Approach to the agitated or violent patient

To see contributor disclosures related to this article, hover over this reference: ^[1]

Physicians may earn CME/MOC credit by reading information in this article to address a clinical question, then completing a brief evaluation in which they identify their question and report the impact of any information learned on their clinical practice.

AMBOSS designates this Internet point-of-care activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only credit commensurate with the extent of their participation in the activity.

For answers to questions about AMBOSS CME, including how to redeem CME/MOC credit, see “Tips and Links” at the bottom of this article.

Agitation is a common, nonspecific symptom of many medical, psychiatric, psychosocial, and substance-related conditions. Initial management should aim to ensure the safety of the patient and staff and identify and treat critical causes of agitation. Once safety measures are initiated, deescalation techniques should be prioritized to help the patient calm down, avoid progression to aggressive and/or violent behavior, and allow a full medical and psychiatric evaluation. Stabilization, treatment of critical illnesses, alleviation of distressing symptoms, prevention of complications, and maintenance of patient dignity are major priorities for care. Calming medications (e.g., sedatives, tranquilizers) and physical restraints should only be used to prevent harm to the patient or others if deescalation techniques are ineffective. Diagnostic studies may be required to evaluate for suspected underlying causes or complications. Optimal management requires familiarity with local institutional protocols and, in some cases, the involvement of a behavioral emergency response team.

• Agitation: a state of heightened arousal that can manifest in a variety of ways, from subtle increases in psychomotor activity to aggressive and/or violent behavior
  • May be caused by a psychiatric disorder, substance use, or occur as a result of a general medical condition, e.g., hypoglycemia or traumatic brain injury
  • There may also be no underlying medical reason and it may simply be a reaction to stressful or extreme circumstances.

• More than 50% of emergency care providers in the US report having experienced patient aggression and/or physical assault. ^[2][3]
• Patient risk factors for violent behavior include: ^[2]
  • Male gender
  • Substance use (including alcohol)
  • Psychiatric illness
  • Prior history of violence (especially incarceration for violent offenses) ^[4]

Epidemiological data refers to the US, unless otherwise specified.

If there is no known history of psychiatric illness or current symptoms differ from previous presentations of a known psychiatric disease, suspect a medical or substance-related cause. ^[5][6]

Medical or substance-related causes ^[5]

• History of general medical illness and/or history of recreational drug or prescription medication use
• First-time occurrence of psychiatric symptoms at > 45 years ^[5]
• Symptoms of:
  • Underlying medical disease (see “Etiology”)
  • Intoxication or withdrawal (see "Substance-related and addictive disorders" and “Classic toxidromes”)
  • Delirium (see “Confusion assessment method”)

Psychiatric causes

• History of psychiatric illness
• Current symptoms consistent with previous presentations
• Symptoms of underlying psychiatric disease: e.g., psychotic symptoms, manic symptoms, symptoms of depressive disorders or anxiety disorders

Red flags ^[5]

The following features increase the risk of a serious medical etiology of agitation:

• Features suggesting physiological instability
  • Abnormal vital signs: e.g., hyperthermia, tachycardia, hypotension, hypertension
  • Clinical features of respiratory distress or signs of increased respiratory effort
  • Obvious signs of trauma: e.g., traumatic brain injury
• Neurological features
  • Focal neurological abnormailities: e.g., anisocoria, hemiparesis, lead pipe rigidity, neuromuscular weakness, ataxia
  • Seizures
  • Cognitive impairment
  • Severe headache
• Psychiatric features: new onset of psychosis
• Other
  • Constitutional symptoms, e.g., recent history of unintended weight loss
  • Intolerance to heat

Patients with any red flag symptoms should be immediately evaluated by a clinician.

Management recommendations in this article are primarily consistent with the 2012 and 2020 American Academy of Emergency Psychiatrists (AAEP) Best Practices in the Evaluation and Treatment of Agitation (BETA) consensus statements. ^{[3][5][7][8][9]}

Maintaining objectivity

Be aware of the following when considering whether to treat agitation as a medical issue:

• Prejudices: regarding, e.g., race, class, gender, psychiatric illnesses, substance use disorders, homelessness
• Biases: e.g, the potential for anchoring bias or countertransference

Gather as much information as possible before reaching conclusions about the etiology of agitation and be aware of provider biases, prejudices, and clinical uncertainty.

Prior to intervention ^[5]

• Identify patients with signs of potential for violence.
• Ensure patient and staff safety when managing agitated patients.
• If necessary, call security staff or activate the behavioral emergency response team.
  • A multidisciplinary rapid response team that can be deployed anywhere in the hospital to provide immediate intervention in behavioral crises.
  • Usually includes a psychiatry-trained clinician and security personnel as well as members from other relevant services (e.g., social worker or pastoral support)
  • Although conventions vary, the call for this team is often "code white."

Patients with agitation may be a threat to their own safety or those of others. Call for help whenever possible.

During intervention ^[5]

• Determine the level of agitation and tailor the treatment approach accordingly.
• Identify and treat life-threatening or easily reversible causes of agitation using an ACBDE approach (see “Management of critical causes of agitation”).
• Attempt deescalation techniques, depending on patient cooperation and level of threat.
• Consider calming medications or physical restraints following local policy and laws only if staff and patient safety are threatened.
• Obtain early IV access in agitated patients, if possible.
• Anticipate the need for airway management in agitated patients.
• Minimize the use of restraints.
  • Follow safe application protocols.
  • Reevaluate orders frequently.
  • Discontinue restraints at the earliest opportunity.

Patients with agitation are often vulnerable and/or subject to neglect and abuse. Maintaining patient and provider safety while respecting patient dignity and autonomy can be very challenging and often distressing to all involved. Avoid making rushed decisions.

Following intervention ^[5]

• Closely monitor the patient for complications of:
  • Agitation
  • Pharmacotherapy
  • Physical restraints
• Continue further medical evaluation based on the suspected cause of agitation as soon as safely possible.
• Consider a psychiatry consult.
• Consider a temporary involuntary hospital admission based on an individual's risk to themselves and/or others in accordance with local laws and policies. ^[10][11][12]
• Participate in a team debriefing session if possible.

Patient and staff safety when managing agitated patients ^[2][4][7]

Follow local security protocols and call for help if patient or staff safety is under threat.

• Prioritize early assessment to prevent escalation.
• Consider early engagement of security staff and/or a behavioral emergency response team.
• Assign the patient to a secure, monitored room or location to minimize the risk to self and others.
• If possible, reduce environmental triggers, e.g., bright light and noise.
• Keep a reasonable distance until it is safe to approach the patient.
• Ensure the patient is unarmed and secure any items that might serve as weapons.
• When dealing with an armed patient, evacuate the area and consider the early involvement of law enforcement. ^[13]
• Ensure that providers have an open escape path and do not block exits.

Do not approach patients alone if there are signs of potential for violence and/or multiple risk factors for violent behavior. ^[4]

Acute stabilization measures ^[3]

Consider the following in patients with suspected medical causes of agitation and/or patients in need of sedation because they are endangering themselves or others.

IV access in agitated patients

• Obtain IV access as soon as possible if necessary for diagnostic and/or therapeutic interventions.
• In uncooperative patients, use an IM medication first to calm the patient and facilitate safe IV access (see “Pharmacotherapy”).
• Consider the following approach for patients with refractory agitation who require immediate IV access for essential interventions:
  • Use extra personnel to assist with immobilizing the patient.
  • Immobilize the joints immediately proximal and distal to the point of access.
  • Attempt IV placement only once the patient is securely immobilized.
  • Once the IV line is in place, immediately administer an IV calming medication and secure the IV line.

Attempt IM sedation prior to IV placement in uncooperative patients. Call for help if agitation is refractory and urgent IV access is still required. Do not attempt IV placement alone.

Airway management in agitated patients

• Airway compromise may be due to the underlying cause of agitation or occur as a result of sedation.
• Be prepared for airway management and ensure appropriate equipment is available and functioning.
• Consider a definitive airway in patients with respiratory failure, airway compromise, or heavy sedation requirements.
• For endotracheal intubation of a patient in whom optimal preoxygenation is not possible, consider delayed-sequence intubation. ^[14]

Early identification of potential for violence ^{[2][3][15][16]}

• Verbal signs
  • Expression of frustration or anger
  • Loud, threatening, or insulting speech
  • Repetitive mumbling
• Behavioral signs
  • Suspicious or angry affect
  • Staring or avoidance of eye contact
  • Pacing and/or restlessness
  • Threatening gestures
  • Signs of anxiety or agitation
• Other patient factors
  • Evidence of drug or alcohol use
  • Presence of a weapon

Rapid risk assessment ^[2][3][5]

• Call an attending as early as possible and always follow hospital protocol.
• Approach each patient based on their individual risk assessment.
• The following classification is loosely based on the Behavioral Activity Rating Scale (BARS).

Frequently reassess the level of agitation and response to interventions.

These include etiologies that are rapidly reversible and/or pose an imminent threat to life.

Immediate assessment ^[3][5][6]

• Check vital signs, SpO₂, and POC glucose.
• For cooperative patients, obtain a brief history and conduct a focused medical examination.
• For uncooperative patients, follow the ABCDE approach.

If an immediately life-threatening cause is strongly suspected in an uncooperative patient not responding to deescalation techniques, consider calming medication and, if necessary, physical restraint to enable further evaluation and treatment. ^[5]

Subsequent medical evaluation ^[5][6]

Obtain the following as soon as safely possible:

• Full patient and corroborative history
• Complete physical examination, including mental status examination
• Focused diagnostic testing based on the suspected underlying cause of agitation
• Consider formal psychiatric evaluation based on findings, if the patient is medically stable.

Patients with a known psychiatric disorder, with no concerning history or physical examination findings, and whose symptoms are consistent with those of their preexisting psychiatric disease are unlikely to require further diagnostic workup. ^[3][5][6]

Diagnostic testing ^[3]

Basic studies

• CBC: to evaluate for anemia, leukocytosis, and/or other hematological abnormalities
• BMP: to evaluate for electrolyte imbalances, acidosis, or renal dysfunction
• Blood gases: to evaluate for hypercarbia, hypoxia, and acid-base imbalances
• Blood cultures: if infection is suspected
• Urine analysis: including urine toxicology screen

Routine laboratory studies are not recommended. Diagnostic testing should be tailored to each patient based on clinical features, history, and physical examination findings. ^[22]

Additional studies

• Further diagnostics studies may be indicated to evaluate: ^[2][3][5]
  • The underlying etiology
  • Complications resulting from agitation, such as:
    • Rhabdomyolysis
    • Hypovolemia
    • Skeletal trauma
    • Metabolic acidosis
    • Respiratory compromise due to efforts to resist restraints.
• See also “Delirium workup” for a symptom-based approach.

Consider a more extensive diagnostic workup in patients with: atypical presentations of known psychiatric illnesses, age > 45 years without prior psychiatric illness, or immune deficiency. ^[3]

Noncoercive verbal and nonverbal techniques are used to help the patient calm down and cooperate with medical evaluation and treatment. This approach can relieve the symptoms of agitation, decreasing the need for coercive measures and potential for violence and associated harm to patients and staff. ^[2][7]

Approach ^[7]

• Attempt deescalation in patients who are potentially cooperative and not actively violent.
• Designate a single care provider to verbally interact with the patient in order to avoid confusing the patient and creating a perceived threat.
• Approach the patient in a quiet and safe physical environment.
• Ensure staff members are close by in case help is needed.

Deescalation techniques ^[7]

Involuntary medications or physical restraint should only be used if a serious attempt at deescalation has failed to ensure the safety of the patient and staff. ^[7]

Consider calming medication if there is an insufficient response to nonpharmacological measures, with the overarching goal of relieving distress, treating underlying conditions, and permitting a safe medical and psychiatric evaluation.

Approach

• Ensure the ethical use of any prescribed calming medication.
• Choose agent, route, and dosage based on:
  • Most likely etiology (see “Medication for agitation based on suspected cause”)
  • Drug properties and risks
  • Patient preference (if possible)
• Monitor all patients closely for complications and adverse effects.

Ethical use ^{[3][9][23][24]}

• Consider whether the medication is helpful for:
  • Treatment of the condition itself
  • Alleviation of symptoms
  • Prevention of complications
• Counsel patients about the risks and benefits of pharmacotherapy whenever possible.
• Avoid using medication to restrain freedom and control behavior unless there is:
  • A clear danger to the patient or others
  • A valid court order for treatment
• Respect the patient's right to refuse medication in all other circumstances.
• When possible, involve the patient in the choice of agent and route.

Do not administer medication involuntarily unless it is to prevent imminent self-harm or harm to others, or it is mandated by a valid court order. ^[5][24]

Safety ^[3][23][25]

• Dosage
  • Use the lowest dose needed to calm the patient and avoid oversedation.
  • Reduce dosages as needed, e.g., for older age, impaired drug metabolism, comorbidities.
  • Whenever possible, use oral medication: e.g., orally disintegrating tablets (ODTs), sublingual tablets.
  • Parenteral administration may be necessary for uncooperative patients.
    • IM medication: Time to onset and maximum effect may be variable due to factors affecting absorption.
    • IV medication: can provide more rapid and reliable sedation than IM or oral medication ^[23]
• Monitor all patients for:
  • Oversedation
  • Hemodynamic instability
  • Respiratory compromise
• Prevent complications
  • Avoid drug accumulation and overdose using careful titration.
  • Allow time for each dose to take effect before repeat dosing or combination therapy.
  • Be prepared for airway management in agitated patients and consider prophylactic airway protection in those requiring heavy sedation.

Calming medications of all classes can potentially cause oversedation, hemodynamic instability, and respiratory compromise, especially if used in combination.

Repeated dosing of intramuscular medication can lead to overdose due to less predictable absorption and drug accumulation. Obtain IV access in the agitated patient as soon as safely possible.

Choice of drug class

For severe agitation, consider combining IM typical antipsychotics (e.g., haloperidol) with short-acting IV benzodiazepines (e.g., midazolam) under careful observation. ^[3]

The following suggested agents and dosages are consistent with the 2012 and 2020 AAEP best practices and expert reviews in the literature. Follow local hospital policy whenever available, as dosage recommendations vary widely. ^{[2][3][8][29]}

General principles ^{[3][8][29][30][31]}

• Benzodiazepines are preferred for off-label treatment of agitation of unknown etiology and agitation due to alcohol withdrawal, benzodiazepine withdrawal, and stimulant intoxication.
• Consider dose reduction for at-risk patients: e.g., older age, impaired drug metabolism, cardiac disease, high risk of hypotension.
• Consult a clinical pharmacist if uncertain about the optimal agent and dosage.
• Midazolam has a faster onset and time to maximum concentration (T_max), but a shorter duration of action compared to lorazepam.
• IV benzodiazepines are typically effective within a few minutes.
• PO and IM benzodiazepines have slower and more variable kinetics.
• Duration of effect can vary widely depending on patient factors and agitation etiology and severity.

Beware of drug accumulation with frequent dosing; respiratory suppression can occur if benzodiazepines are prescribed at high doses or when used in patients exposed to other CNS depressants (e.g., alcohol). ^[8][29]

Lorazepam ^{[3][8][29][30][31]}

• Clinical applications: treatment of acute undifferentiated agitation and/or alcohol withdrawal; adjunctive treatment of psychosis
• Mild agitation
  • Adults: 1–2 mg PO once; may repeat after 2 hours
  • Older adults: 0.25–0.5 mg PO; may repeat after 2 hours
• Moderate–severe agitation
  • Adults: 1–2 mg IM/IV once; may repeat after 2 hours
  • Older adults: 0.25–0.5 mg IM/IV once; may repeat after 2 hours
• Maximum dose
  • Adults: 10–12 mg/day
  • Older adults: 2 mg/day

Midazolam ^{[3][8][29][30][31]}

• Clinical applications: treatment of acute undifferentiated agitation, alcohol withdrawal, and/or stimulant intoxication; adjunctive treatment of psychosis
• Moderate agitation
  • 2.5–5 mg IM once; may repeat after 5–10 minutes
  • OR 1–2.5 mg IV once; may repeat after 3–5 minutes
• Severe agitation
  • 10 mg IM once; may repeat after 5–10 minutes
  • OR 2–5 mg IV once; may repeat after 3–5 minutes
• Maximum dose
  • Not clearly defined
  • Respiratory support may be required at doses > 0.15 mg/kg.
• Specific considerations: Use in older adults is not well established and parenteral routes may be harmful in these patients. ^[32]

Diazepam ^[8][18][29]

• Clinical applications: treatment of stimulant intoxication, acute undifferentiated agitation, and alcohol withdrawal; adjunctive treatment of psychosis
• Dosage: situationally dependent
  • Stimulant intoxication: 5–10 mg IV every 3–5 minutes until the patient is sedated (up to 1 mg/kg may be required) ^[33][34]
  • Alcohol withdrawal: See “Pharmacotherapy for alcohol withdrawal.”
  • Undifferentiated agitation: 5–10 mg PO/IM once ^[8][33]
• Specific considerations: Respiratory depression may result from drug accumulation with repetitive dosing (elimination half-life is > 40 hours). ^[29]

The following suggested agents and dosages are consistent with the 2012 and 2020 AAEP best practices and expert reviews in the literature. Follow local hospital policy whenever available as dosage recommendations vary widely. ^{[2][3][8][29]}

General principles

• Consider dose reduction for at-risk patients: e.g., older age, impaired drug metabolism, cardiac disease, high risk of hypotension.
• Consult a clinical pharmacist if uncertain about the optimal agent and dosage.
• IM antipsychotics and are usually effective within an hour.
• Compared to IM antipsychotics, PO antipsychotics have a slightly slower onset, but a much slower T_max.
• IV antipsychotics have the fastest effect but may be associated with a higher risk of adverse effects.
• The duration of action of antipsychotics in agitated patients is unclear and may be highly variable.

Anticipate common adverse effects of all antipsychotics, such as extrapyramidal symptoms (e.g., akathisia, acute dystonia), QTc prolongation, and orthostatic hypotension.

Beware of drug accumulation with frequent dosing. Avoid repeat dosing before the expected time to effect of each drug.

Second-generation antipsychotics ^{[2][3][8][30]}

Second-generation antipsychotics are preferred over first-generation antipsychotics for the treatment of agitation due to delirium and psychosis.

Olanzapine

• Older adults: 2.5–5 mg PO/IM once; may repeat after 2 hours
• Adults with mild agitation: 5 mg PO/SL once; may repeat after 2 hours
• Adults with moderate agitation: 5–10 mg PO/SL once; may repeat after 2 hours
• Adults with severe agitation: 10 mg IM once; may repeat after 2 hours
• Maximum dose
  • PO: 20 mg/day
  • IM: 30 mg/day
• Specific considerations
  • Avoid within 1 hour of benzodiazepine intake, if possible. ^[2][3]
  • Most significant adverse effects
    • Hypotension
    • Anticholinergic effects
    • QTc prolongation
    • Extrapyramidal symptoms

Risperidone

• Mild agitation: 1 mg PO/SL once; may repeat every 4–6 hours
• Moderate agitation: 2 mg PO/SL once; may repeat every 4–6 hours
• Maximum dose: not clearly established ^[8]
  • Generally should not exceed > 6–10 mg/day
  • Older adults: 3 mg/day
• Specific considerations
  • Often used for psychotic symptoms due to schizophrenia or mania in bipolar disorder
  • Most significant adverse effects
    • Orthostatic hypotension
    • Extrapyramidal symptoms

Ziprasidone ^[35][36]

• Severe agitation: 10–20 mg IM once; may repeat after 2–4 hours
• Maximum dose: 40 mg/day
• Specific considerations
  • Avoid in patients with:
    • Cardiac disease
    • QTc prolongation or exposure to other drugs that cause QTc prolongation
  • Most significant adverse effect: QTc prolongation ^[3]

First-generation antipsychotics ^{[2][3][8][30]}

• Preferred as first-line treatment of agitation caused by a CNS depressant (e.g., alcohol)
• Can be considered as a first-line antipsychotic in combination with a benzodiazepine for treatment of very severe or refractory agitation
• Avoid in patients with:
  • Cardiac disease
  • QTc prolongation and/or exposure to drugs that cause QTc prolongation
  • High risk of seizures
• Significant adverse effects
  • Orthostatic hypotension
  • Extrapyramidal symptoms
  • QTc prolongation and torsade de pointes
• Obtain an ECG before administration or as soon as possible. ^[2]

Haloperidol

• Older adults: 0.25–0.5 mg PO/IM once; may repeat after 0.5–4 hours ^[3][8]
• Adults with mild agitation: 2.5 mg PO once; may repeat after 0.5–4 hours ^[3][8]
• Adults with moderate agitation
  • 5 mg PO once; may repeat after 0.5–4 hours
  • OR 2.5 mg IM once; may repeat every ≥ 15 minutes until adequate effect, then every 0.5–6 hours
• Adults with severe agitation
  • 5 mg IM once; may repeat every ≥ 15 minutes until adequate effect, then every 0.5–6 hours
• Extreme situations (controversial): 2–5 mg IV once; consider repeating in 0.5–6 hours ^{[8][37][38][39]}
• Maximum dose ^[8]
  • PO/IM: 20–30 mg/day
  • IV: 10 mg/day
  • Older adults: 3 mg/day
• Specific considerations
  • Keep dosage to the minimum required.
  • If IV therapy is needed, ensure continuous cardiac monitoring during and after administration.
  • Consider adding a drug to prevent extrapyramidal symptoms, e.g., benztropine, diphenhydramine, lorazepam, or promethazine.

Haloperidol administered intravenously (IV) may be associated with high rates of adverse effects (e.g., extrapyramidal symptoms, QTc prolongation, torsades de pointes) and is likely best reserved for extreme situations. Alternate routes (PO or IM) are generally considered safer. ^{[8][37][38][39]}

Droperidol ^[40][41]

• Severe agitation: 5 mg IM or IV once in combination with midazolam ^[3]
• Maximum dose: 10–20 mg/day
• Specific considerations
  • Faster control of agitation, shorter duration of action, and lower incidence of extrapyramidal symptoms compared to haloperidol ^[2]
  • There is currently an FDA black box warning regarding QTc prolongation, but this is controversial. ^[8]

The following suggested agents and dosages are consistent with the 2012 and 2020 AAEP best practices and expert reviews in the literature. Follow local hospital policy whenever available, as dosage recommendations vary widely. ^{[2][3][8][29]}

Ketamine ^{[2][3][22][26][28]}

Consider dose reduction for at-risk patients: e.g., older age, impaired drug metabolism, cardiac disease, high risk of hypotension. Consult a clinical pharmacist if uncertain about the optimal agent and dosage.

• Clinical application: rapid short-term control of severe refractory agitation and/or violence ^[2][42][43]
• Dosage
  • 4–5 mg/kg IM once; may repeat once at 2–3 mg/kg IM if no initial effect after 10–25 minutes
  • OR 1–2 mg/kg IV once; if no initial effect after 5–10 minutes, may repeat 0.5–1 mg/kg IV once
• Pharmacokinetics
  • Ketamine is effective within minutes.
  • IM ketamine has a comparable onset, but slower T_max than IV ketamine. ^[44]
  • The duration of action, when used for agitation, is ∼ 20 minutes. ^[2][42][43]
• Specific considerations
  • Avoid in patients with:
    • Advanced age
    • Known or suspected schizophrenia
    • Risk of morbidity exacerbated by ketamine-induced increases in blood pressure
  • Significant adverse effects
    • Hypertension
    • Tachycardia
    • Emesis
    • Laryngospasm
    • Respiratory failure ^[45]
  • To reduce the risk of respiratory depression, administer IV bolus doses slowly over > 30–60 seconds. ^[26]

The following recommendations are consistent with the 2008 Joint Commission standards on restraints and seclusion (and their 2020 revision), the 2008 Centers for Medicare & Medicaid Services (CMS) restraint and seclusion guidelines, the 2012 AAEP BETA consensus statement, and the 2020 American College of Emergency Physicians (ACEP) policy statement on the use of restraints. ^{[9][24][46][47][48]}

Definitions ^[9]

• Restraints (manual, physical, or mechanical): methods, materials, devices, or equipment that impair or limit free movement of a patient's extremities, body, or head
• Seclusion: measures taken to confine a patient involuntarily to a location from which physical barriers prevent them from leaving, specifically for the purpose of protecting them or others from violence and harm

Ethical use ^{[3][24][46][47][47][49]}

• Severely limit the use of seclusion and restraints, as they can cause significant harm. ^[9]
  • Use only to prevent imminent harm to the patient or others due to agitation. ^[2]
  • Consider only if less coercive measures (i.e., deescalation techniques or pharmacotherapy) have failed.
• Apply the least restrictive method possible.
• Maximize patient privacy and dignity during restraint application.
• Frequently reassess the indications for ongoing restraint or seclusion.
• Discontinue as soon as possible, i.e., when the patient has regained self-control and is no longer a threat to themselves or others. ^[24]

Physical restraints can cause significant harm, including long-term psychological trauma and death. They should only be considered to enable crucial diagnostics and treatment and/or prevent harm to the patient and others. They should never be used for punishment, discipline, retaliation, or provider convenience! ^[24][50]

Use calming medications before or immediately after applying restraints to reduce the risk of injury, complications from the patient's efforts to resist restraints, and the negative psychological consequences of restraint and coercion. ^[3][51]

Safe application of restraints ^[2][3]

Preparation

• At least 5 trained providers should work as a team.
  • 4 team members to immobilize major joints, i.e., the elbows and knees.
  • 1 team member to ensure immobility of the head and patency of the airway (preferably the team lead)
• Select a team leader who gives orders and communicates with the patient.
• Use appropriate personal protective equipment, especially if the patient is spitting or biting.
• Brief the team about the situation before entering together.
• Choose appropriate restraints.
  • Leather restraints are preferred for actively violent patients.
  • Soft restraints may be considered for partially cooperative, nonviolent patients.

If possible, the treating clinician should avoid actively applying the restraints in order to preserve the clinician-patient relationship. ^[2]

Approaching the patient

• Ensure other team members are visible to the patient.
• Maintain a calm, nonthreatening demeanor.
• Inform the patient of your intent, explain the necessity, and ask for cooperation.
• If the patient does not cooperate, firmly explain the procedure and follow local hospital restraint protocol.

Procedure

• Place the patient in a supine position, with the head of the bed elevated.
• Assist other team members in immobilizing extremities as needed while restraints are applied.
• Apply restraints to all four extremities and secure them to the bed frame.
  • Restrain one arm at head level with the elbow flexed, the other arm below the waist with the elbow extended.
  • Tie each leg to the contralateral side of the bed.
• Consider further restraint as necessary, e.g.:
  • Applying an oxygen face mask can help prevent biting and spitting. ^[3]
  • Chest restraints can be applied loosely to help immobilize the trunk.

Do not restrain patients in the prone position, as this can result in asphyxiation and death. If chest restraints are used, ensure that they do not impede chest expansion and adequate ventilation. ^[2]

Monitoring and ongoing care ^[2]

• Place the patient under continuous observation.
• Frequently check vital signs and respiratory status, mental and cognitive status, level of agitation, and possible complications of efforts to resist restraints.
• Consider continuous pulse oximetry and cardiac monitoring, especially if factors associated with increased risk for sudden death under restraints are present, e.g.: ^[52][53][54]
  • CNS stimulant intoxication
  • Chronic medical disease
  • Obesity
  • Heavy sedation
• Check and reposition the patient frequently to prevent pressure sores, circulatory obstruction, or nerve entrapment.
• Ensure adequate hydration and nutrition and address patient’s comfort and toilet needs.

The level of monitoring should be decided based on an individual risk assessment in accordance with local hospital protocols and regional laws.

Legal considerations ^[24][46]

• Physical restraints are medical interventions that require a formal order from the treating clinician.
• Clearly document the following: ^[2][46]
  • Full medical and behavioral evaluation by an authorized clinician
  • Previous unsuccessful attempts to deescalate the situation
  • Indication for restraints: e.g., suspected medical condition, violent attack
  • Method(s) of restraint used
• If ongoing restraints are necessary, orders need to be revised regularly.
  • Follow the frequency required by regional law and local hospital policy.
  • The 2008 Joint Commission standards recommend the following minimum intervals, unless local and regional laws are more restrictive: ^[46]
    • Care providers should reevaluate the need for ongoing restraints at least every 4 hours for adults.
    • The clinician with the most responsibility for the patient should repeat the full medical and behavioral evaluation at least every 24 hours.

Always follow regional laws and local hospital protocol. Hospitals are obligated to have specific policies on restraint and seclusion that must be in accordance with regional law, including regulating authority to order restraints, patient monitoring, and circumstances that allow the discontinuation of restraints.

• Definition: a potentially life-threatening, undifferentiated syndrome of disorientation, agitation, and aggressive behavior that requires immediate treatment because of the high risk of harm to patients and providers ^{[55][56][57][58]}
• Cause of agitation: may be acutely life-threatening, e.g., stimulant intoxication, alcohol withdrawal, hypoglycemia, intracranial hemorrhage ^[55]
• Clinical features ^[55]
  • Delirium: e.g., altered mental status, disorientation, disorganized thought
  • Agitation: e.g., severe psychomotor agitation, combativeness, threats, violence
  • Hyperadrenergic state: e.g., tachycardia, hypertension
• Management is similar to standard management of violent patients with an emphasis on the following: ^[55]
  • Provide care with a multidisciplinary team led by a qualified specialist. ^[55]
  • Ensure patient and staff safety when managing agitated patients.
  • Attempt deescalation techniques when possible.
  • Strongly consider parenteral calming medications. ^[55]
    • Examples: IM ketamine, IM midazolam, IM droperidol, IM olanzapine ^[55]
    • For detailed dosages, see “Dissociative anesthetics for agitation,” “Benzodiazepines for agitation,” and “Antipsychotics for agitation.”
  • Do not apply physical restraints without calming medications. ^[55]
  • Manage critical causes of agitation.

• One-Minute Telegram 33-2021-1/3: Does ketamine provide faster sedation in severely agitated patients than haloperidol/diazepam?

Interested in the newest medical research, distilled down to just one minute? Sign up for the One-Minute Telegram in “Tips and links” below.