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Acute agitation, psychosis, and violent behavior are common presentations in the Emergency Department (ED) and pose a threat to patients and the staff caring for them.1-4 Management of the agitated patient presents a complex challenge of minimizing the risk of potential violence while enabling appropriate clinical evaluation of the agitated state. The underlying diagnosis is often unknown and treatment must often be rendered urgently with limited time for decision making. Such presentations can interfere with the ED evaluation and treatment as well as compromise both patient and staff safety. These behavioral emergencies may require pharmacologic intervention to reduce agitation, resume a more normal physician-patient relation, and facilitate safety (Figure 233-1).

FIGURE 233-1.

The management of the agitated or violent patient in the ED.

The use of chemical restraint implies that medications are used to control behavior and confine a patient’s bodily movement without an assessment and treatment plan.5 This is rarely the case in the ED as medications to manage behavioral emergencies are administered as part of an evaluation and plan of care. The Emergency Physician (EP) is addressing the medical emergency of agitation and violence in the patient and starting the treatment. While the phrase “chemical sedation for acute agitation” may be more appropriate, for the purposes of this chapter, the phrase “chemical restraint” will refer to the emergent use of medications to control dangerous behavior in a patient. Do not use the phrase “chemical restraint” on your charting. This phrase sets off red flags among personnel from hospital administration, utilization management, and outside official review organizations.


Behavioral emergencies provide complicated medical and ethical considerations. The benefits of chemical restraint should be seriously considered against the potential side effects of the medication. The EP must be aware of alternatives to chemical restraint as well as the careful assessment, reevaluation, and treatment of the acutely agitated patient. Chemical restraint ideally provides a calming, rather than sedating, effect with a continued emphasis on doing no harm to the patient while simultaneously reducing the risk of violence.6,7 An objectively good response to chemical restraint may still leave the patient feeling traumatized and angered. Allow the patient to participate in treatment decisions to the extent possible. This can be achieved through simple tasks such as asking the patient if they have a medication preference or offering a choice between potential medications.7 Attempt further verbal de-escalation or a “show of force” before applying any physical or chemical restraint (Figure 233-1).8-12

EDs should have written policies regarding restraint use and monitoring as mandated by the Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC).5,13,14 Both CMS and TJC have guidelines for the use of restraints. The CMS ...

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