& Restraints/Emergency Detention Guidelines
3. Recent substance (alcohol and drug) use 5. Recent trauma or illness (esp. fever, infection)
1. Contact or notify law enforcement

1. Ensure scene safety. Leave the scene if patient is or becomes violent.
2. Assess and support ABCs.
3. Attempt to calm the patient
4. Assess vital signs minimally every 10 min.; every 3-5 minutes if deemed unstable.

1. Consider checking blood sugar levels. If hypoglycemic, follow hypoglycemia procedures.
2. Consider restraints if indicated and necessary as noted below.

1. Establish an IV/IO TKO. (If condition warrants and is safe for IV/IO access)
2. If hypoglycemic, follow hypoglycemia procedures.
Combative or violent patients: (Defined as a threat to themselves, you, or the public)
1. Consult with medical control with sedation of combative or violent patients.
2. Consider B52 Cocktail. (50 mg Benadryl, 5mg Haldol, 2mg Ativan) IV/IO/IM
3. Consider 2mg Versed IV/IO or IM titrated to patient response up to 5 mg
A. Respiratory depression and hypotension may occur, assess and support ABC’s 4. Consider 2.5 – 5 mg of Valium IV/IO or IM titrated to patient response up to 15 mg A. Respiratory depression and hypotension may occur, assess and support ABC’s 5. Consider 1 – 2 mg of Ativan IV/IO or IM titrated to patient response up to 8 mg (May mix with A. Respiratory depression and hypotension may occur, assess and support ABC’s 6. Consider 5mg of Haldol IV/IO or IM, titrated to patient response up to 10 mg (May mix with Ativan) A. Respiratory depression may occur, assess and support ABC’s Anxious patients:
1. Consider 1 – 2 mg Ativan IV/IO or IM titrated to patient response up to 8 mg
A. Respiratory depression and hypotension may occur, assess and support ABC’s 2. Consider 2.5 – 5 mg Valium IV/IO or IM titrated to patient response up to 15 mg A. Respiratory depression and hypotension may occur, assess and support ABC’s 3. Contact medical control for further orders.
1. Orders for pediatric sedation must come from medical control.
Patient Restraints Guideline

Patients have the right to refuse treatment and/or transport if they are of legal age and competent.
Competence is defined as the capacity or ability to understand the nature and effects of one’s acts or
decisions. A person is considered to be competent until proven otherwise. There are situations,
however, in which the interests of the general public outweigh an individual’s right to liberty:
1. The individual is threatening self-harm or suicide. 2. The individual presents a threat to the community because of a contagious disease or other 3. The individual presents a specific threat to innocent third parties. Certain medical, traumatic and psychological conditions can cause incompetence and behavior
that interferes with the ability of EMS personnel to care for the patient, or that threatens the
physical well being and safety of the patient or others. These conditions include, but are not
limited to: drugs, metabolic disturbances, central nervous system injury or insult, infections,
hypo/hypertension, hypo/hyperthermia, hypoxia, psychological disorders, poisons and toxins.
Verbal threats are a legitimate reason for restraint. The following is a guideline for the use of
restraints in the prehospital care setting. It is not intended to dictate police action that may be
necessary to subdue someone.

1. Behavior or threats that create or imply a danger to the patient or others
2. Safe and controlled access for medical procedures
3. Change in behavior that results from improvement or deterioration of patient condition, i.e.
4. Involuntary evaluation or treatment of incompetent combative patients
1. Be aware of items at the scene or medical equipment that may become a weapon.
2. Assure that the scene is safe before approaching the patient.
3. Patients that are actively seizing should not be restrained.
4. The patient should be restrained in the prone position only as a last resort and only with continuous
monitoring. This position may interfere with the patient’s ability to breathe. 5. Restraining a patient’s hands and feet together behind the patient (hog-tying) is not allowed.
1. Make every attempt not to aggravate or worsen pre-existing injuries or medical conditions.
2. Attempt first to control the patient with verbal counseling.
3. The least restrictive means of control should be employed.
4. Only “reasonable force” may be used when applying physical control. This is generally defined as
the use of force equal to, or minimally greater than, the amount of force being exerted by the resisting patient. 5. Restraints should not interfere with the assessment or treatment of the patient’s ABCs. 6. The decision to restrain a patient should usually be made prior to transport. 7. Do not remove restraints once applied unless the patient seizes. If circulation becomes compromised, the benefit of removing the restraints must be weighed against crew safety. 8. EMS personnel do not apply handcuffs or hard plastic ties (flex cuffs), but if already in place and circulation is adequate, may be left on. Any patient with handcuffs on, or in the custody of law enforcement, appropriate law enforcement personnel must accompany patient in ambulance or immediately accessible to remove cuffs if necessary. The handcuffs must be double locked to prevent inadvertent tightening, and should allow one finger to fit between the handcuff and the wrist. 9. Restraints should be individualized and afford as much dignity to the patient as the situation allows. Implemented: 01/07 Attempt to accommodate patient comfort or special needs whenever possible. 10. Ensure that enough help is available to insure patient and provider safety during the restraint process. Optimally, five people should be available to apply the four point restraint (one for each limb and one for restraint application). Communicate the restraint plan to all help. 11. Assure that the patient’s clothing and personal belongings have been searched for weapons prior to 12. An emergency transport hold must be obtained and completed whenever a patient is transported against their will for the above-mentioned reasons.
1. For combative behavior that is compromising the ability to provide patient care, follow above sedation
guidelines or consult with medical control for sedation medication orders.
1. EMS personnel should attempt to notify and coordinate with parents when restraining children, if
time permits and the situation is appropriate.
1. Pregnant women should be restrained in a semi-reclining or left lateral recumbent position.
1. An emergency existed
2. The need for treatment was explained to the patient (regardless of competence)
3. The patient refused treatment or was unable to consent to treatment
4. Evidence of the patient’s incompetence to refuse treatment
5. Failures of less restrictive methods of control (such as verbal counsel)
6. The restraints were used for the safety of the patient or others
7. The reasons for restraint were explained to the patient (regardless of competence)
8. The type/method of restraint used and which limbs were restrained
9. Injuries that occur during the restraint procedure
10. Which agency placed the restraints
11. Continuously assess CMS (distal to the restraints) and the patient’s ability to breathe
The use of SpO2 monitoring may be useful in assessing distal circulation, but does not take the place of CMS checks. Law Enforcement Officials should be involved, if available, when restraining patients. Emergency Detention & Protection Guideline

Wisconsin Statutes 51.15 (Emergency detention), 55.05 (Protective services), and 55.06 (Protective
placement) allows for the involuntary detention of a patient by a law enforcement officer, for the
transport of that patient to a medical facility or to protect that patient or others from imminent harm.
A competent person of legal age has the right to both refuse and consent to medical assessment,
treatment, and transportation. However, if there is reason to believe that the patient is mentally ill*,
developmentally disabled (suffering from the infirmities of aging or other like incapacities, and is so,
totally incapable of providing for his or her own care or custody, as to create a substantial risk of serious
harm to oneself or others), chemically dependent or intoxicated, then a law enforcement officer may take
the patient into custody and transport him/her (or order him/her to be transported) to a medical facility
for treatment.
1. Every time a patient is transported against his/her will for the above mentioned reasons, a Statement
of Emergency Detention form must be completed. Law enforcement officials have this form. 2. If, after assessment, the patient is refusing treatment and transport and, in the judgment of the EMS crew, the patient requires further medical attention, but is incompetent and therefore incapable of giving informed consent or making an informed refusal, a Statement of Emergency Detention should be obtained from and completed by law enforcement personnel. The patient may then be transported against his/her will to an appropriate medical facility. 3. One copy of the form must be left with the receiving hospital. 4. The law enforcement officer must accompany the patient in the ambulance or follow the ambulance
1. *Mentally ill includes those patients under the influence of their disease (eg: stroke, diabetes,
Alzheimer’s), and those under the influence of their injury (eg: head injury). 2. A law enforcement officer means any person who, by virtue of the person’s office or public employment, is vested by law with a duty to maintain public order or to make arrests for crimes, while acting within the scope of the person’s authority. Emergency medical personnel are not considered law enforcement personnel for the purposes of this statute. 3. An emergency detention order authorizes the transport of an incompetent person to a medical facility for further evaluation, not to exceed 72 hours, exclusive of Saturdays, Sundays, and holidays. It does not automatically commit the patient to a 72-hour hold.

Source: http://www.rfaas.org/2010%20Organizational%20Book/Section%205/Behavioral%20Emergencies.pdf

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