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)
- lorazepam 1 to 2 mg PO/ SL / IV q2-6h, titrated to clinical response, up to a maximum of 10 mg in 24 hours
- 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
Critical Care
Compendium
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