Psych & Ortho Upper Extremity (August 2016)
Research: Coburn and Mycyk, “Physical and Chemical Restraints”, Emerg Med Clin N Am, 2009.
For a Review Article
- How has reading the article changed your practice?
- What information had you believed in previously that were debunked by reading this article?
- What new information did you learn from reading this article?
- What are current areas of uncertainty on this topic that can be potential areas for research?
For an Original Research Article
- What are some strengths of the study?
- What are the limitations?
- What are the main outcomes of the study?
- Does reading this article change your practice? If so, how?
11 comments
Ah, a subject near and dear to our hearts.
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In addition to a brief overall review of restraints, there are multiple pearls in there worth knowing:
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EPS is less common in those given lorazepam and
haloperidol together compared with those given haloperidol alone
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Consider PO atypical antipsychotics for somewhat cooperative patients is certainly reasonable as well to facilitate less sedation, and earlier dispo time to psych evaluation
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Happy reading.
I sent this to Alex
One comment about Victoria and Mark’s older review is that ketamine is not discussed.
Think reasonable person could suggest that there is some evidence in prehospital and ED to use and it seems to me often a safer option. What do you think
Re:
I happen to not agree with Ali Raja’s summary recently for journal watch
Is Ketamine a Safe and Effective Rescue Treatment for Severely Agitated ED Patients?
Cara Adler reviewing Isbister GK. Ann Emerg Med 2016 Feb 18.
1. Cara Adler
Although ketamine seemed effective in this small study, safety data for this use are insufficient to consider it a first-line treatment.
1. Cara Adler
Researchers assessed the safety and effectiveness of ketamine for rescue sedation in a substudy of severely agitated and violent patients. In the parent study, roughly 1300 patients at two emergency departments (EDs) were managed with a standardized sedation protocol recommending 10-mg intramuscular droperidol as first-line treatment. After initial attempts at sedation failed, 49 of these patients (median age, 37; 57% men were given 4–6-mg/kg IM ketamine (median dose, 300 mg; range, 50–500 mg).
Median time to sedation after ketamine administration was 20 minutes (range, 2−500 minutes). Five patients did not achieve sedation within 2 hours, required more sedation within 1 hour, or both. Of these five patients, four had received ≤200-mg ketamine. Adverse effects occurred in three patients: vomiting (2) and transient oxygen desaturation to 90% (1). The authors conclude that ketamine “appeared effective and did not cause obvious harm.” They suggest using a dose of 4–5 mg/kg.
Comment
1. Ali S. Raja, MD, MBA, MPH, FACEP
Severely agitated patients in the ED present a danger — not only to the medical and hospital security teams caring for them, but to themselves as well — and a recent New York Times article has reignited this issue. The findings in this study demonstrate that ketamine is likely effective as a rescue agent for difficult-to-sedate patients, but we don’t have nearly enough safety data to use it as a first-line treatment, especially given the potentially dangerous combination of an agitated patient and a catecholaminergic medication. Please don’t make ketamine your go-to agent for sedation just yet; however, if you’ve tried your standard medications and feel the risks to the patient and staff outweigh the potential risks of ketamine, don’t hesitate to reach for it.
I personally would have considered other information and that the “traditional medications” have risks and limited data from RCT
Jon B. Cole, Johanna C. Moore, Paul C. Nystrom, Benjamin S. Orozco, Samuel J. Stellpflug, Rebecca L. Kornas, Brandon J. Fryza, Lila W. Steinberg, Alex O’Brien-Lambert, Peter Bache-Wiig, Kristin M. Engebretsen, Jeffrey D. Ho. A prospective study of ketamine versus haloperidol for severe prehospital agitation. Clinical Toxicology, 2016; 1 DOI: 10.1080/15563650.2016.1177652
I also thought but could be mistaken that this is discussed in an ACEP draft policy statement- can’t find it
Great points Jim.
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The article is somewhat outdated considering Droperidol has been blackboxed and unavailable for so long.
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I totally agree that Ketamine is potentially a better option. It can be given IM, and can be given in lower doses to achieve our ends. And it does not affect respiratory status. Definitely take a look at Jim’s references residents!
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1) How has reading the article changed your practice?
– I will consider giving atypical antipsychotics in my future practice, depending on the patient and the availability of the drugs.
2) What information had you believed in previously that were debunked by reading this article?
– I had thought that haldol was FDA approved in all forms, but learned that it is not approved for IV administration, even though it is sometimes given that way. I don’t think it would change my practice, but it’s interesting.
3) What new information did you learn from reading this article?
– I knew that giving “5 and 2” sped up the onset of sedation/decreased agitation, but I didn’t know that it actually decreases the incidence of EPS.
4) What are current areas of uncertainty on this topic that can be potential areas for research?
– I think ongoing research and focus on how to make the ED a safer and less frustrating place for both patients and staff (QI, process improvement) will help overall with decreasing the incidence of violence in this setting.
How has reading the article changed your practice?
recognizing the fine line in shift between defensive behavior and aggression is important. it can be tempting to ignore some of this behavior because its a pain to deal with but the potential consequences of allowing this process to foment are severe.
What information had you believed in previously that were debunked by reading this article?
Was not aware of the routine use of atypical antipsychotics in acute sedation/tranquilization (and their benefits extend into this use as well)
Atypical antipsychotics inhibit dopamine-2 and serotonin receptors and thus provide more tranquilization and less sedation. An important benefit of these atypical antipsychotics is the lower incidence of EPS from the serotonergic activity.
What new information did you learn from reading this article?
easy to dismiss organic causes in repeat psych patient but also easy to forget organic consequences – “Quickly sedating patients with methamphetamine intoxication is particularly important because so many are at risk for rhabdomyolysis, hypertensive crisis, cardiac ischemia, and cardiac dysrhythmias.
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What are current areas of uncertainty on this topic that can be potential areas for research?
are systems where patients less plugged into appropriate primary/psychiatric care more prone to violent outbreaks in the ED vs those that are not afforded the same access (with controlling factors)
1. How has reading the article changed your practice? The three phases of escalation are a useful framework to think about when working with aggressive patients and trying to prevent patients from moving to the next phase. Many of us recognize these signs already, but having a formal framework can help organize our thought process. Also, if possible, when restraining female patients I will try to have a female staff member present for medico-legal purposes per this article’s recommendation. Finally, when restraining patients I will try to restrain them on their side as fewer adverse consequences.
2. What information had you believed in previously that were debunked by reading this article? I thought eye contact helped establish a rapport with the patient, but the article recommends not engaging in eye contact with escalating patients.
3. What new information did you learn from reading this article? 50% of health care workers will be victims of physical violence during their career.
4. What are current areas of uncertainty on this topic that can be potential areas for research? The effect of metal detectors in preventing violence in the ED.
How has reading the article changed your practice?
I will consider PO antipsychotics during the early stages of escalation or when patient is agreeable as it seem to be the safer options with less side effects especially of patient with underlying psychotic disorders.
What information had you believed in previously that were debunked by reading this article?
I thought haldol was a better drug to control out of control patient but there are other options that are safer with comparative effect and less side effects.
What new information did you learn from reading this article?
The three stages of escalation patient go through. This is crucial to recognize as early intervention could prevent having to restrain patients.
What are current areas of uncertainty on this topic that can be potential areas for research?
Development of a quick screening during triage to recognize potential patient that can escalate so as to address this earlier and prevent escalation
1. This article, in combination with our discussion during conference last week has encouraged me to offer a PO option to agitated patients, both to give the patient some control over their situation and to avoid unnecessary danger to staff.
2. As a patient transporter during college, many of the patients at the community hospital where I worked were restrained. Seeing these restraints was so common, that I assumed they were innocuous. I had no idea the potential morbidity and mortality from this intervention.
3. 50% of healthcare workers will be victims of physical violence; when using 4-point restraints one arm should be restrained up and one down to prevent the pt from generating enough force to overturn the stretcher; as Alex pointed out above, didn’t know that ativan + haldol = less EPS episodes
4. This is a bit peripherally related, but over my first month in the ED I often saw staff use a “show of force” to pacify agitated patients, which seemed to only agitate them further. I’m curious if there are predictors that can help guide our show of force vs. de-escalation attempts decision to avoid physical/chemical restraints?
1. This review article affects my practice in that I am more likely to consider risperidone IM in acute psychosis (now knowing it is as effective and less sedating than haldol). More importantly, I will try to avoid the need for IM medication altogeher by offering patients PO risperidone early-on if they are becoming agitated.
2. The article did not really de-bunk any beliefs I held about the use of physical and chemical restraints. It did, however, remind me of all the non-physical, non-chemical interventions that should be tried to help de-escalate combative or aggressive patients. I think most notably, the idea of offering patient the opportunity to make choices between several options that are reasonable to the care team AND reasonably appealing (as opposed to “If you don’t calm down, we’ll have to give you medicine.”) was an important reminder for me.
3. From this review article, I learned the appropriate order in which physical restraints should be de-escalated and discontinued, and the required contents for documentation of the restrained patient. I also did not know that Ativan and Haldol could be given together in the same syringe, or that this administration hastens sedation and results in fewer episosed of EPS.
4. The review article comments that, “There is concern that physicians may be less likely to use physical restraints in seting with computarized forced functions, and instead use more pharmacological restraints… that do not require an order, or completely bypass the computerized order entry system.” As these computer systems were demonstated to decrease the amount of time patients spent in restaints, a study comparing what interventions are provided by physicians with and without such a system would be interesting.
1.) How has reading the article changed your practice?
-consideration of using atypical antipsychotics for control as some patients are redirectable initially and it might avoid need for restraints and IM meds; a small segment of patients would be willing to take meds by mouth but, again the majority of agitated patients would probably not allow for this option.
2.) What information had you believed in previously that were debunked by reading this article?
– that atypical antipsychotics are just as effective as IM haldol
3.) What new information did you learn from reading this article?
That reason why droperidol is not being used anymore, I know it was used more commonly but did not know the actual reason why this is no longer common practice.
4.) What are current areas of uncertainty on this topic that can be potential areas for research?
-ways or risk factors that providers can screen for that has been shown to cause patients to escalate their behavior, especially in patients who did not demonstrate any initial agitation because I believe these patients are the highest risk for hurting providers.
1. I like the way the article framed the spectrum of argumentative/combative/violent behavior in 3 different phases. Watching staff (I’m sure I’ve been guilty as well) disregard phase 1 (and at times accelerating the transition to phase 2) is something I’ll be more proactive about. The article is also a good reminder to not simply anchor on the psych dx and to consider a broad ddx including organic causes.
2. I have to state that I was a little naïve about the level of violence seen in the ED. The article states several alarming statistics and spending more time in the ED as a second year has made me more aware of the potential danger the job entails.
3. Didn’t know given haldo + Ativan also decreases incidence of EPS. I was also unaware of the risk of soft restraints (ie, compromise distal circulation). I had previously viewed them as almost harmless. And shout out to Victoria et al. for providing some tips if you’re ever bitten, “If bitten, do not pull away but instead push into the patient and use your other hand to close their nares.” That’s some Steven Segal stuff there!
4. I wonder what the practicality is of restraining people on their side. I don’t think I’ve seen it in the ED (usually only see the prone or supine positions which lend themselves to certain risks). Would be interesting to learn why our institution (at least from what I’ve seen in my limited experience) usually restrains people in the prone or supine position. Is it an issue of simplicity, preference, policy?