Restraining critical patients with heroin overdoses

Specialties Emergency

Published

What are your thoughts on restraining of critical patients with overdoses before you give them narcan. We frequently have patients coming in with heroin overdoses and instead of restaining them before giving the narcan, we give the narcan and wait to see what happens. If they get agitated or violent then we get security officers to hold them down and maybe restrain them.

I feel that this is a dangerous practice in that I had an unsheathed IV needle shot at me when a pt became unruly when we were inserting a second IV. I have been kicked, kicked at, and had the patient rip out his IV and try to pull out an ET tube. I have had to catheterize a pt who was "held down" by security. They let go too early and the patient kicked out and sprayed the cath kit everywhere including urine. I believe as we are working on bagging and intubating starting IV's the security should be putting on restraints. This way if the patient becomes violent we are safe,if he remains docile we take them off. My coworkers disagree they take a wait and see attitude. I thought personal safety was foremost why risk it?

Specializes in Emergency & Trauma/Adult ICU.
However, if you have a patient on sedation and on the vent and have the soft wrist restraints that is considered double restrained and is against JACHO policy. Any time you use medication to sedate or control a patients behavior that is considered chemically restrained and no other form of restraint is allowed. We even have to fill out restraint checkoff sheet every hour on these patiens just like the ones that are phyiscally restrained.

Do you mean that wrist restraints are not applied to intubated, sedated patients? This sounds inherently unsafe to me ... don't we need to protect that tube at all costs?

If for example a pt.'s propofol drip needs to be titrated upwards, I'd rather see this from them beginning to pull at the wrist restraints than reaching up & giving that tube a yank in a split second.

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Specializes in Emergency.

Thats the key we dont use medications to control behavior only as medical treatment. We are also trained that medication is never used as a restraint and that is the answer to any surveyors question as well. All our policys were rewritten to specify the same. This actually occured at another facility I worked in as well. Its a fine line and splitting hairs but thats the system we are given and its what works.

Rj

That is the same policy our hospital has. However, if you have a patient on sedation and on the vent and have the soft wrist restraints that is considered double restrained and is against JACHO policy. Any time you use medication to sedate or control a patients behavior that is considered chemically restrained and no other form of restraint is allowed. We even have to fill out restraint checkoff sheet every hour on these patiens just like the ones that are phyiscally restrained.
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How about giving less Narcan. Back when I first learned about its use the whole point of giving it was to give it till respirations improved not until the patient wakes up.

So I guess my point is if the patients respirtory rate is fine I would hold off on giving it. Also as one of the other posters mention we have different restraint protocols one for tube/lines/stroke pts and another for agressive behavior.

The tube/line one can be used on almost anyone, where as the other comes with more restrictions. For example the first is good for 24hr and the other needs renewal every 4 hrs at my facility.

Rj

Love to give a smaller dose but I am dealing with residents and PA's who rarely if ever take a nurses advice. A minimum of 1 mg usually is given for the smallest person usually 2-3 mg is the dose. Yes they wake up vomitting and violent. It is not a fun time. I know paramedics restrain with triangular bandages before giving narcan. It is not so much the tube but the IV lines that also need protected. A ripped out line leaves a bloody mess not to mention the risk of someone getting sprayed (most addicts are HIV or HEP C positive), and everyone knows how difficult it is to restart a line on a heroin addict,let alone a violent one. I do not understand why we as nurses do not stand up and say sorry my personal safety is the priority here my next priority is the patients safety. Why should we risk getting hit or get blood spray or get hurt trying to restrain a violent patient.

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Just a suggestion,

Ask your firefighters or medics to hang out for a few minutes. We are preatty quick about getting a narcan order and IV if medics have been unsuccessful. The fire guys have helpen me taken down combative patients on many occasions. If you ask for their help (you might tell um your scared) their male egos almost demand that they do.

WHere i work we start with 2mg of narcan. Chicago folks are dropping like flies do to fentanyl laced heroin.

I love nursing, lets git rid of the paperwork.

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TRaumarus,

I am not sure what your state protocals are but: Standard procedure for respiratoy arrest in an unconscious person is first: open airway- ventilate via BVM (not intubate)...First clue in overdose is to assess pupils are they pinpoint , then giving 2mg narcan is appropriate procedure (you will find out quite soon if they took narcotics and that may be the only treatment needed. I am not sure why your institution would go right to ET as first line. As well you would next check a blood sugar (another high suspicion) and give D50 if needed. Once you treat the opiate overdose they usually sign out AMA or refuse further treatment which saves alot of wasted time and energy on placing a tube, restraints, etc.....

Just my thoughts

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Specializes in ER, Hospice, CCU, PCU.

Most of our overdoses are reversed in the field. They arrive awake and :angryfire very, very mad. The Medics restrain them with the bandages to the side rails. If they are awake when they come in, We simply ask "Do you want to be treated", If they say No and they are not petitioned by police {Psych. Hold} the Medics cut them loose and they go on their way.

If we need to reverse a patient we have security at bedside and start with 0.4 mg of narcan and repeat as necessary. This is usually enough to wake them up, but not cause violent physical or psychological symptoms. Too much Narcan and you are doing sudden detox. which may cause you and the patient more problems than necessary; including seizures and death.

If you are wondering how often we treat heroin overdoses, It would be pretty much nightly; some nights a whole lot more frequently than that.

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TRaumarus,

I am not sure what your state protocals are but: Standard procedure for respiratoy arrest in an unconscious person is first: open airway- ventilate via BVM (not intubate)...First clue in overdose is to assess pupils are they pinpoint , then giving 2mg narcan is appropriate procedure (you will find out quite soon if they took narcotics and that may be the only treatment needed. I am not sure why your institution would go right to ET as first line. As well you would next check a blood sugar (another high suspicion) and give D50 if needed. Once you treat the opiate overdose they usually sign out AMA or refuse further treatment which saves alot of wasted time and energy on placing a tube, restraints, etc.....

Just my thoughts

I would think there is plenty of justification for these patients to buy a tube right away, after all, ABC. You have to assume a full stomach. You may be able to mask ventilate them while you get an iv to administer the narcan, but if they aspirate, you've just bought them a whole other set of problems. The tube can always be removed after they wake up enough to breathe.

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