C

71 ● Physical and chemical restraint 1319

------11 such . If any ). supports the 10 . If time permits, time If . Table 71–1 Table Although this concept is laudable, mandating a 8,9 Every attempt should be made to obtain a detailed history detailed a obtain to made be should attempt Every Some authors advocate for “restraint-free” environments environments “restraint-free” for advocate authors Some 7 careful and appropriate use of patient restraints or seclusion. restraint-free restraint-free ED is impractical and poten the regarding vigilant potentially be to need clinicians Emergency dangerous. tial risks inherent to deterred patient from using both restraint physical and but chemical restraint in should appropriate not patients who are be a danger to themselves, fellow patients, or ED staff. Indeed, the American College of Emer gency Physicians, in a 2001 Policy Statement, information is rarely available or accurate, leaving clinical alternativejudg only the clinician treating the of ment an unusual luxury, the clinician medical service providers may and/or contact family question members to emergency elucidate the circumstances before ED information arrival about and previous obtain abnormal or Five groups violent of patients have behavior. been identified as being at risk for the presence of elderly, an those underlying with medical a those with history preexisting or problem: without a prior psychiatric disorder, of the substance abuse, patients tions on the time spent in restraints, and detailed documenta detailed and restraints, in spent time the on tions tion in the ED recognize that competent patients record. do have the legal Furthermore, right to clinicians refuse medical treatment need even if the result to of their refusal is death or serious bodily harm. Coercive measures, including physical restraints or the threat of physical restraints, should not be used simply because a competent patient refuses treat ment or as retaliation for perceived disruptive behavior. ASSESSMENT PATIENT A complete and thorough assessment is patients requiring mandatory physical or for chemical all restraint in the abusive or ED. agitated ascribing avoid must clinicians Emergency behavior to drug or alcohol intoxication or underlying psy chiatric disease before serious or life-threatening considering diagnoses (see the potentially more surrounding the patient’s presentation, as well as her or his past medical and psychiatric histories, including medications, drug and alcohol use, and prior similar events. In reality, by law to report any death or adverse event related to restraint to related event adverse or death any report to law by use. MEDICOLEGAL CONCERNS Emergency clinicians need to be cognizant of the potential legal ramifications stemming patients. Such patients are from often young and previously medi physically restraining cally well, and a death is usually highly charged with and racial social issues, police brutality complaints, and charges of clinician indifference. The risk of litigation can be mitigated departmen and/or institutional written to adherence strict by tal policies regarding the use of restraints and medications. Emphasis should be placed on a timely limita and re-evaluations, patient regular assessment, comprehensive prerestraint Nonetheless, emergency clinicians should not be from deterred using both physical and chemical restraints in appropriate patients who are determined to be a uncertainty danger surrounds to the themselves appropriateness or of others particular restraining patient, early a psychiatric advised, consultation are and counsel legal discus and administration hospital with sion but rarely available in practical terms. in nursing homes, extended care hospitals. facilities, and acute care

4 ------), 3 ). Table 71–2 Table Fig. 71–1 , a condition described as an 71 ). Well-documented examples include

These standards allow the use of restraints of use the allow standards These Since then, the Joint Commission for 5 6,7 excited delirium Table Table 71–1

The term 2 Psychiatric illness, acute intoxication or withdrawal, During the late 1980s and early 1990s, reports of restraint- of reports 1990s, early and 1980s late the During The need to prevent these patients from harming them CHAPTER

Any medical condition that leads to brain dysfunction Patients who abuse alcohol, sympathomimetic agents 1,2 of health care settings, including acute care hospitals and the operate. they EDs Accreditation of Healthcare Organizations (JCAHO) and the Center for Medicare and created standards Medicaid governing the use of Services restraints in a variety (CMS) have and respect. Hospitals and extended care facilities are required are facilities care extended and Hospitals respect. and policies and procedures governing restraint use ( which must address indications, staff training and education, patient assessment and re-evaluations, appropriate documen tation, and patient-focused issues such as maintaining dignity licensed practitioner has evaluated the patient and determined and patient the evaluated has practitioner licensed that less restrictive interventions have been ineffective physical and restraint is needed to being. improve The the standards also patient’s include well- requirements for written for limited periods of time, and only after a physician or nervous system trauma and infection are frequent causes of agitated or violent behavior in the (ED). emergency department delirium, medical illness, uncontrolled rage, and rarely, central central rarely, and rage, uncontrolled illness, medical delirium, caring for agitated, combative, and violent patients who are a danger to themselves and medical and nel. prehospital person Emergency clinicians are often faced with the challenge of Restraint Charles J. Fasano and Gregory Schneider Physical Physical and Chemical for restraint use. associated deaths in psychiatric and extended care facilities led lawmakers to pass legislation that established regulations selves and those around them and to perform monitoring and monitoring perform to and them around those and selves diagnostic testing and institute timely treatment often neces sitates physical and chemical restraint. hypoglycemia, hypoxia, medication intoxication, encephalitis, encephalitis, intoxication, medication hypoxia, hypoglycemia, traumatic thyrotoxicosis, hemorrhage, intracranial meningitis, brain febrile injury, illnesses in the and elderly, dementia. lead to severe agitation. may also result in agitated, behavior ( combative, or frankly violent bipolar disorder can all lead to reality. Patients an with these impaired disorders often perception develop paranoid of delusions, hallucinations, and hostile moods that can easily als who most commonly present with agitation. severe uncontrolled Alcohol withdrawal tremens, a may condition typified by excessive progress agitation. Schizo to phrenia, delirium schizoaffective disorder, and the manic phase of such as cocaine or drugs such as phencyclidine (PCP) are the subset of individu methamphetamines, or hallucinogenic individual totally out of control, unable to be reasoned with some is strength of feats great possessing and down, talked or what vague and ill defined; but it is well known to any police paramedic, officer, or emergency clinician ( C 1320 XII ● SPECIAL PROCEDURES harc ypos r epcal wrioe n require and worrisome illness. medical underlying for especially evaluation careful are symptoms chiatric should include a careful appraisal of the patient’s vital signs vital patient’s the of appraisal careful a include should a cagd ufiinl s a nt e tra t href or herself to threat others. or himself a be not as so sufficiently changed has ( perfusion patient’scondition the as soon as extremity restraints physical Remove and system, spiratory cardiore status, mental including condition neurologic and eeauto i prmut o h ptets aey n is and safety (see patient’s JCAHO the the by required to paramount is re-evaluation and testing. radiologic laboratory both include may and examination physical and history the of results the on based are studies Additional of any patient presenting with agitated or combative behavior. brain traumatic out rule injury. to investigations warrant cated intoxi appear who patients in trauma head of Signs soning. a toxidrome such as sympathomimetic or anticholinergic poi or encephalitis or meningitis as such infection underlying an an of presence the to clue because only the be may temperature elevated overlooked, be not should but restrained, been has or down calms patient the until wait to have measure may ments Temperature derangements. metabolic and tion, patient’sthe of causes organic infec trauma, as such behavior o wl nt e oeae ad il e el wt qiky and quickly with firmly. dealt be will and tolerated be not will ior is important to communicate to it empathy,the patient that and violent behav caring of displays these with agitated Along an patient. soothe often will drink or eat to something ing Similarly,patient. the calm often will staff and clinician offer help you?” This display of empathy on the part of the treating we can “how her or him ask and patient the engage verbally n voet patients. violent and agitated quell help to shown been have techniques escalation de- several with, reasoned be cannot patients many Although DE-ESCALATION TECHNIQUES nomic groups. new medical complaints, and individuals from lower socioeco restraint. chemical consider then control, gain patient, the restrain physically 71–1 Figure i cuslr o mme o te lry my lo be also may clergy, the of member or counselor, ric a worker,psychiat social a as or such individual, trained specially member family a of aid the enlisting behavior, violent beneficial. ne ptet a be rsrie, rqet periodic frequent restrained, been has patient a Once Rapid beside serum glucose determination should be part identifying at aimed be should examination Physical 1 f h ptet otne t dmntae gttd or agitated demonstrate to continues patient the If

The first action when dealing with excited delirium is to is delirium excited with dealing when action first The 12,13 Of these, patients presenting with new psy 1 sml, e efcie patc i to is practice effective, yet simple, A al 71–2 Table ). 15 Re-evaluations a l 71–3 Table 14 ). ------Violent 71–1 TABLE Restraint Healthcare 71–2 TABLE • • • Toxicologic • • • • Metabolic • • • • Infectious • • • • Endocrine • • • • Documentation • • • • Restraint • • • • • Neurologic • • • • Traumatic • • • •

Anticholinergic intoxication Anticholinergic intoxication Sympathomimetic intoxication alcohol Acute Hypernatremia Hyponatremia Hypercarbia Hypoxia infection tract Urinary Sepsis Encephalitis Meningitis Myxedema storm Thyrotoxicosis/thyroid Hyperglycemia Hypoglycemia Significant changes Significant Reassessment monitoring patient of Results use for orders Relevant restraint terminating for Criteria ᭺ restraint for need the reassessing and patient the monitoring for Criteria restraint applying for Criteria for Guidelines accident vascular Cerebral hemorrhage Subarachnoid delirium Acute states Postictal epilepticus Status hemorrhage systemic to due states flow Low Hypoxia injury axonal Diffuse hemorrhage Intracranial withdrawal Narcotic withdrawal Benzodiazepine withdrawal Alcohol tremens Delirium

Monitoring at Monitoring needs

Behavior

Protocols

Protocols

Organization

Conditions

assessing the patient the assessing Should Joint least every 2 every least

Should in the patient’scondition the in

and

Commission Include

Documentation Include

That

hr or hr Requirements

May sooner based on patient on based sooner

for

Cause

Accreditation

Agitated for

Patient

and

of

C

71 ● Physical and chemical restraint 1321

- - - ). 22 2 patient’s patient’s Fig. 71–2 This study appears study This 22 Restraining a (Courtesy of Posey Company,

A fifth-point restraint is a

). They are single-use devices, which devices, single-use are They ). Fig. 71–3 Fig. Leather extremity restraint.

Although the actual prevalence of patient restraint in Hard leather and synthetic leather limb holders are virtu are holders limb leather synthetic and leather Hard Soft limb restraints are usually made from cotton and/or Belts/Fifth-Point Restraint. Limb Holders (Restraints). to support the safe use of restraints by emergency clinicians, who by virtue of their training and experience are experts in recognizing signs of deterioration and skilled in airway man agement and resuscitation. EDs is unknown, it has been estimated that 25% of teaching hospitals physically restrain at least one person per day. foam materials ( materials foam obviates the need for cleaning and restraints are sterilization. less rigid Soft than limb leather limb restraints, making them easier to apply. In addition, because they are fastened without the use of a key, soft limb restraints are more less and easily agitated for used typically are restraints Soft removed. combative patients because they are not as secure as leather limb holders. belt apparatus used to supplement the use of four limb Restraint Devices extremities is the primary method of physical restraint used in the ED. Limb restraints are constructed from a variety of materials including leather, synthetic single-use leather, foam material. cotton, These materials provide and restraints that differ in strength, ease of removal, and cleaning. ally impossible to break or tear but are difficult to sterilize if they become soiled with blood or bodily fluids ( They are more rigid than soft restraints, also making somewhat them more difficult and time consuming More to apply. unlock to key a require holders limb leather most importantly, and, as a result, might take longer to remove after an adverse event such as vomiting or respiratory holders arrest. are generally Leather used to limb restrain combative and violent restraints secure indestructible for need the whom in patients, removal and application time-consuming more the outweighs process. Figure Figure 71–2 Inc., Arcadia, CA.) Physical Restraint Research in the area of ED restraints is limited. In one pro ED 298 in complications restraint-associated of study spective patients, minor complications were patients, and there were no serious complications or deaths. seen in only 7% of The author of this study concluded that dangers of ED patient ED of dangers that concluded study this of author The restraint promulgated by overstated. be may regulators care health professional organizations and -

A during

). Assess Reasons for this Nevertheless, at

20 2,20 to

Table 71–3 Table Areas

Patients

In the mid-1980s, seclusion was Removal

Place agitated and violent patients in 16–19 20 Restrained may calm a potentially violent patient

Recommended of Restraint

for

Status

Status

Comfort 20,21

Signs

Seclusion is often used in conjunction with chemical and/ chemical with conjunction in used often is Seclusion If these conservative measures fail, summon hospital Skin under and around the restraints Hydration Personal hygiene needs Toileting Blood pressure Heart rate Respiratory rate Oxygen saturation Temperature Sensory examination Capillary refill Distal pulses Level of alertness Degree of agitation Pupillary examination Motor examination

Assessment • • Patient • • • • • • Vital • Vascular • • • • • Neurologic • • TABLE TABLE 71–3 Re-evaluation commonly used to calm combative and violent ED patients, but its popularity has declined since then. vals, similar to restrained patients (see seclusion on dedicated hospital stretchers or beds secured in located be should room seclusion The injury. prevent to place near ED staff and inter allow frequent regular at seclusion in placed patients Reassess for constant patient observation. The utility of seclusion in psychiatric and adult both evaluation in documented well is wards hospital inpatient units and pediatric populations. TYPES OF PATIENT TYPES RESTRAINT OF PATIENT Seclusion or physical restraints. strong show of force without the need for restraints. security to ensure the safety of the patient and staff. In these situations, security staff should bedside, but should not instead gather outside rush the door or close to by, the remaining within patient’s eye contact of the patient’s room. is an effective, although underutilized, ED practice for selected for practice ED underutilized, although effective, an is patients. institutions with adequate physical space and well-designed policies and procedures, experience has shown that seclusion and compliance with regulatory agencies. decline are unclear, but probably include space lack and of concerns regarding adequate the provision of medical care C 1322 XII ● SPECIAL PROCEDURES mend the use of restraint jackets and vests in the ED. the in vests and jackets restraint of use the mend sd y a efreet gnis eas te impede they because agencies enforcement law by used locking cuffs ( connecting with ankles patient’s the securing by movement use. their abandon to American Society Geriatric the from recommendations prompting focation, suf and choking to secondary deaths restraint-associated of ( number ED a in implicated the been have in products these Moreover, utility little have they falls; of tion on inpatient wards and extended care facilities for the preven locks. key-release and release quick- both with available are and material synthetic of out made usually are restraints Fifth-point suffocation. accidental the prevent to of risk the increasing enough device, the under slipping snugly from patient belt the place and times all at position upright the in stretcher the of rails side the Place vomiting, especially events, because they may not be able to sit up or turn onto their side. adverse for interventions. monitoring close therapeutic require or pelvis or chest, thighs, the across restrained Patients diagnostic with interferes restraints, and for those whose continued combative behavior limb adequate despite themselves, harming for risk at be to 71–4 ( pelvis or chest, thighs, the down holding by restraints 71–4 Figure CA.) Arcadia, Inc., 71–3 Figure Arcadia, CA.) Arcadia, obe e Restraints. Leg Hobble Vests.and Jackets ). A fifth-point restraint is used for patients who continue

Fifth-point r Fifth-point restraint. extremity Cotton Fig. 71–6 estraint. ). Hobble leg restraints are commonly

Jackets and vests are generally used generally are vests and Jackets

(Courtesy of Posey Company,Inc., Posey of (Courtesy

obe e rsrit limit restraints leg Hobble

(Courtesy of Posey Company,Posey of (Courtesy 9 We do not recom not do We i. 71–5 Fig. Fig. ). - - - n/r prpit tetet edrd Lm rsrit are restraints Limb rendered. treatment appropriate and/or performed be can tests diagnostic important that so restraints limb require often status mental altered with without Patients delay.her or him restrain others, or herself or himself to threat immediate an deemed is patent a if However, earlier). “ (see attempted are techniques de-escalation verbal while delayed be can restraints of use the or violent patients from harming themselves or others. Often, combative, agitated, prevent to indicated are restraints Limb Indications “ (see used widely longer no is violent psychiatric patients ( tie patient’s a a as to referred commonly binding back, his or her behind hands and restraints, leg hobble positioning, prone of combination encounter The devices. will these in clinicians placed patients emergency most that means ties but their use by law enforcement agencies and prison authori ED, the in used seldom are restraints leg Hobble a risk. flight pose who those and patients to violent method potentially effective transport an them making kicking, and running Figure 71–6 Figure 71–5 Figure Arcadia, CA.) Arcadia, Arcadia, CA.) Arcadia, ws cmo mto fr etann pioes and prisoners restraining for method common a was ,

Hobble leg restraint. leg Hobble vest. Restraint

(Courtesy of Posey Company,Inc., Posey of (Courtesy Fig. 71–7

(Courtesy of Posey Company,Inc., Posey of (Courtesy Positional Asphyxia Positional eEclto TechniquesDe-Escalation ). However, this practice ,” later). ,” hog ,” - C

71 ● Physical and chemical restraint 1323 - - Table Table Other Chemical cause skin Restraints may

For some patients, being placed in placed being patients, some For A minimum of five well-trained

force.

of

,” later). In these patients, the addition of Show

,” later). In contrast, the use of extremity restraints ). If leather restraints are used, have a restraint key readily key restraint a have used, are restraints leather If ). Local Skin Complications. Increased Agitation. Increased Apply the limb holders snugly enough to control move Once the patient has been safely restrained, frequent re- because the natural progression of sedation and alcohol sleep. Intoxicated intoxication patients may is benefit from a brief period of observation administer before chemical sedation. Most of these patients a will fall decision is accompanying the and sedation for need the obviating asleep, made to risks. irritation or breakdown. Risk factors include restraints that have been placed too tightly and those that have been left on for prolonged periods of time. Leather restraints are more physical restraints is so emotionally disturbing that it actually con who Patients behavior. combative and agitation increases tinue to struggle despite restraints are at risk for a number of potentially serious adverse events ischemia, including metabolic skin acidosis, damage, and Complications even death (see “ chemical sedation is highly recommended Restraint (see “ alone is often effective in the alcohol-intoxicated patient Figure Figure 71–8 individuals should be available to restrain a patient. This show of force may help discourage the patient from resisting and is an important part of the restraint process. ment and prevent escape, but not so tight as to cause pain or impair circulation. If necessary, place a fifth-point restraint across the patient’s thighs, pelvic, or chest motion. to A surgical mask further may be temporarily limit placed over the patient’s mouth to prevent members of the her restraint team or ED staff. or him from spitting at evaluation in accordance with your institution’s policies and procedures is the key to preventing complications (see 71–3 available in the event that the restraints need to be removed Restraints urgently. should have well-defined time limits and should be removed as soon changed as sufficiently that the he patient’s or condition she is has no longer himself or herself a or others. threat to Complications injury to these joints and concentrates center of Such patient’s gravity. patients rarely perceive force pain, closer to the digits, patient’s the twisting or manipulating of practice the so nose, or ears should be avoided because it is generally useless violent and combative patient’s the escalate further might and behavior. - Fig. . hog tie The combination

restraint.

of

). This show of force may help method

Fig. 71–8 “hog-tie”

The

). Control above the elbow and knees reduces the risk of Always restrain patients in the supine, rather than the Avoid Avoid fifth-point restraint of the abdomen and pelvis The addition of a fifth-point restraint is indicated in 71–9 prone, position. Assign one person to each limb, which they hold firmly against the stretcher by applying direct pressure proximal to the elbows and knees. The fifth member of the team places restraints around the wrists and ankles ( but should be promptly searched and all potentially harmful and matches, combs, razors, knives, guns, as such possessions, lighters, taken for safekeeping. police or hospital security. When possible, undress the patients the undress possible, When security. hospital or police and place them in a hospital gown before restraining them. When this is not practical, the patient can still be restrained, restrain a patient ( part important an is and resisting from patient the discourage of the restraint process. and technicians, nurses, clinicians, include may team restraint The individuals making up the Procedure A minimum of five people, all of whom have had training in restraint technique and patient safety, should be available to ostomies, and percutaneous feeding tubes. In addition, it or pulmonary underlying with patients that is note to important cardiac disease may not tolerate restraint of their thorax. arterial injury or surgery. region in patients with pelvic fractures, suprapubic tubes, limb restraints on extremities with fractures, open wounds, or wounds, open fractures, with extremities on restraints limb acute skin and soft tissue infections and use them cautiously in patients with uncertain or unreliable extremity perfusion, such as those with peripheral vascular disease or previous Contraindications delayed be may restraint physical situations, appropriate the In in favor of an attempt at verbal de-escalation. Do not place therapeutic interventions. In general, the ED use of restrain ing vests and recommended. jackets and hobble leg restraints is not patients who continue to be at risk for harming themselves, whose patients those for and restraints, limb adequate despite continued combative behavior interferes with diagnostic or also used to prevent patients tubes from endotracheal as such removing devices, life-saving potentially or with interfering and indwelling intravenous lines and catheters. discouraged. Although this was a common method for restraining prisoners and violent psychiatric patients in past, the hog tie is no longer recommended. The exact physiologic and metabolic derangements from this position by itself is likely minimal, but the practice is strongly Figure Figure 71–7 of prone positioning, hobble leg restraints, and binding a patient’s hand behind his or her back, is commonly referred to as a C 1324 XII ● SPECIAL PROCEDURES the patient’s thighs, pelvis, or chest to further limit motion. limit further to chest or pelvis, patient’sthighs, the across placed be may restraint fifth-point necessary,a If circulation. impair or pain cause to as tight so not but escape, prevent and movement control to enough snug applied be should holders limb The ankles. and wrists the around restraints places team the of member knees. and elbows the to proximal pressure direct applying by stretcher the against firmly hold they which limb, each to assigned is person One position. supine the in restrained be always should ity of ischemia. of ity complaints patient’s restrained also a regarding extremity pain without first evaluating the possibil also ignore is to it are not previously, function important mentioned sensory As important. and extremely motor and temperature, and color skin refill, capillary pulses, of assessment Frequent proper fit, and limiting to restraint time will attention help avoid injuries, ischemia. occult for search thorough A risk. this increase further may restraints the against injury.Struggling occult an from swelling develop who those in and tightly too placed are restraints whose patients in occur to likely more is extremity.Ischemia distal the of ischemia in result cases, could this extreme In feet. and hands the to flow blood impede event. adverse an of plaints of restraint pain without first evaluating the possibility patient’sa ignore to not important also is com It struggle. to restraint will help avoid skin damage in patients who continue chemical of use judicious the addition, In complications. skin and reevaluating frequently (see time, restraint limiting restraints, tight overly avoiding sible, despite struggle to being placed in restraints. continue Using soft restraints whenever pos who patients in true ticularly par is This damage. skin cause to restraints soft than likely 71–9 Figure VascularCompromise. A

Technique B

to

restrain

Restraints have Restraints

Table 71–3 a

violent

patient. ) will help prevent the potential to potential the

A, B, Patients The fifth The - - - - tion, some restraint positions (e.g., prone, hog tie) may not may tie) hog prone, (e.g., positions restraint some tion, restraint belt in patients with underlying COPD. underlying with patients in belt restraint supplemental a use to need the negate may sedation chemical the prone or in patients restraining not by avoided be can Respiratory complications chest. the across restraint fifth-point a tolerate with chronic obstructive pulmonary disease (COPD) may not dium. catecholamine surge in an already cocaine-sensitized myocar to due arrhythmias cardiac fatal of risk the increases process restraining the by caused stress that suggested been also has It death. and asphyxia to leading ultimately hypoxemia, and hypercarbia, hypoventilation, of likelihood the increases ics prone position, interference with normal respiratory mechan the in especially restrained, are delirium agitated associated n toe ih nelig umnr disease. pulmonary underlying with those and to likely more positions hog-tie or prone the isin restrained patients in occur This patients. some in mechanics ratory ie o ccie binges. cocaine of times during excess dopamine subsequent with receptors dopamine of down-regulation involving process complex a is delirium some cases of sudden death in restraint. in death sudden in of cases some implicated been has pathophysiology this but unknown, is arrhythmias malignant for potential The stressed. severely is individual the until silent clinically often cardiomyopathy, arrest and death. and arrest respiratory to progress can that agitation severe and delirium delirium agitated ated be used in not the ED. should therefore and asphyxia positional for risk retical bolic acidosis. bolic meta severe to lead can struggling and agitation continued aty n h 19s wn t te ouaiy f crack of popularity the to owing 1990s cocaine. the in signifi cantly increased incidence the but 1985, in described first was syndrome The syndrome. this for risk high particularly ing exertion far beyond normal physiologic limits. physiologic normal beyond far exertion ing psychosis and delirium, which may alter pain sensation, allow of presence the by increased further is lactate of buildup the impeding lactate clearance by the liver. the by clearance lactate impeding by acidosis lactic exercise-induced enhance to believed is and may result from agitation or cocaine (and other stimulant) use by compounded exertion vasoconstriction Such vasoconstriction. physical sympathetic-induced from acid lactic of tion produc the involves probably but unclear, is acidosis this of factors. contributing be to thought are use stimulant concurrent and unclear is death sudden underlying cardiac and pulmonary disease, prone positioning, to restraint of contribution restraint. from promise com pulmonary severe experience to seem not volunteer do and subjects unproved, and vague are restraint to ondary sec embarrassment respiratory of specifics The positioning. patient to related solely theoretically asphyxia to due death unexpected is use, restraint to attributed complication ratory tts s niae i ptet wt oeiy n CP and COPD and obesity with patients in indicated respiratory is status of monitoring close Extremely asphyxia. tional posi prevent help will re-evaluating frequently and position those using cocaine or other stimulant drugs. stimulant other or cocaine using those Positional Asphyxia. Positional Compromise. Respiratory Metabolic Acidosis. agitated cocaine-associated of pathophysiology The Delirium. Agitated Cocaine-Associated 31 hoi siuat s las o adrenergic-induced to leads use stimulant Chronic 23,25,27–30 31,32 hog-tie 34 The hog-tie position places patients at theo at patients places position hog-tie The The pH is often less than 7.0. The etiology The 7.0. than less often is pH The 25,27,30,31,34 23–26,29,31–33 positions. In addition, the use of adequate s snrm o hprhri with hyperthermia of syndrome a is

31,35–37 In patients who have been restrained, Restrained patients appear to be at be to appear patients Restrained lhuh fe ipiae, h exact the implicated, often Although

Positional asphyxia Positional Restraining patients in the supine hn ains ih cocaine- with patients When

Restraints may Restraints 38,39 In some patients, some In , a severe respi severe a ,

Cocaine-associ impair respi impair 23–27 34 . Obesity, Patients In addi In ------C

71 ● Physical and chemical restraint 1325 ------40 ). Droperi droperidol are Table 71–5 Table ). . Low-potency neuroleptics such as such neuroleptics Low-potency . Haloperidol and

In addition, like all neuroleptic agents, Table 71–4 Table 41 Despite recent concerns intra unapproved about recent Despite ). 64,66 The emergency clinician is often faced with an uncon Contraindications. Table 71–4 Table haloperidol and droperidol can cause QT prolongation, they so should be used with caution in patients at risk for QT prolongation and torsades de pointes ( others, attenuate psychosis, decrease the time spent in physi medical a permit to enough patient the calm and restraints, cal tests diagnostic perform and examination physical and history and procedures. Contraindications and Adverse Effects Absolute and relative contraindications and adverse vary by agent effects and are discussed separately for each agent. Neuroleptic Agents not do usually agents neuroleptic of effects antipsychotic The occur for 7 to 10 days, but making the them onset useful of in sedation the is acutely rapid, agitated neuroleptic patient. agents Potent such as haloperidol preferred because they lack and tolerance with repeated use, have droperidol are index therapeutic high a possess and potential, addiction low a (see been have agents these prolongation, QT and administration venous used safely and effectively for years in the ED patient with undif delirium agitated ferentiated incidence higher a to owing desirable less are chlorpromazine of hypotension, seizures, and anticholinergic effects. contraindicated in patients with thyrotoxicosis (neurotoxicity may develop), Parkinson disease, or severe hepatic These drugs disease. can lower the seizure threshold, so they should be used with caution or not at all in patients with a history of seizures or trauma patients who may be at risk for seizures. with patients in safely used been has droperidol Nevertheless, a seizure disorder. ment ment of benzodiazepines added another medication arsenal. to These the agents, because of their solid have virtually replaced safety barbiturates in the treatment profile, of acute agitation. Recently, intramuscular preparations of “atypical antipsychotic” medications such as olanzapine and done ziprasi have provided additional treatment options tranquilization. for rapid chemical restraint. Recommendations for the drug selection are also discussed ( Indications and patient the to injury prevent to used is restraint Chemical trollable individual with an undifferentiated etiology for the delirium and one who has been resistant to reason and physi in controlled quickly be must individual an Such restraint. cal The restraint. chemical of use the to equates this and ED, the ideal drug for chemical restraint should have multiple routes of administration (i.e., intramuscular, intravenous, transmu cosal), a rapid onset of action, and negligible hemodynamic effects, should be familiar to the clinician, should possess medica one No effects. side minimal with record safety good a tion fits this profile for every patient, but with proper patient assessment and careful drug selection, most ED patients can rapid which in setting ED the In sedated. safely and rapidly be tranquilization is usually the goal, administered medications intramuscularly should (IM) be other or routes may be intravenously used when parenteral administration (IV); is not practical or feasible. The remainder of this chapter dis cusses the safety, efficacy, for used commonly side most medications the for dosages mended effect profile, and recom ------The 3 . These 15 The utility 34 The develop Patients who 3 34 -aminobutyric acid , which seems more γ The JCAHO defines 7 Such statements do not reflect reflect not do statements Such Clues to the presence of a 34 rapid tranquilization Restrained patients with severe metabolic acidosis should should acidosis metabolic severe with patients Restrained The CMS states a chemical restraint is “a medication Regardless of the etiology, profound metabolic acidosis The pathogenesis of agitation is poorly understood, but psychotropic drug to manage or control behavior.” chemical restraint as “the inappropriate use of a sedating benefit of treating underlying psychotic states. discovery of antipsychotic medications treatment revolutionized of acute the agitation. Not become only safer, but did many of tranquilization these new agents had the added receive aggressive saline hydration and sedation with benzo diazepines to counter sympathetic hyperactivity. with signs and symptoms suggestive of metabolic acidosis and acidosis metabolic of suggestive symptoms and signs with in those with a suspicion of a potentially lethal co-ingestion (e.g., salicylates and toxic alcohols). adequate intravenous fluid administration. Laboratory testing, Laboratory administration. fluid intravenous adequate including arterial blood gas analysis, serum electrolytes, and serum creatine phosphokinase are recommended in patients metabolic acidosis include severe agitation, signs abnormal (e.g., vital persistent tachycardia, tachypnea, and hyperpy rexia), and decreased or concentrated urine output despite particularly high risk for death. remain combative despite restraints, have especially used cocaine those or other who sympathomimetic agents, are at used to control behavior or to restrict the freedom patient’s of movement and is not a standard treatment for the patient’s medical or psychiatric condition.” have used the term descriptive and less pejorative. ity, quell dangerous behavior, limit pathophysiologic derange pathophysiologic limit behavior, dangerous quell ity, ments, and permit a more thorough evaluation of a patient’s underlying condition. The term “chemical restraint” carries with it a negative connotation to many practitioners. Others Chemical Restraint tranquil induce to medication of use the is restraint Chemical reserved for patients with pH cardiac arrest below has occurred, 7.0. resuscitative However, efforts are once futile. usually of sodium bicarbonate is unknown but is probably best and unexpected death in restrained patients. maced/pepper-sprayed, maced/pepper-sprayed, leading to unproven speculation that these interventions may have been culpable. has been associated with cardiovascular collapse and sudden individual individual suddenly stops struggling and experiences a brady cardic/asystolic death that is not Such patients may immediately have been recognized. subdued by force, or Tasered, allow allow adequate respiratory compensation, resulting in further enhancement of the acidosis. The common out-of-hospital cardiac scenario arrest, in which is the severely an agitated able side effects and, in some cases, resulted in death. (GABA). Prior to the development of antipsychotic medica tions, pharmacologic management of agitation included bar biturates, insulin undesir of coma number a had treatments These agents. anesthetic therapy, bromides, and various is thought to arise from increases in dopamine and noradrena and dopamine in increases from arise to thought is lin with concomitant decreases in after all other measures fail and the health and safety of the threatened. are staff and/or patient standard care in the ED, and should not be interpreted as prohibi tion of the appropriate short-term use of chemical restraint definitions lack perspective on the use of chemical restraint in the ED where these medications are typically employed C 1326 XII ● SPECIAL PROCEDURES spasms of neck, eyes [oculogyric crisis], tongue, or jaw), drug- (see blockade cholinergic and tension, prolongation, neuroleptic malignant syndrome (NMS), hypo QTc (EPS), symptoms extrapyramidal include agents leptic be avoided in these patients. these in avoided in be syndrome should serotonin and (LSD) diethylamide with acid lysergic taking associated patients been also has dol diethylamide. acid lysergic LSD, symptoms; extrapyramidal EPS, with used often currently are medications These use. ED short-term to equated be cannot use long-term of efficacy and safety the concerning caveats the of *Many TABLE71–4 Olanzapine Ziprasidone Midazolam Lorazepam Droperidol Haloperidol Agent safety and efficacy for short-term sedation in clinical ED practice. ED clinical in sedation short-term for efficacy and safety Adverse Effects. Adverse P icue ktii (eteses, ytna (muscular dystonia (restlessness), akathisia include EPS

Children: 0.03– Children: 5 Adults: > 6–12 Children: 5 Adults: Children: Not Children: 10 Adults: Not Children: 10–20 Adults: Children: 5 Adults: Children: 2–4 Adults: 12.5 indicated indicated 0.1–0.2 0.05–0.1 2.5 (maximum, 0.07 Drugs 12

yr: 2.5–5 yr:

mg/kg mg Dosage

Adverse effects common to all neuro all to common effects Adverse Used mg/kg mg IM/IV mg IM/IV mg IM/IV mg

mg/kg mg IM mg

mg IM/IV mg

mg

mg IM mg

yr: 40

for mg)

Chemical Duration: 2–24 Duration: 15–30 Onset: 4 Duration: 15–30 Onset: Duration: 5 IM: IV:3 Onset: 8–10 Duration: 30–45 IM: IV:Onset: 2–12 Duration: 3–10 Onset: 4–24 Duration: 30–45 Onset: Onset/Duration 30–120 15–20 Table71–4 of

min

Restraint Action

min

min

min

hr

min min

min min min

). hr hr hr hr

in

the All forms of forms All of forms All of forms All Psychiatric Psychoses, of forms All Indications agitation agitation agitation illness intoxications agitation

Emergency - - oe ae edm f vr ie hetnn. Anticholinergic threatening. life ever if seldom bother are although some, and, action antidopaminergic drugs’ the to due are effects These dyskinesia. tardive and tremor), ing, drool gait, shuffling stiffness, (muscle parkinsonism induced leptic drug use is prolongation of the QTc interval, leading QTcinterval, the of prolongation is use drug leptic EPS. minimizing or preventing (1–2 benztropine and IV) or (25–50 diphenhydramine as such agents A potentially deadly, but exceeding rare, effect of neuro of effect rare, deadly,exceeding potentially but A Patients with Patients a with Patients a with Patients Patients with Patients with Patients with Patients Contraindications

pregnant women pregnant and depression respiratory LSD with intoxication and disease, hepatic severe disease, Parkinson thyrotoxicosis, prolongation, QT of history disease hepatic severe and disease, Parkinson thyrotoxicosis, prolongation, QT of history dementia dementia women pregnant and depression respiratory Department Respiratory Extrapyramidal Extrapyramidal Somnolence, QT Respiratory Adverse hypotension ataxia, depression, blockade cholinergic hypotension, syndrome, malignant neuroleptic prolongation, QTcsymptoms, blockade cholinergic hypotension, syndrome, malignant neuroleptic prolongation, QTcsymptoms: EPS EPS somnolence, prolongation, hypotension ataxia, depression,

mg IM/IV) mg

Events

mg orally mg are very effective in effective very are First-line therapy for therapy First-line warning box Black alone given be Can Lower incidence of incidence Lower of incidence Lower for therapy line First intoxication owing intoxication alcohol with patients in caution with use children; children in caution with use IM; onset rapid arrhythmias; serious and prolongation QT regarding threshold seizure the lower may benzodiazepine; a with combination in or with dementia with patients elderly in use regarding warning box black droperidol; and haloperidol with compared EPS dementia with patients elderly in use regarding warning box black droperidol; and haloperidol with compared EPS depression respiratory of risk the to owing intoxication alcohol with patients in caution with use onset; IM rapid children; depression respiratory of risk the to Comments [PO], IM, [PO], * - - - C

71 ● Physical and chemical restraint 1327 . - - - -

be Table Table “Black

msec for

(see The recom The 50 3 Years of clinical Years males or 450 Haloperidol can In elderly patients, the

Administration

analogue of haloperidol, is * msec for Drug

mg PO.

and

every 4 to 8 hours with a maximum Droperidol Food

Children older than 12 years can receive Droperidol, an for

mg IM

U.S.

be administered. For patients in whom the potential mg/kg/day. mg/kg/day. NOT

Warning

). Droperidol. Dosage and Administration. mg IM or IV or 5 to 10

INAPSINE should be administered with extreme caution to Due to its potential for serious proarrhythmic effects and death, Cases of QT prolongation and serious arrhythmias (e.g., torsades INAPSINE is contraindicated in patients with known or suspected of such agents in the ED is unknown, and long-term or high dose use are not necessarily applicable to ED care. Droperidol is currently often used with safety and efficacy for short-term sedation in clinical ED practice. syndrome. patients who may be at risk for development of prolonged QT syndrome (e.g., congestive heart failure, bradycardia, use of a diuretic, hypokalemia, cardiac hypertrophy, hypomagnesemia, or administration of other drugs known to increase the QT interval). Other risk factors may include age over 65 years, alcohol abuse, and use of agents such as benzodiazepines, volatile anesthetics, and IV opiates. Droperidol should be initiated at a low dose and adjusted upward, with caution, as needed to achieve the desired effect. Cases of QT prolongation and/or torsades de pointes have been reported in patients receiving INAPSINE at doses at or below recommended doses. Some cases have occurred in patients with no known risk factors for QT prolongation and some cases have been fatal. INAPSINE should be reserved for use in the treatment of patients who fail to show an acceptable response to other adequate treatments, either because of insufficient effectiveness or the inability to achieve an effective dose due to intolerable adverse effects from those drugs (see package insert Warnings, Adverse Reactions, Contraindications, and Precautions). de pointes) have been reported in patients treated with INAPSINE. Based on these reports, all patients should undergo a 12-lead ECG prior to administration of INAPSINE to determine if a prolonged QT interval (i.e., greater than QTc 440 females) is present. If there is a prolonged QT interval, INAPSINE should benefit of INAPSINE treatment is felt to outweigh the risks of potentially serious arrhythmias, ECG monitoring should be performed prior to treatment and continued for 2–3 hours after completing treatment to monitor for arrhythmias. QT prolongation, including patients with congenital long QT TABLE 71–6 TABLE Box” mended dosage for rapid tranquilization in agitated patients a high-potency butyrophenone with rapid tranquilizing intravenous haloperidol is not FDA approved. attest to experience its with safety IV in haloperidol, stan however, dard doses required for the short-term control of agitated delirium IM, haloperidol has a peak clinical minutes effect and may within last 30 up to to 24 45 hours when agitation. When given given PO, its for bioavailability is acute 60% and the onset of action is 30 to 60 minutes. Haloperidol is metabo lized by the liver and excreted by the kidneys *The relevance of these observations and recommendations for short-term use ECG, electrocardiogram. administered PO, IV, and IM chosen. is route and which of regardless oversedation has a low incidence of is 5 dose should be halved. In children aged 6 dosage is to 1 to 12 3 years, the of 0.15 the adult dosage. Although it is common practice, the use of 71–4 ED for undifferentiated agitated delirium. It is usually com bined with benzodiazepines.

3 - - - - -

44–49 and Table Table

Risk factors Risk 43 is a neuroleptic and Prolongation

Ziprasidone has been 43 QTc

). It is categorized as a high- for

40 Factors Table 71–4 Table

Haloperidol (Haldol) QT syndromes specific cytochrome P-450 enzymes

c prolongation Risk In addition, a number of case reports and

42 Pointes

. . Haloperidol is universally used IV, despite lack of . Haloperidol is universally used IV, de

) regarding its propensity to cause QTc prolongation and prolongation QTc cause to propensity its regarding ) Symptoms of NMS include rigidity, hypertension, hyper hypertension, rigidity, include NMS of Symptoms Haloperidol. Hypotension is usually orthostatic in nature and tends to Independent QT Inhibition of specific cytochrome P-450 enzymes Competition for Overdose Overdose of antipsychotic drug Female sex Restraint use and psychological stress Substance abuse Miscellaneous factors Elderly patients Renal and hepatic impairment Congenital long Cardiac disorders (ventricular heart hypertrophy, failure, bradycardia) Electrolyte imbalance (especially hypokalemia)

Pharmacodynamic Factors • Pharmacokinetic Factors • • • • Pharmacologic • • • • • • Nonpharmacologic • • TABLE TABLE 71–5 Torsade and endotracheal intubation. thermia, and altered with sedation measures, cooling dantrolene, of administration mental status. paralysis neuromuscular cases, severe in and benzodiazepines, Treatment includes for QTc for prolongation QTc and torsades de pointes are 71–5 listed Table in associated with any cases of torsades de pointes. de torsades of cases any with associated shown to prolong the QTc interval more than chotic agents except thioridazine, but to all date, it has not been antipsy small case series document QTc prolongation and torsades de torsades and prolongation QTc document series case small pointes after administration of haldol. Haloperidol has been evaluated in a large number of clinical trials alone and in combination with benzodiazepines. potency neuroleptic due to its strong antidopaminergic activ ity. The antidopaminergic activity is responsible for both its psycho and hallucinations, delusions, against effects intended motor agitation and its unintended parkinsonian symptoms. a butyrophenone (see to torsades de pointes, a polymorphic ventricular arrhythmia death. sudden and fibrillation ventricular to progress can that any etiology U.S. Food and Drug Administration (FDA) approval, in the These studies demonstrate that intramuscular haloperidol is both safe and effective in the treatment of agitation caused by virtually much less severe than the lower-potency agents. haloperidol and droperidol have a lower incidence of hypo tension than neuroleptic lower-potency agents. Likewise, the anticholinergic effects (e.g., confusion, dry mouth, vision, blurred urinary retention) of haloperidol and droperidol are be more pronounced when the drugs are given IV. In general, In IV. given are drugs the when pronounced more be agent that has been tagged with a “black box warning” ( 71–6 sudden death. Droperidol has been the most prolongation with publicized and QTc is currently the agent only neuroleptic associated C 1328 XII ● SPECIAL PROCEDURES and seizure disorders. seizure and intoxication, cocaine and alcohol injuries, head with patients and ziprazidone. and lorazepam, than control tive effec and rapid more provides droperidol that found ization results. excellent with for tranquilization it rapid used who psychiatrists and clinicians emergency and droperidol use for the treatment of acute agitation. acute of treatment the for use droperidol with mortality or morbidity increased demonstrate to failed large retrospective studies encompassing over 15,000 patients ot ains ufrn fo aiae dlru, n large and used. safely delirium, been have benzodiazepines all of agitated doses from suffering patients most (see distress respiratory 71–4 in patients in caution with benzodiazepines use depression, respiratory of possibility the of Because restraint. chemical a as benzodiazepines of use the droperidol’sbut hours 12 to up last may effects sedative clinical peak a hours, 4 to 2 is half-life elimination The minutes. with 30 at effect minutes 10 to 3 is action of onset The 5 is sedation for 5–10 (i.e., dosage recommended the at used restraint. chemical for useful it found EDs psychiatric after, Soon agent. chotic antipsy and antiemetic an as 1970 in approved FDA initially significant possesses (see activity droperidol antidopaminergic haloperidol, Like effects. used droperidol frequently for treating postoperative nausea who anesthesiologists from reaction harsh sparked warning box black The use. its prohibit or restrict to pharmacies and and successful ED use. Unlike the neuroleptics, benzodiaze neuroleptics, the Unlike use. safe ED successful of and history long a predictable and andIM or rapid IV chemical given their when absorption to for due likely used is This commonly restraint. most benzodiazepines the are midazolam and Lorazepam agent. antipsychotic an with combination in or alone used be can Benzodiazepines netics. pharmacoki and administration, of primarily route dosage, are to related effects) adverse duration, onset, (e.g., effects tranquilization of agitated patients. The differences in clinical for choice excellent an them makes combination This neurotransmission, ation. relax GABA muscle and hypnosis, sedation, anxiolysis, in enhance resulting benzodiazepines All Benzodiazepines Table71–4 minutes. 5 within usually benzodiazepines, other than sooner evident are toxicity and effects the because diazepam intravenous of use preferred the for support some is There term. long used pines do not treat underlying psychiatric disorders, even when rhythmias (see rhythmias dys fatal cause to potential box” the had “black it a that stating issued warning, FDA the when 2001 until popularity action. of tion dura shorter and onset rapid more its to owing haloperidol use of droperidol has declined dramatically.declined has droperidol of use the warning, box black the behind evidence of lack apparent cate reports. cate The warning. box authors black of this review found the a number of to anomalies and dupli led that FDA the to mitted controversy prompted an independent review of the data sub Contraindications. Administration. and Dosage tranquil rapid for agents of variety a comparing Studies rprdls s a a hmcl etan icesd in increased restraint chemical a as use Droperidol’s . eprtr dpeso i, oee, ey niey in unlikely very however, is, depression Respiratory ). ). They concluded that droperidol is a safe drug when drug safe a is droperidol that concluded They Table71–6

57 mg IM mg In addition, droperidol has proved safe in safe proved has droperidol addition, In 51 ay hscas rfr rprdl to droperidol prefer physicians Many 41

or IV. There is no oral formulation. oral no IV.is or There There are few contraindications to contraindications few are There ). 52 56 This prompted many hospitals many prompted This haloperidol, al 71–4 Table

h iiil oae used dosage initial The

mg) . rprdl was Droperidol ). 55 44 51,54 midazolam, . 54 ned two Indeed, ept the Despite 41,51 59 This Table (see 57,58 53 ------

more protracted (see protracted more is lorazepam of dose intramuscular an after sedation of onset the lorazepam, and haloperidol of combination a and azolam, neuroleptics. than However,mid droperidol, haloperidol, with compared when tolerated better was and effects ramidal aiir o h ciiin Al r gvn n irtd amounts, titrated benzodi in preservative in the IV.glycol, preferably Propylene given are All clinician. the to familiar 71–4 ie o nte, o hnig h du my e rfrbe to class. another to preferable switching be may drug the changing so another, to tive some For used. are reason, patients resistant to one benzodiazepine may doses be sensi gargantuan when acidosis bolic meta cause rarely and gap osmolal the elevate can azepines, in f oaea ms b rfieae, hs potentially setting. hospital thus pre the in refrigerated, and countries underdeveloped be in use its limiting must lorazepam of tion prepara intramuscular or intravenous The interactions. drug drug- few has lorazepam so system, P-450 cytochrome the of involvement require not does This glucuronide. inactive an to conjugated rapidly is Lorazepam goal. the is sedation term long- when choice better a lorazepam makes This hours. 10 to 8 of effect of duration a produces which hours, 15 to 12 is benzodiazepine of choice when rapid, short-term sedation is sedation short-term rapid, when choice of benzodiazepine the is Midazolam action. of more duration shorter and its onset rapid of virtue by benzodiazepines other from differs It epine shown to be effective for rapid tranquilization. rapid for effective be to shown epine minutes. 45 to 30 in achieved usually is sedation adequate lorazepam, of injection muscular intra an Following established. been has dose maximum No sublingually,IV,PO, IM, (see istered rectally or admin be can and doses 4-mg to 2- in given usually is epam a son o e n fetv du fr ai chemical rapid for drug effective an be restraint. to shown was tia. demen and syndromes, brain organic with delay, developmental patients in especially occur, may disinhibition para doxical rare, exceedingly Although loss. blood occult or tion dehydra severe or moderate with patients in pressure blood in drop considerable a cause may benzodiazepines However, ED. the in used typically doses the in not but COPD, with those in and elderly the in greater also is depression respiratory of risk The barbiturates. have or opiates taken who or alcohol patients consumed agitated treating when cautiously pines nacd n h peec o ehnl r te depressive other or greatly ethanol barbiturates. especially and of drugs, presence dose-dependent the in is enhanced compromise respiratory of severity The use. benzodiazepine with associated lication circumstances. most in choice of drugs the benzodiazepines making rare, are events these agitation, treat to dose typical the in given when However, ataxia. and oversedation, hypotension, depression, s at f h wl-salse “v ad w” treatment 2 two” lorazepam, and “five 5 haloperidol, intramuscular well-established of consisting regimen, the of part as popularity enjoys It agitation. treat to used frequently most tion occurs in 15 to 20 minutes. 20 to 15 in occurs tion 3 Benzodiazepines are not associated with EPS (see EPS with associated not are Benzodiazepines The best benzodiazepine to use is the one that is most is that one the is use to benzodiazepine best The eprtr dpeso i te ot orsm comp worrisome most the is depression Respiratory Adverse Effects. Midazolam. Administration. and Dosage Lorazepam. Hypotension is usually mild and clinically insignificant. clinically and mild usually is Hypotension ). 45,48,49,56

mg. 3 In these studies, lorazepam had no extrapy no had lorazepam studies, these In

62 Lorazepam (Ativan) Lorazepam Midazolam (V Midazolam In a number of clinical trials, lorazepam trials, clinical of number a In

Table71–4 Benzodiazepines may 60,61 56 When given IV,tranquiliza given When 48,49 ). ersed) is another benzodiaz another is ersed) Therefore, use benzodiaze use Therefore, 45,48,49,56

The elimination half-life elimination The When used alone, loraz alone, used When is the benzodiazepine the is cause respiratory Table71–4

mg, and mg, 47,48,57,58 Table ). ------

C

71 ● Physical and chemical restraint 1329

- - - -

57 min,

with “Black

Patients

is a benzylisothia (Second-Generation)

Administration

Elderly

In a prospective, open-label in 57 Drug

Atypical

midazolam), but were more deeply more were but midazolam), and

of

Atypical antipsychotic agents may

Use Food

Ziprasidone (Geodon) min for min

Medications for

U.S.

In an observational study of agitated psychiat 66 * Warning

Adverse Effects. Ziprasidone. The atypical antipsychotics fall into three drug classes based on use of such agents in the ED is unknown. Such cautions and concerns extrapolated from long-term retrospective data are not necessarily applicable to their short-term use in the ED. These medications are currently often used with safety and efficacy for short-term sedation in clinical ED practice. clozapine (Clozaril) and ziprasidone (Geodon). All of the atypical antipsychotics are approved for the treatment of schizophrenia. None, is however, approved for the treatment of behavioral disorders in patients with dementia. The Food and Drug Administration has determined that the treatment of behavioral disorders in elderly patients with dementia with atypical (second-generation) antipsychotic medications is associated with increased Of mortality. a total of seventeen placebo-controlled trials performed with olanzapine (Zyprexa), aripiprazole (Abilify), risperidone (Risperdal), or quetiapine (Seroquel) in elderly demented patients with behavioral disorders, fifteen showed numerical increases in mortality in the drug-treated group compared to the placebo-treated patients. These studies enrolled a total of 5106 patients, and several analyses have demonstrated an approximately 1.6–1.7 fold increase in mortality in these studies. Examination of the specific causes of these deaths revealed that most were either due to heart-related events (e.g., heart failure, sudden death) or infections (mostly pneumonia). their chemical structure. Because the increase in mortality was seen with atypical antipsychotic medications in all three chemical classes, the Agency has concluded that the effect is probably related to the common pharmacologic effects of all atypical antipsychotic medications, including those that have not been systematically studied in the dementia population. In addition to the drugs that were studied, the atypical antipsychotic medications include TABLE 71–7 TABLE Box” Antipsychotic Dementia The relevance of these observations and recommendations for the short-term is generally considered minor. date, To there have been no clinical reports of adverse events due to with QTc prolongation the short-term ED use of atypical antipsychotic agents. Experience with these agents in the undifferentiated acutely delirious patient in the ED is limited, but their use is increas ing, and initial reports are supportive but not yet definitive. ziprasidone and droperidol took longer to be sedated (30 sedated be to longer took droperidol and ziprasidone 15 with compared sedated at 60 and 120 minutes. * cause somnolence, EPS (although EPS occur less often than with haldol and droperidol), often, anticholineric symptoms and QTc muscle weakness. prolongation, and less zolylpiperazine antipsychotic antipsychotic agent atypical first the was It unknown. remains action whose mechanism of agent available in a fast-acting intramuscular preparation and has that agent antipsychotic atypical intramuscular only the is been studied for undifferentiated agitation in the ED. double-blind, In a randomized study, Martel and coworkers noted that ziprasidone was as droperidol effective in controlling as acute agitation. midazolam Patients receiving and study, study, ED patients receiving improvement ziprasidone in had anxiety, progressive hostility, starting at 15 minutes and continuing through the 90-minute and uncooperativeness study period. ric ED patients with nonspecific psychosis, alcohol intoxica ------be elderly recep 2 been safely -hydroxy-mid mg) should and D

1 α ). mg have This report led the

studies also noted that 65 . ). The initial dosage for an

uch warnings have not been S Table 71–4 Table 42 but the degree of prolongation ). 3 min). The

Table 71–4 Table In 2005, a meta-analysis of placebo- of meta-analysis a 2005, In or IM, which may be repeated at 5-

Previously, medications in this class 64 (see mg IV

Diazepam (Valium) has a long positive safety positive long a has (Valium) Diazepam 48,63 Table Table 71–7

It was found to have a more rapid onset of However, the interval QTc may not be avail 65 ). Midazolam is hydroxylated by the cytochrome ). 47,48,58 The FDA has also advised caution with ziprasidone Dosage and Administration. Midazolam Midazolam compares favorably with haloperidol, loraze Contraindications. Diazepam. mg IV every 5 to 10 minutes. No maximum dose has been

sedation than the other drugs except droperidol, which had a controlled trials demonstrated an increased risk of death asso death of risk increased an demonstrated trials controlled ciated with atypical antipsychotic agents used to treat patients with dementia-related psychosis muscular formulation and low incidence of EPS make these newer agents an attractive option for rapid tranquilization in the undifferentiated patient in the ED. were available only in an oral formulation, limiting their use in the management of acute agitation. intramuscu Recently, lar formulations of ziprasidone (Zyprexa) (Geodon) have been and developed. The olanzapine combination of intra (serotonin) receptors, and less affinity for D tional titrated doses. Atypical Antipsychotic Agents Atypical antipsychotic agents have a high affinity for 5-HT used. Intramuscular diazepam should not be used. In about 5 to 6 minutes, the maximum effect and maximum respiratory addi for allowing reached, been have diazepam of depression record for the treatment of agitated delirium, especially delir especially delirium, agitated of treatment the for record ium tremens/alcohol withdrawal. The standard dose is 5 to 10 established and doses of 500 to 2000 30 and 120 minutes and does not vary significantly by route of administration Table 71–4 Table P-450 system to its azolam, primary which metabolite, undergoes between is action of duration glucuronide The urine. the in excreted being conjugation before onset of sedation occurs approximately 3 intravenous dose, minutes 5 minutes after an after intramuscular injection, an and 15 minutes after oral, nasal, or rectal administration (see lished. Owing to first-pass metabolism, only 40% to 50% of a PO-administered dose reaches therefore the twice systemic the parenteral circulation, dose (i.e., 10 given. It may be given nasally in oral dosing regimens. The agitated adult is 5 to 10-minute intervals. No maximum dose has been estab similar time of onset (5–10 midazolam, as expected, had a shorter duration of effect than the other medications. This may be advantageous in certain circumstances and undesirable in others. pam, droperidol, and ziprazidone for treatment of agitation in the ED. desired, desired, whereas lorazepam is used for patients who require a longer period of restraint (see conditions that increase the risk of 71–6 Table QTc prolongation (see translated into the prohibition of such agents for short-term use in the ED. owing to its tendency interval, especially to prolong the QTc when used in patients taking other drugs or with medical tors. As a result, they have a haldol lower and droperidol. incidence of EPS than FDA to issue a black box warning regarding the use of atypical of use the regarding warning box black a issue to FDA antipsychotics for “behavioral disorders” in elderly patients with dementia ( droperidol, and olanzapine, able when the use of these drugs interval prolongs more the frequently is QTc than haloperidol, indicated. Ziprasidone C 1330 XII ● SPECIAL PROCEDURES Melamed and colleagues and Melamed disorder.bipolar with associated agitation of management the in monotherapy lorazepam to superior and it has become standard practice. Ketamine has no significant no has Ketamine practice. standard become has it where ED, the in procedures painful undergoing children for anesthetic dissociative effective rapidly and safe a as ketamine preced the after hours 4 to 2 considered be may doses tional acute managing dementia and in schizophrenia with monotherapy associated agitation lorazepam or peridol cular olanzapine has been shown to be comparable with halo treatment of agitation in acutely psychotic patients. Intramus been recently has approved by the FDA in Olanzapine an intramuscular formulation for the receptors. 2 type serotonin and dopamine both of antagonism through effects its exert to tion thienobenzodiazepine antipsychotic agent that is thought cular route lending itself to ED use when intravenous access intravenous when use ED to itself lending route cular increased pressure. harmful causing intracranial ketamine with issue proven no is there caution, a as raised Commonly seen. be may cardia tachy and and hypertension Minor bronchodilatation. pressure promotes blood supports release catecholamine related adverse effects on blood pressure or respirations. A ketamine- undifferentiated agitation in the ED. the in agitation undifferentiated in olanzapine intramuscular using trials clinical no been have is 1 to 1.5 to 1 is monitoring. minimal with and surgery major for world the throughout safely used been oxidation. P-450–mediated cytochrome hours. The drug is metabolized via direct glucuronidation and 24 as long as lasted have effects clinical the patients, some In hours. 2 least at lasts typically and injection intramuscular an after minutes 30 to 15 begins usually sedation hours. of 54 onset The to 21 of half-life elimination an has and minutes 45 to 15 in concentrations plasma peak reaches Olanzapine 30 of dose recommended maximum a with dose ing 10 is agitation acute of treatment for dosage hours. 4 least at last usually effects clinical The hours. 2 around at peaks and minutes 30 to 15 within begins usually sedation injection, intramuscular an Following hours. 4 to 2 of half-life elimination an has and minutes 45 to 30 in concentrations plasma peak reaches drug 2 hours, or 20 10 is ziprasidone of dosage minutes. 15 as early as patients tranquilizing in effective was ziprasidone 20 psychosis, substance-induced or tion, patient cocaine-intoxicated agitated acutely an control chemically to ketamine describe reports case Other patients. trauma bative com of transport and management prehospital the for amine tef o hs s, n cs rprs upr sc a role. a such support reports case and use, this to itself lends profile pharmacologic its patients, delirious and tated ED. the in anesthesia ketamine for adjuncts as given routinely been has neither but issues; emergence the quell may benzodiazepines and secretions, dry can pyrrolate glyco or atropine of co-administration The hallucinations. and thoughts bizarre short-lived of consisting phenomenon emergence the or laryngospasm, vomiting, salivation, include The dose of ketamine to produce profound dissociation profound produce to ketamine of dose The Ketamine. Olanzapine. Administration. and Dosage oae n Administration. and Dosage Although ketamine is not commonly used to control agi control to used commonly not is ketamine Although 76 and for an agitated patient bent on suicide. on bent patient agitated an for and

mg/kg IV mg/kg 67

mg IM,

Ketamine is a widely used anesthetic. It has It anesthetic. used widely a is Ketamine

Olanzapine (Zyprexa) Olanzapine , or 4 to 5 to 4 or , 74 which may be repeated at 4 hours. The osbe ie fet o ketamine of effects side Possible 75 73 reported the successful use of ket of use successful the reported

Many clinicians are familiar with familiar are clinicians Many 68 mg IM, mg

mg/kg IM, mg/kg which can be repeated at repeated be can which

72 h recommended The recommended The

mg of mg is a second-genera a is with the intramus the with 71

To there date, mg IM. mg intramuscular

77 mg/day. Addi 46,69,70 75–77 ------

Choosing the Best Agent Best the Choosing clarified. been not has ED the in patient delirious and tated agi acutely the of control exact chemical the the for time, ketamine of current role the At (IM). minutes 5 to 2 to seconds (IV) 30 within effective are routes Both problematic. is tored setting. tored of carefully titrated intravenous benzodiazepines in the moni use prudent the with depression cardiovascular or respiratory the profile and safety and record safety drugs’ clinicians to familiarity of because circumstances such in choice prudent most the be to seem benzodiazepines of doses Large short. is record track their but favor, gaining are psychotics often with judicious doses of haloperidol. Newer atypical anti benzodiazepine, intravenous an been traditionally has agent safest agitated The monitoring. and evaluation medical for controlled acute with ED expeditiously be must history, the who no or little to with delirium brought patient a is nario the possibility of respiratory depression. respiratory of possibility the intoxicated patients and those taking sedative agents owing to alcohol- to caution with administered be should diazepines provide rapid, safe, and effective tranquilization. effective and safe, rapid, provide will ziprasidone or droperidol, haloperidol, agents, sedative other or alcohol with intoxicated obviously are who patients dose, usually 2.5 to 5.0 to 2.5 usually dose, 2.5 0.075 to 0.025 is peridol manage agitation in children. The dose of intramuscular halo 71–4 Table 0.2 to 0.1 is midazolam of dose intramuscular the The intramuscular dose of lorazepam is 0.05 to 0.1 first-line therapy for the management of agitation in considered children. are benzodiazepines record, safety proven a and population. patient antipsychotic atypical this of in use the agents support to seems antipsychotic dence atypical agents, evi of body However,growing benzodiazepines. a or agents, antipsychotic typical with treated be may disorder bipolar of phase manic the order,or dis schizoaffective schizophrenia, to attributed agitation and Disorder. agent. single a of doses smaller using consider impairment, renal known has or elderly or frail is patient the If therapy. first-line as used be should benzodiazepines or antipsychotics typical required, is tranquilization rapid If pathology. underlying the correcting at aimed be should treatment illness, medical to due agitated avoided in these patients. these in be avoided should and LSD, taking patients in syndrome serotonin bination of the two. com a or butyrophenones or benzodiazepines of doses large hallucinogens such as PCP or LSD may be safely treated with sympathomimetic agents such as cocaine, methamphetamines, to owing agitated are who Patients wide. is profile safety the to due zodiazepines are the eetae aiain sbtneidcd scoi, and patients. psychosis, substance-induced alcohol intoxication, common findings in acutely agitated ED agitation, ferentiated undif with patients in safe be to shown been has ziprasidone

g Cide odr hn 2 er cn eev te adult the receive can years 12 than older Children mg. gtto De o loo ad rg o Abuse. of Drugs and Alcohol to Due Agitation The Undifferentiated Patient. gtto i Children. in Agitation Psychiatric Underlying an to Due Agitation Illness. Medical to Due Agitation alcohol withdrawal alcohol

ains ih n salse pyharc history psychiatric established an with Patients . erlpi aet hv as be ue to used been also have agents Neuroleptic ). 41,45,56 drugs drugs of choice mg (see mg Droperidol has been associated with . Large doses may be required, and required, be may doses Large . 40

gk, with mg/kg,

wn t yas f experience of years to Owing Table71–4 in patients who are agitated . There is little concern for concern little is There .

46,57,66,67,69,70,76 The most common sce 60,61 mxmm oe of dose maximum a

In patients who are who patients In In contrast, ben contrast, In ). Although dro Although ). 41,51,57 Moreover,

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71 ● Physical and chemical restraint 1331

). 83,84 mm in

Taser uses Taser Conducted Fig. 71–10 83 ® Barbs embedded in soft tissues

TASER electrode-tipped TASER barb. TASER electrical TASER control device. After removal, clean and dress the

84

). The barbs may attach to clothing and fail and clothing to attach may barbs The ). Owing to the small size and linear shape of the ). If the patient cannot tolerate the procedure, 83 Figure Figure 71–11 Figure Figure 71–10 Fig. 71–11 Fig. Removal Techniques. Fig. 71–12 barb, there is no need to advance the barb through the skin to remove the tip as removal of is fishhooks. commonly performed during the wound (see Chapter 35, Methods of Wound wound (see Closure), Chapter but do 35, Methods of Wound anti-inflammatory nonsteroidal (e.g., Analgesics it. suture not drugs, acetaminophen) may be administered. excellent excellent text by Kroll MW and Ho JD: TASER are similar in size to a No. 8 ( length fishhook measuring 4 to penetrate the skin, or they may become embedded in the skin and must be removed. can be easily removed with direct pressure. Place one hand on the skin surrounding the barb to hold the skin taught and use the other hand to apply direct pressure to the barb compressed nitrogen to propel two electrode-tipped that are attached barbs to the device by two thin wires. The barbs Electrical Electrical Weapons: Physiology, Pathology, and Law. New Springer York: Science, 2009. Because darts often penetrate the skin and must be removed, the remainder of this section focuses on the procedure electrodes. for removing embedded Taser Electronic Taser Control Devices is Taser an acronym for “Thomas A. Swift’s Electric Rifle” and has been in existence since the early 1990s ( military and correctional, enforcement, law 11,000 than More agencies in 44 countries purchase to civilians allow States United the in municipalities deploy Taser devices and and carry many these weapons for personal protection. a No. 11 scalpel to cut down through the soft tissue to the tip the to tissue soft the through down cut to scalpel 11 No. a of the barb. ( use and barb the near anesthetic local of amount small a inject ------). mg/ drive

Efforts 65 82 Benzodi 79 Table 71–4 Table (see 40 mg

Psychotropic Psychotropic medications Patients 65 years of age or

Based on years of accumulated 78 Low doses (e.g., half the usual 80 The majority of these cases also 81 . Law enforcement and correctional personnel 62 Despite claims of lethality in the lay press, there are no Agitation in the Elderly. Agitation Agitation in Pregnancy. complete discussion of this topic, the reader is referred to the sympathomimetic/drug intoxication or cardio catecholamine-induced clandestine as underlying (such pathology cardiac myopathy) obscure the exact etiologic contribution of these electrical devices to deaths occurring in For police a custody. to define the actual cause of death in forensic investigations of individuals dying unexpectedly after having been shocked while in police custody, or during efforts to subdue or inca pacitate, fail to show definitive causation. The role of severe azepine are also commonly used short term. observation for respiratory depression. Atypical antipsychotic agents should be avoided in this population owing to the risk of death associated with dementia-related psychosis. dose) of benzodiazepines can also be used, but require close clinical experience, but very little scientific data, conventional data, scientific little very but experience, clinical recom are droperidol and haldol as such agents antipsychotic mended to control agitation in pregnant women. a number of fatalities. fail to provoke cardiac arrest or significant cardiorespiratory or metabolic studies, derangements scientific limited by safe considered Although charges. after standard electrical conducted electrical weapons dis have been temporally linked to documented immediate deaths directly caused discharge in by humans. a Volunteer studies and Taser animal models intense pain without incapacitating the target, so-called stun devices typically use drive technique. stun devices as a pain compliance shock prods) or via a small dartlike electrode fired from a gun a from fired electrode dartlike small a via or prods) shock using small gas charges (e.g., similar Taser) to some air rifle propellants. There are also electrical weapons that cause electrical discharge to overcome the body’s muscle-triggering electrical discharge to overcome the body’s mechanisms, resulting in widespread uncontrollable muscle deliv is current The victim. the incapacitate that contractions ered by direct contact with a handheld device (i.e., electric Conducted electrical weapons (Tasers, stun guns) are used by Conducted electrical weapons (Tasers, law enforcement agencies throughout the world. These non lethal weapons use a temporary high-voltage low-current Conducted Weapons Electrical psychotic medications such as haloperidol and droperidol are safe and effective for both psychotic symptoms and nonpsy chotic agitated behavior. tion medications (which increase the risk of drug-drug inter actions), and age-associated changes in pharmacokinetics and anti conventional that suggests Research pharmacodynamics. older are particularly susceptible to adverse drug owing to coexisting medical reactions illness, use of multiple prescrip should be used during pregnancy only when the potential risk risk potential the when only pregnancy during used be should to the fetus from exposure is outweighed by the risk untreated maternal of disorder. the kg with a maximum initial dose of 2.5 peridol peridol is a highly effective drug for rapid tranquilization in adults, there is a paucity of literature 0.07 to 0.03 is droperidol of dose pediatric The children. supporting its use in involved drug overdoses (e.g., cocaine, methamphetamines) and/or the use of additional excessive physical force. Combination Combination therapy is generally children. not recommended for C 1332 XII ● SPECIAL PROCEDURES o a eand oeg bd. infiat neto after infection Significant body. foreign retained concern a a is there if for and remove, to difficult was barb the when wounds, contaminated in prudent be may check wound 48-hour a infection; of signs for watch to patient the Advise barb. the to pressure direct apply to hand other the use and taught skin the hold to barb the surrounding skin the on hand one Place pressure. direct with removed easily be can tissues soft in embedded 71–12 Figure After removing the barb, provide standard wound care. wound standard provide barb, the removing After

Removal

of

an

electrode-tipped

barb.

Barbs

a TASER barb, but these are rare. are these but TASERbarb, a from resulting injuries intracranial and intraocular serious of reports case been have There literature. the in cases reported no been have there although exists, genitalia and structures vascular to injury of risk TASERtheoretical a small. is device a from bowel or lungs, heart, the to injury significant of risk required. not is observation ED long-term and scenario, time real individual the on based is patient the of disposition the TASERdart, a of removal sary.Following barb removal is rare, and prophylactic antibiotics are unneces ie f h br i smlr o eie ue t oti central obtain to access. used venous devices to similar is barb the the of because size wound the on pressure direct by followed tion vascular structure can probably be removed with manual trac of acute thoracic compression fractures. compression thoracic acute of cause a as contraction implicated been has muscle discharge electrical the Severe from cases. complicated in required Complications. REFERENCES 84 Consultation with a vascular surgeon may be may surgeon vascular a with Consultation

CAN

BE Owing to the small size of the barb, the barb, the of size small the to Owing

FOUND

ON

E XPERT 85–87

C A barb embedded in a in embedded barb A ONSULT 88 - -