I. Indications

  1. Dangerous and uncontrolled Violent Behavior (e.g. Agitated Delirium)

II. See Also

III. Precautions

  1. Refer to these procedures as "Sedation of the Violent Patient"
    1. Joint Commission views "Chemical Restraint" as an inappropriate term

IV. Monitoring

  1. Chemical Restraints require 1:1 monitoring
  2. Consider End-Tidal CO2
  3. Reassess every 15 minutes including Vital Signs
  4. Document the indications, monitoring, reassessment and the indications to continue Sedation

V. Management

  1. Consider alternatives to Chemical Restraints
    1. But be prepared with strong, large, burly security guards at the ready in case of dangerous agitation
    2. Provide a calm, quieter, comfortable setting with dimmed lights to help de-escalate agitation
    3. Offer food, drink, warm blanket , phone call and other comforts to those able to reason
    4. Offer Nicotine Replacement as needed
    5. Benzodiazepines for Alcohol Withdrawal protocol or anxiety
    6. Apologize for delays (in some cases, days for boarding psychiatric patients)
    7. Express empathy and compassion
  2. Evaluate for other causes of agitation
    1. Hypoglycemia (obtain bedside Glucose)
    2. Hypoxia
    3. Sepsis
    4. Intracranial bleeding (if preceding Head Trauma)
  3. General Approach in dangerously combative patients
    1. Physical Restraint allows access to patient for IM injection
    2. Intramuscular Chemical Restraint (e.g. Ketamine) allows for Intravenous Access and maintained chemical Sedation
    3. Consider Rapid Sequence Induction and intubation for a sick, agitated patient

VI. Dosing: Adults (lower doses in the elderly)

  1. Ketamine
    1. Excellent choice for prehospital Sedation of an agitated Trauma child or adult on long transport
    2. Minimal ABC suppression, and may bridge to RSI as induction agent
    3. Ketamine Bolus
      1. IV/IO: 0.5 to 1 mg/kg
      2. IM: 3-5 mg/kg (typically 5 mg/kg)
    4. Ketamine maintenance
      1. Dose: 1 to 1.5 mg/kg/hour IV
    5. Duration
      1. Recovery within 10-15 minutes of discontinuing the infusion
    6. Safe in prehospital use (including non-intubated patients)
      1. Iwanicki (2014) Clin Toxicol 52:685-6 [PubMed]
  2. Benzodiazepines
    1. Preferred fall-back agent
      1. Safest agent when potential drug interactions, allergies, QT Prolongation or other patient risk factors
      2. Preferred agents in Overdose patients with toxin or Unknown Ingestion (offers additional Seizure Prophylaxis)
      3. Consider as adjunct in patients using Sympathomimetics (e.g. Cocaine or Amphetamines)
    2. Risks
      1. Unpredictable effects (especially in tolerant drug and Alcohol Abusers) and effect may subside quickly
      2. Risk in elderly and in respiratory conditions for Hypotension and hypoventilation
      3. Maintain arway management, End-Tidal CO2 monitoring with Advanced Airway at the ready
    3. Lorazepam (Ativan)
      1. Dosing: 1-2 IM/IV/PO every 6 hours prn
      2. Also may be used in combination with Haloperidol (see below)
    4. Midazolam (Versed)
      1. Preferred Benzodiazepine due to shorter duration of action
      2. Dosing: 2.5 to 5 mg IM every 3-5 minutes prn
      3. Larger patients may require 10 mg IM
  3. Butyrophenones
    1. Precaution: Risk of QT Prolongation
      1. Risk with Haloperidol, Droperidol as well as all Atypical Antipsychotics
      2. Avoid these agents in higher risk comorbidities
        1. Unknown Ingestion
        2. Hypokalemia
        3. Hyomagnesemia
        4. Bradycardia
        5. Combination with other agents causing QT Prolongation
      3. Generally considered safe with low Torsades risk (despite the FDA black box warning)
    2. Haloperidol (Haldol)
      1. Haldol alone: 5-10 mg PO/IM/IV prn
        1. Consider with Benadryl 50 mg or Cogentin 1 mg to prevent Dystonic Reaction
      2. Haldol with Ativan and Benadryl q30 minutes prn (Mnemonic: B52)
        1. Benadryl 50 mg (prevents Dystonia)
        2. Haldol 5 mg
        3. Ativan 2 mg
        4. Draw up the 3 agents into same syringe and deliver IM
    3. Droperidol (Inapsine)
      1. Unfortunately is unavailable in most regions of U.S.
      2. Preferred over Haloperidol due to better Sedation, faster action, and shorter half-life
      3. Very effective in psychotic patients and those unresponsive to Benzodiazepines
      4. QT Prolongation risk appears to be very low (occurs at much higher dose than is typically used)
        1. Horowitz (2002) Acad Emerg Med 9(6): 615-8 [PubMed]
        2. Calver (2015) Ann Emerg Med 66(3): 230-8 +PMID:25890395 [PubMed]
      5. Droperidol (use with Cogentin 1 mg)
        1. Intravenous dose: 2.5 to 5 mg IV prn (up to 5-10 mg IV, with maximum of 20 mg IV)
        2. Intramuscular dose: 5 to 10 mg IM prn
      6. Common Combinations
        1. Droperidol 5 mg with Midazolam 2 mg mixed in same syringe (1.5 inch needle) and delivered IM, may repeat once in 3-5 minutes
        2. Droperidol (Inapsine) 5 mg with Cogentin 1 mg IV
  4. Atypical Antipsychotics
    1. Olanzapine (Zyprexa)
      1. Preferred in Psychosis (Bipolar Disorder, Schizophrenia)
      2. Contraindications
        1. Unknown Ingestion
        2. Liver disease
        3. Neuroleptic Malignant Syndrome
        4. Seizure disorder
        5. Hypotension
      3. Dosing: 10 mg ODT sublingual wafer or 10 mg IM
      4. Diphenhydramine 1.25 mg/kg PO/IM/IV up to 50 mg prn Dystonia
    2. Ziprasidone (Geodon)
      1. Dose: 10-20 mg IM
    3. Aripiprazole (Abilify)
      1. Dose: 9.75 mg IM
    4. Risperidone (Risperdal)
      1. Dose: 2 mg orally
  5. Miscellaneous agents (older agents)
    1. Fluphenazine (Prolixin) 5 mg IM q6h prn
    2. Chlorpromazine (Thorazine) 50 mg IM q6h (or 0.25 mg/kg IM prn in children and adolescents)
    3. Thiothixene (Navane) 5 mg PO or 10 mg IM prn

VII. Dosing: Children

  1. Precautions
    1. Avoid combining intramuscular Olanzapine with Benzodiazepines
      1. Risk of Hypotension and Bradycardia
    2. Limit Antipsychotic doses to half dose or less for children under age 9 years old
  2. Benzodiazepines (esp. Lorazepam)
    1. Preferred agents in suspected ingestion or Intoxication
    2. Lorazepam 0.05 mg/kg IV/IM/PO up to 2 mg per dose
  3. Olanzapine (Zyprexa)
    1. Contraindicated in Unknown Ingestion, liver disease, Neuroleptic Malignant Syndrome and Seizure disorder
    2. Dose for age 6-10 years old: 2.5 mg ODT or IM injection
    3. Dose for age >10 years old: 5 mg ODT or IM injection
    4. Dose for adult weight: 10 mg ODT or IM injection
    5. Observe for Dystonic Reaction
      1. Diphenhydramine 1.25 mg/kg PO/IM/IV up to 50 mg prn Dystonia
  4. Haloperidol
    1. Age 6-12 years: 1-3 mg IM every 4-6 hours as needed (max: 0.15 mg/kg/day)
    2. Administer with Benadryl 5 mg/kg/day divided IV/IM every 6 hours as needed
    3. Frequently used in combination with Lorazepam

VIII. References

  1. Glauser and Peters (2016) Crit Dec Emerg Med 30(4): 17-27
  2. Orman in Herbert (2012) EM: Rap 12(8): 3-5
  3. Orman and McCollum in Herbert (2016) EM:Rap 16(1): 12-14

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Ontology: Chemical restraint (C1320374)

Definition (NIC) Administration, monitoring, and discontinuation of psychotropic agents used to control an individual's extreme behavior
Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 406164000
English Chemical Restraint, chemical restraint, chemical restraints, Chemical restraint (procedure), Chemical restraint
Spanish restricción química (procedimiento), restricción química