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NAEMSP releases position statement on agitated patients

The statement addresses assessment, restraint, use of sedatives such as ketamine and law enforcement involvement when caring for an agitated patient

By Laura French

OVERLAND, Kan. — The National Association of EMS Physicians (NAEMSP) released a joint position statement with the National Association of State EMS Officials (NASEMSO), National EMS Management Association (NEMSMA), National Association of Emergency Medical Technicians (NAEMT) and American Paramedic Association (APA) on the assessment, treatment and restraint of agitated patients.

The position statement replaces the NAEMSP’s previous statement on patient restraint published in 2002, which was last updated in 2017. The new joint statement includes positions on the assessment and care of agitated patients, the use of sedatives such as ketamine, the restraint of agitated patients, scene safety and caring for agitated patients restrained by or in the custody of law enforcement.

“When such encounters occur, patients, the public, and all emergency responders are at risk for injury. Furthermore, excited delirium is associated with continued patient agitation or struggling, with or without physical restraint, and is associated with hyperthermia, hyperkalemia, rhabdomyolysis, and cardiac arrest,” the statement reads. “In these severely impaired patients, rapid pharmacological management/sedation may prevent these adverse and life-threatening conditions and maximize patient safety.”

The NAEMSP states that the primary goal in any encounter with an agitated, combative or violent patient is to protect the patient from injuring themselves, while also protecting the public and first responders from injury. The statement recommends that all EMS agencies develop specific protocols for dealing with agitated individuals, which can include input from EMS system administrators and providers, legal counsel, community members and local law enforcement.

EMS providers should quickly assess the situation with the resources and information available to them, and work to identify and manage clinical conditions that may be causing agitation, according to the statement. The treatment of many of the conditions that cause agitation may help to decrease the agitation, and providers should use an agitation score such as the Richmond Agitation Sedation Scale as part of their assessment, according to the NAEMSP.

Agitated patients who lack decision-making capacity are assessed and treated with implied consent, and their dignity should be maintained to the extent possible, the statement says. Providers should aim to use the least restrictive method of restraint necessary to prevent injury to the patient, public and first responders, and “the use of appropriate de-escalation techniques should take precedence over physical restraint or pharmacologic management whenever possible.” the statement reads.

The statement details when it is appropriate to physically restrain an agitated patient, what to consider when choosing to apply a restraint technique and techniques providers should be prohibited from using, such as tying a patients hands or feet together behind their back or restraining them in a way that would compromise their airway. The statement notes that law enforcement and EMS restraint techniques differ and that EMS providers should work cooperatively with law enforcement while continuing to assess and care for a patient who has been restrained by or is in the custody of law enforcement when it is safe to do so.

“At all times, the EMS practitioner must act as an advocate for the safety, medical monitoring, and clinical care of the patent,” the statement reads.

Pharmacologic management of agitation with agents such as ketamine, benzodiazepine (midazolam) or butyrophenone (droperidol) is an effective method of preventing patient self-injury, the NAEMSP states. The statement adds that the use of neuromuscular blocking agents to paralyze or restrain a patient is not acceptable but that such agents can be used to treat an underlying medical or traumatic condition. Agitated patients who are administered medications to manage agitation should be continually monitored and treated, and should always be transported to the hospital for further evaluation and treatment, according to the NAEMSP.

Law enforcement officers, when available, should always be involved in cases in which a patient poses a threat to themselves, the public or first responders, the NAEMSP says in the statement. EMS providers who are in danger of harm should retreat to a safe location until law enforcement arrive, the statement adds.

“If there is no safe option for retreat, EMS practitioners who are being physically attacked may defend themselves as permitted by local law,” the NAEMSP states.

Read the full statement below: