Rural Emergency Room Simulation Teaching and Education Resource

This page was originally published in February 2016, but has been updated July 2017.

This page covers managing the violent patient in the ER.
Although ideally we would never like to restrain a patient, it is often in the sake of safety for the patient and safety for staff.
Physical restraints should be used for as short a time as possible.
Using 'chemical restraints' ie medications, can shorten the time for physical restraints.  Sedation should be given as soon as possible, even during the physical restraint process.

Summary for restraining a patient:
1. Collect your team (6 staff) and designate exact roles. 2 people, one for each arm, 1 to lay across the thighs, 1 person to hold the head and ideally place an oxygen mask over the mouth, 1 person to attach the restraints, 1 person to administer medications.
2. Ideally attach your restraints under and to the stretcher (not bed rails) before you restrain the patient.
2. Give meds IM early and through clothing if necessary.
3. If using the Pinel system, if you have enough team members restrain the torso first. Otherwise restrain the arms first. With the Pinel 'shoulder' restraints, there is usually no need to having one arm over the head. (see video below)
4. ALWAYS elevate the head of the bed after.
5. Apply an oxygen saturation monitor with an alarm and continuously monitor the patient.
6. Remember, if using Midazolam (or other benzo) and you get into respiratory problems, you can reverse it with Flumazenil.

Below is the Power Point on managing the violent patient in the Emergency Department. Originally presented in February 2016, this has been updated in July 2017.

Managing The Violent Patient.pptx Managing The Violent Patient.pptx
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Below is a link to a great talk by Dr. Reuben Stayer from New York on managing the agitated patient in the ER.
Click HERE

Another good video is by Dr. Gary Mark on how to properly restrain a patient on a stretcher when using single piece restraints.  Click on the link below. You will need VLC media player to view.
Or you can go via this link HERE

Gary Marks and restraining a Pt.xspf Gary Marks and restraining a Pt.xspf
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PINEL Restraint system:
Below are links to videos showing how to use the Pinel restraint system which we use in our hospital.
The first video is the basics of the Pinel system.
The second video shows how to restrain an aggressive patient. You only need to watch the first 6 1/2 minutes. The remainder is about geriatric patients.

Lastly, below is a YouTube video of a violent patient in the ER being 'restrained'.
Two points. First, it is advisable to restrain any overdose patient BEFORE you give them Naloxone.
Second, unless you like having a rodeo in your ER,there are probably better ways to restrain patients than are demonstrated in this video!

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