemical restraints is to subdue excessive agitation and struggling against restraints. Butyrophenones
(haldol) and/or benzodiazepines (midazolam, lorazepam) are the most commonly used medications prehospitally.
The most common effects of benzodiazepines are hypotension and respiratory depression that may lead to
hypoxia or hypoventilation. Monitor vital signs closely and ensure that the patient is able to maintain their airway.
Extrapyramidal symptoms (treat with diphenhydramine), along with prolonged QT interval and torsade de pointes
are adverse effects of butyrophenones.

Source: http://www.parklandambulance.ca/ops/mcg/REF/REF_3038.0_FE09.pdf