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Inotropic effect in isolated animal tissue preparations. hemodynamic studies in humans with normal ventricular function have not shown a reduction in cardiac index nor consistent negative effects on contractility dp dt . acute study of oral diltiazem in patients with impaired ventricular function eiection fraction 24% 6' o ; showed improvement in indices of ventricular function without significant decrease in contractile function dp dt ; . Worsening of congestive heart failure has been reported in patients with preexisting impairment of ventricular function. Experience with the use of CARDIZEM diltiazem hydrochloride ; in combination with beta-blockers in patients. If these andrx products and particularly andrx's bioequivalent version of cardizem cd were to experience increased competition from existing and or new competitors with accompanying price reductions and or reduced market shares, andrx's operating results would be materially adversely affected and claritin and cardizem.

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This policy shall attempt to establish guidelines to ensure the safety of EMS personnel as well as patient safety in situations when the patient may be extremely agitated and the potential for harm to self and or others may exist. Pre-hospital Patient Restraints PPR ; should be considered whenever a patient requiring immediate medical treatment becomes a threat to himself or other emergency personnel. This should be accomplished with the least amount of force necessary to protect the patient and emergency personnel. Law enforcement officers should be requested for assistance on any patient who requires physical restraints. A blood glucose level should be obtained as soon as it is safe to do so. Whenever possible the Alarm communicator should advise responding personnel of potentially unstable or known unstable scenes and or situations locations when a request for EMS is received. Additionally, responding personnel are to stage for Law Enforcement personnel and should not enter the location until Law Enforcement Officers have assessed scene safety A detailed evaluation of the patient's mental status is required prior to initiating Patient Safety Restraint. Full documentation of all events and patient's condition should appear on the Patient Care Report PCR ; whenever Patient Safety Restraint is utilized. Agitation or acute behavioral disorders may manifest differently. Always suspect an organic cause first. Life-threatening organic conditions that may present with behavioral agitation are subdural hematoma, intracerebral hemorrhage, meningitis, hypertensive crises, hypoglycemia and drugs especially atropine and cyclic antidepressants ; . This procedure applies to patients being treated under implied consent and is not to be used on patients specifically refusing transport. A Supervisor consult is required before PPR is attempted. Exceptions would be imminent threat to EMS personnel by the patient that may pose immediate physical injury to EMS personnel. If EMS personnel have entered a location that becomes unstable and physical injury is threatened verbally and or the patient or other parties on scene threaten physical harm, EMS personnel should physically remove themselves from the scene and move to a location of safety until Law Enforcement officials arrive. If necessary EMS personnel should leave medical equipment to accomplish this task. The safety of EMS personnel comes first. In all events, attempts should be made to "talk the patient down" before restraint is considered. The conversation should be honest and straightforward. EMS personnel should attempt to have equally open escape routes for both the EMS providers and the patient. Do NOT endanger yourself or other EMS personnel. At All times the safety of the medical personnel should remain first priority. Assess the patient's mental status. Determine if the patient has suicidal or homicidal ideation.

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