Full text of DOI:10.1080/10903120290938436

POSITION PAPER
NATIONAL ASSOCIATION OF EMS PHYSICIANS
PATIENT RESTRAINT IN EMERGENCY MEDICAL SERVICES SYSTEMS
Douglas F. Kupas, MD, Gerald C. Wydro, MD
PPR protocol should undergo qual-
ity improvement review with spe-
cific filters for the appropriateness
of restraint for the patient, the type
of restraint utilized, and the care
provided to the patient during
transport.
The NAEMSP believes that the
following principles should be
incorporated in an EMS system
PPR protocol:
and manage medical condi-
POSITION
The National Association of EMS
Physicians (NAEMSP) recognizes
that emergency medical services
tions that contribute to a
patient’s violent behavior.
Such conditions include, but
are not limited to, hypoxia,
hypoglycemia, alcohol or drug
intoxication, stroke, and brain
trauma.
(
EMS) personnel encounter agitat-
ed and combative patients, and
these patients frequently require
medical treatment and transporta-
tion. To minimize the possibility of
injury to patients and EMS person-
nel, NAEMSP believes that all EMS
systems should develop specific
protocols for dealing with the vio-
lent or combative patient. Protocols
may have input from EMS system
administrators, providers, legal
counsel, and law enforcement rep-
resentatives, but review and
approval by the EMS system med-
ical director are essential.
In addition, the EMS service
must assure that all EMS personnel
are knowledgeable about the med-
ical conditions that are associated
with agitated or combative behav-
ior and are trained to apply the
principles of the system’s prehos-
pital patient restraint (PPR) proto-
col during patient care. Use of the
6
. The protocol must address the
types of restraint devices that
will be used (verbal, physical,
or chemical), when each will be
used, who can apply them, and
when direct medical oversight
must be involved.
1
. The safety of EMS personnel is
the paramount factor during
PPR, followed by the impor-
tance of protecting patients
from injuring themselves or
others.
7. Direct medical oversight may
be required for combative
patients who refuse treatment,
for orders to restrain a patient
2
. Every EMS service should have
a PPR protocol that is applica-
ble to all violent or combative
patients.
(
before or immediately after
restraint), or for orders for
chemical restraint (before or
after medication is adminis-
tered).
3. The protocol should outline the
indications for patient re-
straint. The policy should be
consistent with state laws and
local EMS protocols regarding
patient refusal of care and the
EMS system’s responsibility to
care for patients with psychi-
atric or behavioral emergen-
cies.
8
. The PPR protocols should ad-
dress the type of physical
restraints that are permissible.
Any restraint used should
allow for rapid removal if the
patient vomits or develops res-
piratory distress. Patients
should never be transported
while hobbled, “hog-tied,” or
restrained in a prone position
with hands and feet behind the
back. Patients should never be
transported while “sand-
wiched” between backboards
or mattresses. Restraint tech-
niques should never constrict
the neck or compromise the
airway.
Dr. Kupas is at Geisinger Medical Center,
Danville, Pennsylvania; and Dr. Wydro is at
MCP Hahnemann University, Philadelphia,
Pennsylvania.
4
. Patient dignity should be
maintained during restraint,
and the method of restraint
should be individualized to use
the least restrictive method of
restraint that protects the
patient and EMS personnel
from harm.
Approved by the NAEMSP Board of
Directors February 25, 2002. Received
February 28, 2002; accepted for publication
February 28, 2002.
Address correspondence and reprint re-
quests to: Douglas F. Kupas, MD, Depart-
ment of Emergency Medicine, Geisinger
Medical Center, 100 North Academy
Avenue, Danville, PA 17822-2005. e-mail:
5. The protocol must include a
patient assessment to identify
<
dkupas@geisinger.edu>.
340

Kupas and Wydro POSITION PAPER: PATIENT RESTRAINT IN EMS SYSTEMS
341
9
. Hard restraints, such as hand-
cuffs, are generally not accept-
able for EMS use. If patients are
restrained in devices that
require a key, the key must
accompany the patient during
treatment and transportation.
15. Law enforcement officers
should be involved in all cases
when a patient poses a threat to
EMS personnel or others. If law
enforcement is not immediate-
ly available, EMS personnel
should retreat to a safe place
and await the arrival of law
enforcement. If there is no
option for retreat, EMS person-
nel may use reasonable force to
defend themselves against an
attack.
EMS providers, and allow for time-
ly and appropriate treatment and
transportation of a patient to a
medical or psychiatric facility.
There are hazards to improperly
applied restraint. Severe and
potentially life-threatening compli-
cations have been reported in indi-
viduals who were restrained by
law enforcement, health care, and
EMS personnel. The American
College of Emergency Physicians
1
0. Continued patient struggling
after restraint application can
lead to hyperkalemia, rhab-
domyolysis, and cardiac arrest.
Chemical restraint may be nec-
essary to prevent continued
forceful struggling by the
patient.
2
endorses restraint principles, and
the recommendations in this posi-
tion paper are consistent with these
principles.
16. It is not appropriate for EMS
personnel to use weapons as
adjuncts in the restraint of a
patient.
1
1. Chemical restraint, usually
with a butyrophenone, a benzo-
diazepine, or both, is an effec-
tive method of protecting the
violent or combative patient.
Paralytic agents are not an
acceptable alternative for PPR
unless they are also clinically
indicated to treat an underlying
medical or traumatic condition.
The Joint Commission on Ac-
creditation of Healthcare Organi-
zations (JCAHO) requires restraint
policies and procedures within
hospitals in an effort to minimize
1
7. In rare situations, it may be
necessary for law enforcement
to apply restraint techniques to
EMS patients that are not sanc-
tioned by EMS policies. In
these cases, a law enforcement
officer must accompany the
patient during transportation,
and EMS personnel must
assure that the patient is med-
ically assessed, treated, and
reassessed based upon the PPR
protocol.
3
adverse events. EMS services that
are owned or operated by hospitals
should consult with their hospital
administration during the develop-
ment of the PPR protocol to assure
that the protocol is consistent with
applicable JCAHO requirements.
The purpose of this position
paper is to provide guidance to
EMS providers and medical direc-
tors in developing PPR policies
and protocols for use in their sys-
tems. This is an overview of the
current literature and assessment
of the methods that are currently in
use throughout the United States
by EMS systems.
1
2. After patient restraint, there
must be regular and frequent
evaluation of the neurovascular
status of all restrained extremi-
ties and the respiratory and
hemodynamic condition of the
patient.
INTRODUCTION
The role of providing emergency
medical care in the relatively
uncontrolled prehospital environ-
ment frequently places EMS per-
sonnel in harm’s way. Agitation or
confusion related to medical prob-
lems and violence from psychiatric
disorders are frequently encoun-
tered by EMS personnel. A conven-
ience sample of registrants at an
NAEMSP meeting found that about
half of the EMS systems sampled
did not have protocols for the man-
1
3. Documentation of patient as-
sessment, reason for restraint,
restraint procedure, frequency
of reassessment, and care dur-
ing transportation should occur
for all patients who require
restraint. These components
should be evaluated during
system continuous quality
improvement processes. Sys-
tems should consider review-
ing every case of patient
restraint for compliance with
the PPR protocol.
DISCUSSION
Medical Issues
Conditions such as hypoxia, hypo-
glycemia, acute drug or alcohol
intoxication, stroke, and brain trau-
ma may present as confusion, com-
bativeness, or agitation. EMS per-
sonnel must assess every agitated
patient for these disorders. Some of
these medical conditions are
reversible and may be treated
before completely restraining the
1
agement of violent patients.
Prehospital patient restraint pro-
vides verbal, physical, and/or
chemical restraint to allow for the
safe transportation and treatment
of the violent, combative, or agitat-
ed patient by EMS personnel.
Properly applied PPR may reduce
the possibility of patient injury,
reduce the potential for injury to
1
4. Local law enforcement policies
may differ from the EMS
restraint policies, but both
agencies should recognize their
roles and work cooperatively
and proactively to assure the
safe restraint of EMS patients
when necessary.
4
patient. In one metropolitan EMS
system, 9% of violent patients
encountered by EMS were suffer-
1
ing from hypoglycemia. Oxygen,

342
PREHOSPITAL EMERGENCY CARE JULY / SEPTEMBER 2002 VOLUME 6 / NUMBER 3
dextrose, and naloxone should be
used to treat the underlying condi-
tion when appropriate.
Emergency medical services
Medicolegal Issues
should anticipate the potential for
exposure to blood and body fluids.
Restraint procedures can expose
EMS providers to blood, spit,
urine, or feces. Based upon the sit-
uation, appropriate barrier protec-
tion should be worn during patient
restraint activities.
The methods of restraint include
verbal deescalation, physical re-
straint, and chemical restraint. The
chosen method of restraint should
be the least restrictive method that
assures the safety of the patient and
the EMS personnel. These methods
of restraint may be applied in a step-
wise fashion in many cases, but in
extremely violent individuals,
immediate physical restraint may be
indicated to assure the safety of the
patient and personnel.
Emergency medical services sys-
tems and medical directors must be
aware of the laws of their state.
Local legislation related to an indi-
vidual’s rights, the processes for
involuntarily restraining or holding
patients with mental health disor-
ders, an individual’s right to refuse
treatment, and other related laws
must be considered when devising
a PPR protocol. In general, legisla-
tion attempts to assure the safety of
individuals who are an immediate
threat to themselves or others. It
may be necessary to involve law
enforcement or a mental health offi-
cial to restrain a competent individ-
ual against his or her will.
When possible, systems should
assure that patients are accompa-
nied by personnel of the same gen-
der as the patient during treatment
and transportation. This is of par-
ticular importance when pharma-
cologic agents are used for chemi-
cal restraint.
The application of physical and
chemical restraints to a patient
must be performed with the under-
standing that overstepping the
boundaries of restraint may be per-
ceived as battery, assault, or false
imprisonment. Restraint of an indi-
vidual could even lead to serious
allegations of civil rights viola-
tions. For this reason, the EMS
service should always review PPR
policies with legal counsel.
5
Agitated delirium, drug over-
dose or intoxication, comorbid
medical conditions, recent extreme
exertion, fighting against re-
straints, and inappropriately ap-
plied restraints can contribute to
adverse medical conditions. These
conditions include positional
asphyxia, aspiration, severe acido-
sis, rhabdomyolysis, and sudden
6
,7
cardiac death.
Restraint in the hobble, or hog-
tied, position is particularly dan-
gerous and has been the suggested
cause of several deaths during both
11
8
,9
police and EMS transport.
Hobble restraint is the technique of
restraining an individual’s wrists
and ankles together behind the
back. In an Austrian study, healthy
volunteers were restrained in the
hobble position, and physiologic
parameters were measured in the
upright and prone positions.
During hobble restraint in the
prone positions, the mean forced
vital capacity (FVC) decreased by
Verbal Deescalation
The application of verbal tech-
niques to calm the patient is usual-
ly the first methods that EMS per-
sonnel should employ. This meth-
od is safest because it does not
require any physical contact with
the patient. The conversation must
be honest and straightforward
with a friendly tone. Providers
should avoid direct eye contact
and encroachment upon the
patient’s personal space, as this
may provoke stress and anxiety.
EMS personnel should always
attempt to have equally open
escape routes for both the EMS per-
sonnel and the patient. Providers
should assess the patient for suici-
dal and/or homicidal ideation.
Verbal intervention sometimes dif-
fuses the situation, can prevent fur-
ther escalation, and may avoid the
4
0%, the mean end-tidal carbon
dioxide increased by 15%, and the
mean cardiac output decreased by
9
3
7%. A similar study by Chan et
al. had less dramatic results. In this
study, the restraint position was
associated with a 13% decrease in
FVC and no evidence of hypoxia or
1
0
hypercapnea.
The method of patient restraint
must allow for continuous patient
assessment and for medical inter-
ventions during transport. If a
patient vomits, becomes unstable,
or develops cardiopulmonary
arrest, prompt treatment is needed.
Many EMS training programs do
not include education about agitat-
ed delirium and its associated aci-
dosis, hyperthermia, and psychotic
behavior. EMS systems should
assure that their personnel have
been trained to recognize, evaluate,
and treat the medical conditions
that may cause or be related to agi-
tation.
Types of Restraints
If a patient or individual is known
to be violent, EMS personnel
should assure that law enforce-
ment secures the scene before EMS
enters. Obviously, this is not
always possible, and EMS provid-
ers should always be alert for
unexpectedly agitated patients or
escalating emotions. The safety of
the EMS personnel is paramount,
and it is appropriate for EMS to
withdraw from a violent situation
until law enforcement or addition-
al assistance arrives.
1
2
need for further restraint tactics.
Physical Restraint
When physically restraining a
patient, EMS personnel must make
every effort to avoid injuring the
patient, and PPR policies must
choose restraint devices that are
associated with the least chance of
injury. Physical restraint is accom-

Kupas and Wydro POSITION PAPER: PATIENT RESTRAINT IN EMS SYSTEMS
343
plished with materials and tech-
niques that allow for the restriction
of movement of a person who is
considered a danger to himself/
herself or others. Examples include
soft restraints (sheets, wristlets,
and chest posey) and hard
restraints (plastic ties, handcuffs,
and leathers).
In general, EMS protocols should
avoid the use of hard restraints. If a
system chooses to use hard
restraints, all personnel should be
trained in their use, and the
patient’s extremities should be
evaluated frequently for injury or
neurovascular compromise.
extremely vigilant for respiratory
cal agents to decrease agitation and
increase the cooperation of patients
who require medical care and
transportation. EMS systems may
use a variety of agents for chemical
restraint of the agitated or combat-
ive patient. The goal of chemical
restraint is to subdue excessive agi-
tation and struggling against phys-
ical restraints. Ideally, this pharma-
cologic sedation will change the
patient’s behavior without reach-
ing the point of amnesia or altering
the patient’s level of consciousness.
Butyrophenones and/or benzo-
diazepines are the most commonly
used medications for chemical
restraint in emergency depart-
ments and in the out-of-hospital
arena. Some other historical, but
less advisable, medications include
the barbiturates (pentothal), opi-
oids (morphine), and phenoth-
compromise. Gaining initial con-
trol of the patient in the prone posi-
tion limits the patient’s visual
awareness of the environment and
decreases the range of motion of
the extremities. As soon as the
team has control of the patient’s
movement, the team should work
to move the patient into a supine
four-point restrained position.
Again, a patient should never be
hobbled or “hog-tied” with the
arms and legs tied together behind
the back. During transport, a
patient should never be restrained
to a stretcher in the prone position
or sandwiched between back-
boards or mattresses.
Once the patient has been
restrained, he or she should never
be left unattended. Also, providers
should perform and document fre-
quent neurovascular assessments
of the extremities that are re-
strained to assure adequate circula-
tion. A patient who has undergone
physical restraint should not be
allowed to continue to struggle
against the restraints. This may
lead to severe acidosis and fatal
arrhythmia. In general, for the safe-
ty of EMS personnel, physical
restraints applied in the field
should not be removed until the
patient is reevaluated upon arrival
at the receiving facility.
Weapons used by law enforce-
ment officers, including but not
limited to pepper spray, mace
defensive spray, stun guns, air
tasers, stun batons, and telescoping
steel batons, are not appropriate
choices for PPR by EMS. They
should be avoided since they may
exacerbate the patient’s agitation
and increase the risk of injury or
death. While appropriately trained
law enforcement officers may use
these weapons, the use of these
weapons should be excluded from
routine EMS protocols.
A minimum of five people should
ideally be present to safely apply
physical restraint to a violent
patient. This allows for control of the
head and each limb. This personnel
requirement may be difficult for
some EMS systems. There should be
a plan and a team leader who directs
1
3
iazines (chlorpromazine).
Chemical restraint protocols
often include a butyrophenone, a
benzodiazepine, or a combination
of both. Lorazepam and midazo-
lam are the benzodiazepines that
are most commonly used for PPR.
Droperidol and haloperidol are the
butyrophenones that are common-
12
the restraining process.
Four-point restraints (restraining
both arms and both legs) are pre-
ferred over two-point restraints. It
is often helpful to tether the hips,
thighs, and chest. Tethering the
thighs, just above the knees, often
prevents kicking, more than
restraint of the ankles does.
Contrary to the Emergency Med-
ical Technician National Standard
Curriculum (U.S. Department of
Transportation, 1994), patients
should not be transported while
restrained in a prone position. This
has been associated with asphyxia.
Nothing should be placed over the
face, head, or neck of the patient. A
surgical mask placed loosely on the
patient may prevent spitting. In
addition, a hard cervical collar may
limit the mobility of the patient’s
neck and may decrease the
patient’s range of motion in
attempting to bite.
1
4,15
ly used for PPR.
All four of
these medications can be given
intramuscularly or intravenously.
A
few studies, summarized
below, have evaluated the appro-
priate dose, route, and combina-
tion of medications administered
for PPR. This limited prehospital
literature supports the effective-
ness of droperidol in decreasing
the agitation of combative patients
in the prehospital setting. Halo-
peridol and benzodiazepines have
been shown to be effective in the
1
4,15
emergency department setting,
and these are probably also effec-
tive in the prehospital environ-
ment.
While gaining initial control of
the patient during restraint, it may
be acceptable to temporarily
restrain the patient in a prone posi-
tion or sandwich the patient with a
mattress, but personnel must be
A placebo-controlled trial by
Rosen et al. reported the effective-
1
6
ness of prehospital droperidol.
Chemical Restraint
Hick et al. recently examined the
safety and efficacy of droperidol (5
mg intramuscular) for prehospital
Chemical restraint is defined as the
addition of specific pharmacologi-

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PREHOSPITAL EMERGENCY CARE JULY / SEPTEMBER 2002 VOLUME 6 / NUMBER 3
sedation of combative patients. In
this one-year study of 53 EMS
patients, droperidol quickly and
effectively sedated 87% of the
patients without any serious
tranquilization after surgical or
severe head injury, may benefit
from paralysis and intubation, but
the decision to paralyze a patient
should be based upon medical
indications beyond violent or com-
bative behavior.
diagnostic procedures. These
reports have also led to a decrease
in the recommended doses of par-
enteral droperidol. In the United
Kingdom, oral droperidol was dis-
continued after reports of QT pro-
1
7
adverse events. In comparing
lorazepam with droperidol for
chemical restraint in the emer-
gency department, Richards et al.
concluded that droperidol pro-
duced a more rapid and better
Two surveys have addressed the
practice of chemical restraint in air
medical transport. Although they
do not provide much scientific cre-
dence to the effectiveness or safety
of chemical restraint in air medical
transport, they indicate that benzo-
diazepines are the most commonly
used medication for chemical
restraint in air medical trans-
2
0
longation during chronic use.
The new “black box” package
warning states that all patients
receiving droperidol (Inapsine)
should undergo a 12-lead electro-
cardiogram (ECG) to assess for QT
interval prolongation prior to
administration. “If there is a pro-
longed QT interval, INAPSINE
should NOT be administered. For
patients in whom the potential ben-
efit of INAPSINE treatment is felt
to outweigh the risks of potentially
serious arrhythmias, ECG monitor-
ing should be performed prior to
treatment and continued for 2–3
hours after completing treatment to
1
8
sedation than lorazepam.
Benzodiazepines may be the
drug of choice for patients who are
agitated from the effects of toxico-
logic syndromes or drug overdos-
es. The most common adverse
effects of benzodiazepines are
hypotension and respiratory
depression that may lead to hypox-
ia or hypoventilation.
23,24
port.
A combative patient is a
potentially higher threat to the safe-
ty of an aircraft crew than to a
ground EMS crew. For this reason,
some would argue that the use of
paralysis and intubation is a valid
means of restraining a combative
air medical patient. This may be
appropriate for severe head injury
or multisystem trauma when intu-
bation is usually indicated based
upon the injury severity. Less
restrictive methods of restraint, for
example, chemical sedation, should
be considered for patients without
evidence of high injury severity.
When considering the use of
chemical restraint, medical direc-
tors must weigh the risks of strug-
gling while physically restrained
against the side effect profile of the
medications that are considered for
sedation of agitated patients. At
present, there is no consensus on
the best medication or dosage for
chemical restraint, and this deci-
sion is best deferred to the individ-
ual EMS system and its medical
director.
Extrapyramidal symptoms and
orthostatic hypotension are the
most common side effect of buty-
rophenones. Prolonged QT inter-
val and torsades de pointes are rec-
ognized adverse effects of both
droperidol and haloperidol. In the
past, the majority of these adverse
effects were reported in critically ill
patients or those receiving more
than 50 mg/day of the butyrophe-
21
monitor for arrhythmias.” These
new warnings will be almost
impossible to follow when treating
an agitated patient in the field, and
the post-administration ECG moni-
toring recommendation may strain
the resources of the receiving emer-
gency facility. Unfortunately, the
current wording in these new
warnings does not address the pos-
sibility that some patients may be
too combative for the recommend-
ed ECG monitoring, but these
patients may still have potential
benefit from treatment that out-
weighs the very small chance of
cardiac dysrhythmia.
1
9
none.
The Food and Drug Administra-
tion (FDA) recently reported “100
unique spontaneous cardiovascu-
lar adverse events following dro-
2
0
peridol administration.” Twenty
of these cases had torsades de
pointes or QT interval prolonga-
tion. Eighteen deaths were report-
ed, and six of these were associated
with torsades or QT interval pro-
longation. Five of the deaths
occurred in patients who received
Neuromuscular-blocking med-
ications with endotracheal intuba-
tion are never indicated to paralyze
a patient solely for the purpose of
restraining violent behavior. One
small study reviewed combative
trauma patients who were para-
lyzed and intubated to facilitate
their trauma evaluation. While
patients with high injury severity
may have benefited from paralysis,
those with low injury severity had
higher costs and required more
2
0
2
.5 mg or less. These adverse
events associated with droperidol
have occurred in the context of the
widespread use of droperidol for
many years.
Droperidol did not previously
have a listed indication for the
chemical restraint of agitated
patients, but the recently reported
adverse cardiovascular events led
the FDA to remove several of the
approved indications, including
CONCLUSION
Emergency medical services pro-
viders routinely encounter patients
who are violent or combative due
to a behavioral illness or a medical
condition. Verbal, physical, and
chemical restraint techniques pro-
vide effective ways of restraining
patients who are a threat to them-
selves or require medical assess-
2
2
care if they were paralyzed.
Patients who have coexisting med-
ical conditions, for example,

Kupas and Wydro POSITION PAPER: PATIENT RESTRAINT IN EMS SYSTEMS
345
ment and treatment for a condition
associated with combative or agi-
tated behavior. Life-threatening
adverse events have occurred in
restrained individuals, and adher-
ence to the principles of restraint
presented here will minimize the
occurrence of these adverse events.
EMS systems and their medical
directors should assure that their
systems are prepared to appropri-
ately treat violent or combative
patients by providing training,
policies, and protocols to deal with
these situations.
Emerg Med. 1996;28:384.
15. Thomas H Jr, Schwartz E, Petrilli R.
Droperidol versus haloperidol for
chemical restraint of agitated and com-
bative patients. Ann Emerg Med.
1992;21:407-13.
16. Rosen CL, Ratliff AF, Wolfe RE,
Branney SW, Roe EJ, Pons PT. The effi-
ciency of intravenous droperidol in the
3
. JCAHO issues revised restraint stan-
dards. Hosp Peer Rev. 2000;25:73-4.
. Young G. The agitated patient in the
emergency department. Emerg Med
Clin North Am. 1987;5:765-81.
5. Park KS, Korn CS, Henderson SO.
Agitated delerium and sudden death:
two case reports. Prehosp Emerg Care.
4
prehospital setting.
1997;15:13-7.
J Emerg Med.
2
001;5:214-6.
6
7
8
9
. Hick JL, Smith SW, Lynch MT.
Metabolic acidosis in restraint-associat-
ed cardiac arrest: a case series. Acad
Emerg Med. 1999;6:239-44.
. Reay DR, Flingner CL, Stilwell AD,
Arnold J. Positional asphyxia during
law enforcement transport. Am J Forens
Med Pathol. 1992;13:90-7.
. Stratton SJ, Rogers C, Green K. Sudden
death in individuals in hobble restraints
during paramedic transport. Ann
Emerg Med. 1995;25:710-2.
. Roeggla M, Wagner A, Muellner M, et
al. Cardiorespiratory consequences to
17. Hick JL, Mahoney BD, Lappe M.
Prehospital sedation with intramuscu-
lar droperidol: a one-year pilot. Prehosp
Emerg Care. 2001;5:391-4.
18. Richards JR, Derlet RW, Duncun DR.
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Med. 1998;16:567-73.
19. Lawrence
KR,
Nasraway
SA.
The authors thank the members of the
Standards and Clinical Practice Committee
and the Board of Directors of the National
Association of EMS Physicians for their
review of this position paper and manu-
script. The authors also thank the following
individuals for their thoughtful review of
the manuscript: W. Ann Maggiore, JD,
EMT-P, Clinical Instructor, University of
New Mexico School of Medicine; Robert
Fonte, RN, Med, Clinical Educator/Crisis
Specialist, Western Psychiatric Institute and
Clinic, Pittsburgh, PA; David Julian, MEd,
Clinical Educator/Crisis Specialist, Western
Psychiatric Institute and Clinic, Pittsburgh,
PA.
Conduction disturbances associated
with administration of butyrophenone
antipsychotics in the critically ill: a
review of the literature. Pharmaco-
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