OVERVIEW

Chemical restraint or emergency sedation is used for management of acute behavioral emergencies.

• A drug is considered a restraint when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition.
• The goal is to rapidly and safely sedate the patient to control symptoms and allow them to be safely managed without providing a threat to themselves or to staff
• all available alternative treatment options should be considered before administering chemical or physical restraint, as it infringes an individual’s autonomy and dignity

INDICATIONS

• actual or high risk of harm to self, others or property where verbal de-escalation is inappropriate or ineffective

CONTRA-INDICATIONS

• medical instability
• risk of harm to staff in applying restraint
• alternative strategies available and appropriate

ASSESSMENT

Ensure the following assessments are made before administering chemical restraint:

• The patient is a serious threat to staff and/ or to themselves, (staff feel directly under threat)
• The patient is unable to make rational decisions
• Other less invasive options are inappropriate or ineffective (e.g. verbal de-escalation, involvement of trusted others)
• The patient needs urgent medical assessment, intervention or treatment

Ensure that appropriate security staff and/ or police are always nearby during assessment to ensure staff safety

• activate the appropriate code
• safe physical restraint is often temporarily needed to safely administer chemical restraint

Investigations can be performed once the patient is stabilised (i.e. cooperative, physically restrained or sedated) – tests that are typically required include (others are performed on a case-by-case basis):

• glucose
• ethanol level
• paracetamol level if suspected overdose

Bedside

• ECG (e.g. check for underlying long QT if antipsychotics used)

Laboratory

• FBC
• UEC
• LFTs
• septic screen if clinically indicate

Imaging

• CT brain (if suspected organic cause or traumatic brain injury) – may require intubation and sedation

Special tests

• Urine drug screens do not affect initial management and are unnecessary; may be useful for documenting the possible cause for future reference

APPROACH TO CHEMICAL RESTRAINT

Exclude other therapeutic options first

• e.g. attempt verbal de-escalation and involvement of trusted others

Prepare for chemical restraint

• in emergency situations a psychiatry recommendation / Compulsory Treatment Order is not needed
• assemble sufficient and appropriate security staff and/ or police members to physically restrain the patient (see physical restraint)
• physiological monitoring is needed for any patient that receives IV sedatives

Consider factors that affect doses and dosing interval

• level of agitation
• response to treatment
• body size
• age
• medical history
• medication history (e.g. drug dependence)
• previous response to sedative drugs

Choose route of drug administration

• IM route is preferred if significant risk of harm to staff from attempting to obtain IV access
• Take caution before giving additional doses if apparent failure to respond after IM administration (onset may be slow and erratic)
• often initial sedation can be IV if appropriate physical restraint is performed
• IV is more rapid, more predictable, more reliable, and easily titratable
• subsequent sedation should be IV and titrated to effect

Choose agent and dose

• benzodiazepines
  • lorazepam 1 to 2 mg PO/ SL / IV q2-6h, titrated to clinical response, up to a maximum of 10 mg in 24 hours
    • rapid onset
    • longer duration than midazolam
    • experts may consider administering higher doses in resistant patients
    • no CYP450 metabolism (undergoes conjugation), so compared to midazolam and diazepam:
      • no active metabolites
      • less affected by liver disease
      • less drug interactions
      • less individual variability
  • midazolam is a rapid, effective, short-acting sedative agent is an alternative
    • midazolam IM 5-10mg or IV 2.5-5mg q3min, titrated to response, up to 30mg (halve dose in the frail elderly)
    • ceiling doses of 30mg are typical (in tolerant patients >100mg may be needed; experts may give 10-20mg boluses in these cases)
    • midazolam is more likely to need repeat dosing than lorazepam due to shorter duration of action
  • diazepam 5 mg IV, q3min, titrated to response, up to 30 mg is an alternative
    • Diazepam has slower onset IV and is not recommended for IM injection as absorption is poor and erratic
  • Use benzodiazepines with caution in the elderly and patients with respiratory compromise
  • Droperidol or olanzapine should be considered in patients who are tolerant of benzodiazepines or if there is a failure of midazolam, effect is synergistic and patients may respond to low doses of antipsychotic (drugs should not be mixed in same syringe if given in combination)
• typical antipsychotics e.g. haloperidol or droperidol
  • droperidol is more sedating
  • useful for controlling psychotic symptoms (e.g. delusions, hallucinations)
  • can be given IM or IV
  • associated with QT prolongation (risk is overstated, as is FDA’s black box warning for droperidol
  • Droperidol IM: 5 to 10 mg IM
  • Droperidol IV: 2.5 to 5 mg IV, q3min, titrated to response, up to 20mg
  • Haloperidol IM dose: 5 to 10 mg IM, up to 20mg in 24 hours.
  • Haloperidol IV titratable dose: Haloperidol 2.5 to 5 mg IV, repeated every 2 to 3 minutes, titrated to clinical response, up to 10 mg per sedation event. Halve these doses in the frail elderly patient
  • obtain ECG to monitor QT prolongation once sedated
• atypical antipsychotics
  • in less extreme situations a longer acting IM dose may be appropriate
  • e.g. IM olanzepine 10mg
  • though not licensed for IV use in Australia, research supports the use of the IM formulation IV
  • e.g. olanzapine 5 mg IV, q5min, titrated to response, (maximum 20 mg IV)
  • IV onset similar to that of IV droperidol, but is longer acting
• ketamine
  • an option in extreme situations, especially prehospital
  • e.g. ketamine 1mg/kg IV or 5 mg/kg IM
  • if patient remains non-sedated then give titrated midazolam in addition

Monitoring (according to depth of sedation) may include:

• Pulse and respiratory rate
• An initial temperature should be recorded
• Pulse oximetry
• ECG
• Blood pressure
• Close monitoring of conscious state and airway adequacy

Seek and treat complications

• over-sedation (consider flumazenil to reverse benzodiazepines, but in dependent patients this may trigger withdrawal and/or seizures
• complications of sedation and immobilisation
• extra-pyramidal effects (consider IV benztropine)
• physical injury to patient, staff or others

Documentation

• reason for restraint
• alternative therapies attempted
• assessment of potential injuries and any complications of restraint
• monitoring plan
• thresholds for further interventions
• ongoing sedation options and sedation chart

Debrief

• once patient has stabilised and recovered from sedation explanation should be given
• discuss strategies the patient can use to self-modulate behaviour in the future to prevent recurrences (if appropriate)
• provide explanation and reassurance to the family

Disposition

• close observation will be necessary until the patient recovers from sedation (able to safely eat, drink and toilet)
• psychiatric assessment

References and Links

LITFL

• CCC — De-escalation
• CCC — Physical restraint

Journal articles

• Coburn VA, Mycyk MB. Physical and chemical restraints. Emerg Med Clin North Am. 2009 Nov;27(4):655-67, ix. PMID: 19932399.
• Downes MA, Healy P, Page CB, Bryant JL, Isbister GK. Structured team approach to the agitated patient in the emergency department. Emerg Med Australas. 2009 Jun;21(3):196-202. PMID: 19527279.
• Isbister GK, Calver LA, Page CB, Stokes B, Bryant JL, Downes MA. Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: the DORM study. Ann Emerg Med. 2010 Oct;56(4):392-401.e1. PMID: 20868907.

FOAM and web resources

• EMCrit — Podcast 060 – On Human Bondage and the Art of the Chemical Takedown (2013)