In the course of managing patients in an acute care setting, we sometimes find it necessary to restrain the violent or uncooperative patient. Approximately 50% of human service providers are victims of violence (1). Twenty-five percent of adult emergency departments restrain at least one patient per day (2). There are limited available data on use of restraints in children in the emergency department, leaving the practitioner only generalizations from the adult literature. In the absence of psychiatric illness, intoxication, or organic brain syndromes, the most common indication is the uncooperative child requiring an emergency procedure. It is therefore important that both the equipment and the overall approach used be safe, effective, and developmentally appropriate. Since restraint procedures are also used in the prehospital, inpatient, and intensive care settings, emergency medical technicians, nurses, physicians, and security personnel should be familiar with the risks, benefits, and proper use of these techniques. The various forms of restraint should be thought of as having a temporizing purpose, and frequent reassessment of the need and method of restraint is imperative. Although the actual application of physical restraints or sedation is straightforward, the ethical and legal issues surrounding these procedures are complex.

One must be familiar with and sensitive to the developmental level of the child in need of a potentially painful or anxiety-provoking procedure (see Table 2.1). Whereas 5- and 6-year-old children might be adept at the art of negotiation, they are not as adept at keeping their end of the bargain during a painful procedure. Most developmentally appropriate 10- and 11-year-old children have the ability to understand the necessity for a procedure in the abstract but will often require some help immobilizing during the procedure itself.

In contrast, the older patient who is uncooperative with emergency medical care or is combative may have some physiologic disturbance that can alter judgment, self-control, or the ability to assess pain. These patients may suffer from a variety of conditions, including organic brain syndrome, intoxication, functional psychosis, and personality disorder. In these cases, one must recognize that the patient may not stop struggling even if that struggle causes personal harm. A striking example of this is seen in adolescent patients with exposure to phencyclidine (PCP), which is discussed in the following section.

Two situations exist in which health care professionals must consider the use of physical restraints or the rapid tranquilization (often referred to as “chemical restraint”) of a patient. In the first, the patient will not or cannot cooperate with the performance of a medically necessary emergent procedure. As noted, this may be developmentally appropriate for a child or may represent an alteration of mental status in an older individual. A psychiatric consultant is helpful in the diagnosis and treatment of patients with psychosis or personality disorders and should always be involved if physical restraint or rapid tranquilization is required for these patients.

In the second situation, the patient’s actions may be assessed as being either personally harmful or harmful to others. If the hospital personnel cannot verbally de-escalate the situation, physical restraint or rapid tranquilization reduces the risk of injury to the person and those around him or her.

There are few absolute contraindications to restraining patients in need of acute care. Restraints should only be used when deemed to be in the best interest of the patient or the safety of the staff. They should never be used punitively or for staff convenience. Furthermore, alternative methods should be considered if the use of chemical or physical restraints would exacerbate a medical condition and render the patient medically unstable or would inhibit the continuous monitoring required by a critically ill patient. In addition, one should not attempt to restrain a patient if there are not enough personnel or inadequate equipment to perform the technique safely and efficiently.

A special circumstance in which physical restraint may be harmful to the patient is after recreational drug use, such as with cocaine, amphetamine, or PCP, and/or overdose with a variety of sympathomimetic, anticholinergic, or other stimulative agents. Such patients can be unpredictable and are not aware of their behavior. Some authors have recommended that patients who are agitated after PCP use, in particular, do better with an environmental sensory deprivation approach and should be allowed to remain in a quiet, dark room with as little stimulation as possible (3). However, this approach has never been validated in controlled studies. Physical restraint should be applied if such intoxicated persons become a danger to themselves or others, as with any other severely agitated patient. Because patients are not aware of the tissue damage occurring as a result of fighting against the restraints, severe physical injury can occur if adequate pharmacologic sedation is not provided as well.

The equipment necessary for restraining patients appropriately is listed in Table 3.1. Equipment used for restraint should be easy to apply, size appropriate, padded, and contoured to minimize damage to the patient. Equipment specifically designed for restraining patients should be used, and “makeshift” methods (such as tying a patient down with sheets or towels) should be avoided, as they are difficult to implement and often require excessive force to maintain. A papoose board should have a portion for head immobilization that is part of the unit. In order to minimize the risk of the patient getting free during a procedure, it is better to overestimate than to underestimate the board size. Leather restraints should be padded internally and have adjustable ring clips.

Appropriate monitoring equipment is mandatory to supplement the continuous observation required of the restrained patient. This includes continuous assessment of vital signs in potentially unstable patients and frequent assessment in all others. The exact requirements for monitoring are discussed later in this chapter. Further details regarding monitoring devices are reviewed in Chapter 5.

As mentioned, patients may require restraint for a variety of reasons. The approach to the uncooperative pediatric patient depends on the size and strength of the child. In addition, the overtly violent patient is more likely to require a systematic approach directed toward the protection of hospital or office personnel.