The teaching point here is that not all “take-downs” are the same.
For Emergency Services personnel, a common danger is an ill patient who may kill you if you’re not careful. The safety of providers must be balanced against the treatment of the patient. When the patient is delirious, this means the patient must be restrained. You can’t reason with or talk down a patient who is incoherent; their brains are not working.
Numerous take-downs occur daily in U.S. EDs (in some days, it seems like that’s all I’m doing), but some are different. The combination of factors here presents a medical disaster waiting to happen – a psych pt, cocaine (or PCP), agitation / fighting, patient placed on his stomach, and a hot, humid day. These factors are the setting for “agitated delirium” or “excited delirium”. The great danger is sudden, unexpected cardiac arrest. The only thing missing in this patient is a “police burrito”.
Most take-downs involve patients that are trying to kill you intentionally. They curse at you. They try to bite you. They are not incoherent. For whatever reason, delirious patients don’t bite, but I’ve never seen a human with rabies.
Many medications are useful in sedating violent, intoxicated patients – benzos, haldol, ketamine, etc. My usual drugs of choice are a combination of haldol and ativan. When I suspect agitated delirium, I give benzos only, usually a combination of versed and ativan. There is a theoretical disadvantage to most any other medication in this scenario.
We placed an IV into this patient and gave him 2 mg each of versed and ativan (while he was still laying prone). We then flipped him over, released the police cuffs, and put on 4-point restraints. We were relatively safe at this point.
I told the chief to look at the pt carefully. “Look at how he’s breathing.” The guy was panting like a dog, which is atypical for a patient who is simply intoxicated or psychotic. The patient’s temp was nearly 106 F (41 C). We started IV saline, put him on a cooling blanket, and admitted him to the ICU. His labs were mildly abnormal, nothing critical. He had an unremarkable recovery.
It is unclear exactly what kills patients with excited delirium (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5061757/). Patients with high temps tend to go into vfib arrest in my experience. It doesn’t matter what they die from, it only matters that you’re prepared for it. I’ve never had a patient die, even when they go into vfib, but they die all the time.
I like to waste a few dollars and put the defib pads on the patient prophylactically. We don’t have paddles anymore, it takes longer to defib patients with pads (because you have to put the pads on).
“How did you know?” asked the chief. “You just know.” It’s the difference between a jacobi-10 and a pgy-5.
It’s funny (to me), but a big part of a resident’s job is reading the attending’s mind. If you see me doing something out of character (sending a lactate, sono’ing a trauma), you may want to ask why. In this case, I 2&2’d the patient instead of the usual 5&2 or 10&4.
I can’t think of a great reason why we would need to start their sedation with an IV, especially when the patient arrives in handcuffs. When I ask for IM sedation, the usual groan I get is “it takes too long”. Who cares? The patient can stay in handcuffs until that IM medication starts to kick in. My team’s safety takes priority over anything else, I’m not in a rush to get myself or anyone else stuck by a needle.
Depends on the patient / situation.
In most patients, it’s not a big deal to put in an IV safely.
When it’s not safe to put in an IV, IM is a good alternative, but that’s not necessarily much safer than an IV attempt (think flying needle). Having said that, I IM’d a guy last night.
While you are waiting for your IM to kick in, your patient may hurt himself or someone else. Police leave, restraints break, patients get out and jump to their death.