Chemical Restraint

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