Chapter 195. Chemical Restraint

Acute agitation, psychosis, and violent behavior are common presentations in the Emergency Department (ED). It has been estimated that 32% of EDs in teaching hospitals report daily verbal threats and that 25% restrain at least one patient per day.1,2 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.

The use of chemical restraint implies that medications are used to control behavior and confine a patient's bodily movement, but without an assessment and treatment plan.3 However, 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. For the purposes of this chapter, chemical restraint will refer to the emergent use of medications to control dangerous behavior in a patient.

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. Emergency Physicians must be aware of alternatives to chemical restraint as well as the careful assessment, reevaluation, and treatment of the acutely agitated patient. Ideally, chemical restraint 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.4,5 An objectively good response to chemical restraint may still leave the patient feeling traumatized and angered. To the extent possible, allow the patient to participate in treatment decisions. 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.5 If this approach fails, attempt further verbal de-escalation or a “show of force” before any physical or chemical restraint.6

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).3,7 Both CMS and TJC have protocols for the use of restraints. The CMS defines chemical restraint as use of a medication to restrict a patient's behavior or freedom of movement but is not the standard treatment or dosage for the patient's underlying condition. Both CMS and TJC recognize the legitimate use of restraint for the acute medical or surgical patient to prevent patient injury and alleviate violent behavior that places the patient, staff, or others in immediate danger. Both organizations identify restrictions, including that restraints must only be used when less invasive interventions have failed; must be ordered by a licensed clinician (can be a nonphysician); require the patient to be evaluated by a Physician within 1 hour after restraint initiation; and cannot be written as a standing or as needed order.3,8–10

A brief consideration of the legal and ethical implications of chemical restraint deserves mention. In general, consent for evaluation and care is implied during an emergency. The courts assume a competent lucid adult would consent to treatment necessary to maintain health or life.11 Emergency Physicians must also consider whether the patient has the decisional capacity to refuse offered care. The more life threatening the emergency, the greater should be the Emergency Physician's comfort in treatment. If there is doubt as to the competency of the nonconsenting patient, it is best to err in favor of treatment.11 If the patient is competent, then some leeway must be given to patient preference for treatment. The Emergency Physician must document their thought process and justification for administering chemical restraint. The covert administration of chemical restraint may be problematic and no universal ethical standard has been established in an ED setting.12,13 It is also always advisable to review the ED and hospital restraint protocols that have been vetted through the hospital administration and legal review.

There is no precise definition of clinical agitation or violent behavior in the ED that necessitates chemical restraint.14 Experts have agreed that explosive and/or unpredictable anger, intimidating behavior, restlessness, pacing, excessive movement, physical and/or verbal self-abusiveness, demeaning or hostile verbal behavior, and impulsive or impatient behavior are components of clinically significant agitation.5 A history of violence (regardless of diagnosis), male sex, drug abuse, and alcohol abuse are associated with violent behavior.11,14–16 However, there is no reliable way to clinically predict which patients will be imminently violent. The history and physical examination will usually determine which patients are agitated, violent, or have imminently violent potential. Verbally engage the patient to the extent possible to obtain preliminary information and assess their potential for verbal de-escalation. The patient should ideally be asked about their intent to harm themselves or others, if they possess a weapon (on their person or at home), a history of recent violence, current alcohol or illicit drug use, medical conditions, and psychiatric conditions. The possibility of violence should be taken seriously and acted upon quickly.

Chemical restraint may, however, be necessary if verbal interaction is not adequate to alleviate violent behavior. For most agitated patients, de-escalation through verbal communication should be attempted before initiating chemical restraint. However, the Emergency Physician must gauge the potential to manage agitation and violence through verbal and behavioral interaction given the clinical situation and available resources. Not every violent patient can be managed in a stepwise fashion. Do not delay appropriate intervention for violent behavior. The ultimate decision to use chemical restraint, either alone or after less restrictive alternatives, is a clinical decision that must be made at the time the behavior is occurring.

Attempts should be made to determine if the patient has any known allergies through a review of the medical record, through collateral history from the patient's family, and any known medical or psychiatric providers. A known allergy to a specific medicine is a contraindication to its use and to use of other medications within the same class. Dosing adjustment and caution should be used when administering medication in patients who are elderly, debilitated, have comorbid medical conditions, or a history of side effects with the use of such medications. Contraindications to the specific medications (classes) described in this chapter are listed in Table 195-1. Chemical restraint is not indicated for a patient who refuses to cooperate or intensely stares. It is also not appropriate to use chemical restraint for punishment or for the convenience of staff.

• Personal protective equipment (gloves, mask, goggles or face shield, and gown)
• Alcohol pads
• Syringes, various sizes
• Needles, various gauges
• Pharmaceutical agents
• Resuscitation equipment
• Defibrillator
• Oxygen source
• Oxygen masks
• Nasal oxygen cannulas
• Oral airway
• Nasal airway
• Bag-valve mask device
• Continuous pulse oximetry
• Capnography, if available
• Continuous cardiac monitoring
• Intravenous access supplies
• Equipment for physical restraint

Do not attempt to chemically restrain a patient until they are searched for dangerous objects and disarmed by hospital security or police. Identify a single team leader for the chemical restraint process. This is generally the Emergency Physician, who should assign roles and instruct other involved providers.15,17 If the patent is voluntarily willing to take oral medications, less preparation is required compared to that for an agitated patient that is unwilling to take medications. Safely make attempts to decrease external stimuli, such as offering to place the patient in a more quiet area in the ED. Consider how many staff members may be needed to intervene and formulate this team prior to any intervention. It may be prudent to have more staff members readily available if needed. For instance, a patient may be so physically combative as to require five people, one person to restrain each limb by immobilizing at the major joint and a fifth person to hold the head. If possible, brief the team on what is expected and of possible dangers. Universal precautions should always be used to protect the healthcare provider.

Always approach the patient face-to-face and not from behind or without warning. Staff must appear calm and in control, speaking in a nonprovocative, nonconfrontational, and noncondescending manner. Within a room, the patient should not obstruct a staff member's ability to exit the room. Thus, staff should initially not have the patient between them and a door until the situation is under reasonable control.

Always leave the door to the room open to facilitate escape if the staff feel they are not safe. The open door also allows additional staff to enter and assist. It may be necessary to have security nearby and aware of the situation.

Improvements in pharmacologic treatment of the acutely agitated or psychotic patient have been recently made, resulting in more medication choices. The medication selected should be based on diagnostic or etiologic considerations, onset and duration of action, efficacy, route of administration available, patient's history of response to the medication, patient preference, ease of administration, and potential for adverse effects (Table 195-2).4,5 The ideal agent for sedation of the acutely agitated patient in the ED is one that is rapidly effective without causing excess sedation, easily administered, available via multiple routes of administration, and safe.18,19 Here, we present a summary of the pharmacologic options available for chemical restraint based upon the currently available evidence.

Benzodiazepines have achieved popularity because of their tolerability and safety. These medications bind to the alpha subunit of the GABAA receptor to enable inhibitory neurotransmission. Lorazepam and midazolam are the most often used benzodiazepines in the ED. They are an effective monotherapy for the initial treatment of the undifferentiated acutely agitated ED patient.20 Multiple studies have shown that benzodiazepines reduce agitation and are as effective as haloperidol alone.5,21 They should be used when no past medical history is available, no specific treatment is indicated (i.e., personality disorder), or when benzodiazepines have specific benefits (e.g., EtOH intoxication). Benzodiazepines have fewer significant side effects than conventional antipsychotics. They have been associated with excessive sedation and rarely paradoxical disinhibition. Combination therapy with a typical antipsychotic may be more effective than either benzodiazepine agent alone.

Clonazepam, diazepam, and flunitrazepam are benzodiazepines which have been shown to be potentially effective in reducing agitation. However, this information is based upon extremely small studies in hospitalized patients with known psychiatric diagnoses. Moreover, there have been inconsistent results and flunitrazepam is not available in the United States.20 Diazepam has erratic absorption after intramuscular (IM) administration and its active metabolite make this medication less useful in the ED. Therefore, these benzodiazepines will not be discussed.

Benzodiazepines are contraindicated if the patient has a known allergy to a benzodiazepine (Table 195-1). Administer benzodiazepines cautiously and adjust the dose in patients who are elderly, debilitated, have respiratory insufficiency or sleep apnea, hepatic disease, or renal disease. The most common side effects of benzodiazepines include excessive sedation and respiratory depression, which can be found in over 10% of patients receiving these medications.

Emergency Physicians should be careful not to overdose benzodiazepines, especially with the possible adverse effects of excessive sedation and respiratory depression. Use flumazenil to reverse benzodiazepine-related sedation. The initial dose is 0.2 mg IV over 30 seconds. This can be redosed at 0.3 mg IV over 30 seconds if the desired level of consciousness is not obtained.22 Extreme caution should be exercised if flumazenil is administered. Its use may result in withdrawal seizures if the patient is chronically taking benzodiazepines.

Lorazepam

Lorazepam has excellent absorption after IM administration with a rapid onset of action and a short duration of action (Table 195-3). The medication has minimal risks when used as a single dose or short-term administration.19 The onset of action varies slightly depending upon the formulation administered. Sedative effects are achieved within 15 to 30 minutes of IM administration. Peak plasma concentration is achieved within 60 to 90 minutes with a duration of action of approximately 8 hours.22,23

Lorazepam PO or IM is recommended as first-line therapy for undifferentiated agitation, alcohol-related agitation, and substance-induced agitation.5 Expert consensus guidelines suggest optimal lorazepam dosing as 1 to 3 mg PO or 0.5 to 3 mg IM. Studies in the acutely agitated patient show that 2 or 4 mg lorazepam IM is as effective in reducing agitation and violent behavior with significantly fewer side effects compared to 5 mg haloperidol IM.5,20,21

Midazolam

Midazolam is a water-soluble benzodiazepine with good IM absorption, rapid time to onset, rapid time to recovery, and with minimal side effects (Table 195-3). Traditionally this medication has been used more for conscious sedation than rapid tranquilization. Sedation is achieved within approximately 15 minutes, while peak effect occurs at 30 to 60 minutes. The mean duration of action of IM midazolam is 2 hours. This medication is metabolized by the liver and excreted in the urine.22

Midazolam has a shorter time to onset of sedation and more rapid time to arousal compared to lorazepam and haloperidol.24 One potential limitation includes the short half-life, which may require frequent re-dosing to maintain tranquilization.19,25 As with all the benzodiazepines, midazolam can cause significant respiratory depression. Midazolam appears to be safest at a dose of 5 mg and without the concomitant use of narcotics.4,25–27

Combination Therapy

Medications can often be combined to achieve synergistic therapeutic effects while reducing potential adverse outcomes. For example, previous studies have focused on combining benzodiazepines with typical antipsychotic agents. Combination treatment allows for lower doses of antipsychotic medication to achieve adequate sedation. Moreover, a lower incidence of extrapyramidal symptoms (EPS) may be due to benzodiazepine prophylaxis or treatment of antipsychotic-induced side effects.23

The combination of lorazepam and haloperidol is the most commonly studied and utilized combination therapy in clinical practice. A combination of 2 mg lorazepam with 5 mg haloperidol has been shown to more rapidly reduce agitation than either agent alone, and with fewer side effects relative to haloperidol alone. The combination can be mixed together in the same syringe and administered IM if used immediately.21,28 It is important to note that studies supporting these data do not control for re-dosing. Nevertheless, current ACEP guidelines recommend that the combination of a benzodiazepine and haloperidol may produce more rapid sedation than monotherapy in the acutely agitated psychiatric patient in the ED.20

Typical, also known as first-generation or conventional, antipsychotics and benzodiazepines have historically been the mainstay of treatment for acute agitation and psychosis. These medications have been available in parenteral formulations for years. However, conventional antipsychotics and benzodiazepines can cause serious adverse effects. The utility of atypical, also known as second-generation, antipsychotics is expanding as rapid-acting preparations become available. Atypical antipsychotics have differing mechanisms of action, a broader spectrum of response, and a lower side effect profile.29

Choosing the initial antipsychotic medication depends upon the patient's mental health and medical history, the need for concurrent sedation, and the side effect profile (Table 195-4). A typical or atypical antipsychotic drug can be used as monotherapy in the acutely agitated patient with known psychiatric illness. Use an oral preparation of either an antipsychotic or benzodiazepine in the cooperative but agitated patient. Options for the oral treatment of agitation related to schizophrenia or mania include olanzapine, risperidone, risperidone in combination with a benzodiazepine, or haloperidol in combination with a benzodiazepine. Use IM preparations for uncooperative schizophrenic patients. Options include olanzapine, ziprasidone, haloperidol in combination with a benzodiazepine, or ziprasidone in combination with a benzodiazepine. IM benzodiazepines are preferred over newer atypical antipsychotics in patients where no history is available or the underlying illness is undifferentiated.5,29,30

Haloperidol and Droperidol

Haloperidol is a butyrophenone antipsychotic. It blocks dopaminergic D1 and D2 receptors in the brain. It is the best studied of all the typical antipsychotics, though the majority of studies have been conducted in psychiatric patients with unclear applicability to the undifferentiated acutely agitated ED patient.20 The peak serum concentration is achieved in approximately 20 minutes after IM administration (2 to 6 hours after PO administration), while adequate sedative effects can be expected within 30 to 60 minutes for both IM and IV administration. The duration of effect is approximately 24 hours.6,22,23

Dose–response studies have demonstrated that a single dose of 7.5 to 10 mg of haloperidol may produce the best outcome with the fewest side effects. Higher doses yield lesser degrees of improvement while increasing the risk of adverse effects.4,5,31 While the utility of haloperidol as monotherapy is limited, the traditional combination therapy of haloperidol with a benzodiazepine is a first-line option for schizophrenia, mania, and psychosis.

Droperidol is another butyrophenone neuroleptic that inhibits dopaminergic transmission. It is closely related to haloperidol but only available in a parenteral formulation. Compared to haloperidol, it has rapid absorption with a quicker onset of action (15 to 30 minutes) and a much shorter half-life (2.2 hours).22,23 The peak effect is achieved within 30 minutes of IM administration and the duration of effect is 6 to 8 hours. Consequently, compared to haloperidol, it has been shown to be more effective at acutely reducing agitation while requiring fewer repeat doses and causing fewer side effects.23 This medication has also been compared to benzodiazepines. Droperidol produces better sedation, requires fewer repeat doses, and results in a shorter ED length of stay compared to lorazepam alone.19,20,32–34 Despite these promising results, continued use of droperidol became controversial after the FDA issued a black box warning in 2001 secondary to the drug's potential for QTc prolongation.35

Emergency Physicians should be aware of relevant side effects associated with typical antipsychotics. This includes EPS, cardiac arrhythmias, and neuroleptic malignant syndrome. Haloperidol has been associated with acute dystonias, parkinsonism, and akathisia. The frequency of EPS associated with haloperidol use varies significantly across studies, but has been cited to affect between 0% and 50% of patients.21,34 These side effects are of particular concern given that they may lead to increased patient agitation and medication refusal. Anticholinergic medications such as benztropine (0.5 to 2 mg IM or IV) or diphenhydramine (50 mg IM or IV) may be used to prevent or treat EPS. Droperidol has a lower incidence of EPS in the acute setting.33,34,36 Caution should be used when administering typical antipsychotics in patients with Parkinson disease, anticholinergic toxicity, PCP intoxication, or movement disorders. There was concern that antipsychotic agents lowered the seizure threshold in mice, but this has not been found in humans.11

Typical antipsychotics cause QT interval prolongation, most likely due to their quinidine-like cardiac affects.6,19 While there have been reports of sudden death occurring with chemical restraint using typical antipsychotics, haloperidol is considered to have a low risk of causing QTc prolongation. Droperidol is recognized for its potential for causing dose-dependent prolongation of the QTc and subsequent dysrhythmias. However, multiple reviews of large series of patients receiving droperidol have concluded that while this medication can be associated with prolonged QT interval, there is not conclusive evidence that it can cause life-threatening cardiac events. ACEP guidelines recommend that if rapid sedation is needed, and after consideration of the possible adverse affects, droperidol may still be preferable to haloperidol.20 Despite this, droperidol use has dramatically decreased since the FDA black box warning. When using antipsychotic medications, it is important to understand the potential effects on the QTc interval. The likelihood of QTc interval change is increased when patients are already taking other medications that prolong the QTc, or when they have certain comorbidities. Caution should be used, especially in patients with cardiac disease or those taking antipsychotics chronically. If possible, obtain an ECG prior to the administration of a typical antipsychotic. Withhold typical antipsychotic medication if the QTc is above 500 ms or if the patient has risk factors associated with QT prolongation. If administered, do not give additional doses if the QTc increased by >25% after administration.19

There has been additional concern that typical antipsychotics may be affiliated with neuroleptic malignant syndrome (NMS), which is characterized by mental status changes, muscular rigidity, fever, and autonomic instability. The risk of this complication may increase in patients receiving large amounts of typical antipsychotics over a short period of time, and may be further exacerbated in those who are poorly hydrated and restrained in a poorly ventilated holding room. It has been estimated that NMS is a rare complication seen in approximately 0.2% to 1% of patients using typical antipsychotics, thus these patients should be monitored for such physiologic changes.4,6,23

With the advent of newer neuroleptic medications available in IM formulations, atypical antipsychotics are considered a breakthrough for the treatment of agitation and psychosis (Table 195-4). Currently olanzapine, ziprasidone, and risperidone are available in rapid-acting forms that can be used to treat acute agitation. These medications are generally well tolerated and do not cause excessive sedation compared to typical antipsychotics. This can lead to shorter ED stays and increased patient participation in care. These medications show promise to be as effective as the typical antipsychotics with a better side effect profile.29 Caution regarding QTc prolongation should still follow the general considerations as with typical antipsychotics discussed above.

The use of atypical antipsychotics for treatment of acute agitation holds great promise. There is currently limited data on the use of these medications in the undifferentiated agitated patient. Most studies have been conducted in selected, consented, and less agitated individuals compared to the typical unselected, involuntary use in ED patients.20

Ziprasidone

Ziprasidone is a benzylisothiazolylpiperazine antipsychotic with serotonin-dopamine antagonist effects. It was the first available atypical antipsychotic in the IM formulation. The IM preparation achieves peak concentration in 30 to 45 minutes and has a duration of effect of at least 4 hours.19,22,23

Multiple randomized controlled trials demonstrate that 20 mg IM ziprasidone is effective at rapid tranquilization of the agitated patient with a psychiatric history. There seems to be a dose–response effect, as studies have shown increased efficacy when comparing 2, 10, and 20 mg doses. The 20 mg dose is well tolerated without evidence of increased EPS, dystonia, akathisia, respiratory depression, excessive sedation, tachycardia, or clinically significant QTc prolongation.37,38 Ziprasidone appears to be comparable in efficacy to droperidol, midazolam, and haloperidol in combination with a benzodiazepine.25,39 It may be more effective and better tolerated than IM haloperidol at treating acute psychosis.

Ziprasidone's high serotonin-2A/dopamine-2 ratio neurotransmitter affinity results in a low incidence of EPS compared to conventional antipsychotics. Ziprasidone appears to cause greater prolongation of the QTc interval compared to haloperidol, olanzapine, and risperidone.40 However, this medication has not been associated with torsade de pointes, sudden cardiac death, and only rarely increases the QTc interval over 500 ms.19,40 In summary, ziprasidone seems to be a safe and well-tolerated medication for the treatment of acute agitation, but should not be used in patients who are at risk for QTc prolongation.

Risperidone

Risperidone is a benzisoxazole antipsychotic medication with serotonin-dopamine antagonist effects. Due to its serotonin (5-HT2) and dopamine (D2) antagonism, risperidone has a low risk of EPS. This medication comes as an orally disintegrating tablet, and thus should be placed on a patient's tongue using dry hands. The tablet will dissolve within seconds. It achieves peak plasma concentration within 1.5 hours.22,23

The combination of 2 mg PO risperidone plus 2 mg PO lorazepam has been shown to be equivalent to 5 mg IM haloperidol in combination with 2 mg lorazepam in reducing agitated psychosis in the emergency setting. Patients receiving the oral combination were also less somnolent and thus could be appropriately examined. Such data suggest that oral risperidone is an acceptable agent for the agitated but cooperative patient.20,41

Olanzapine

Olanzapine is another atypical antipsychotic with combined serotonin-dopamine antagonist effects. The medication is available in both an orally disintegrating tablet and an IM formulation. The IM preparation achieves peak plasma concentration in 15 to 45 minutes (5 hours for PO form) and has a duration of action of up to 24 hours.22,23

IM olanzapine effectively treats acute agitation in patients with schizophrenia, bipolar mania, and dementia. Olanzapine appears effective at reducing agitation with a quicker onset of action, while having a lower incidence of dystonia and EPS when compared to haloperidol for the treatment of agitated schizophrenic inpatients.42 IM olanzapine was shown to be more effective than IM lorazepam at acutely reducing agitation and required less re-dosing in agitated patients with bipolar mania.43 IM olanzapine was as effective with quicker onset of action compared to IM lorazepam for the treatment of agitated patients with Alzheimer's disease and vascular dementia.44 A Cochrane review of olanzapine use for agitation remarked that data for the oral formulation is insufficient and essentially remains untested. While each of the above trials was industry-sponsored, they conclude that IM olanzapine has some value in managing acute aggression.45

Pooled analysis of QTc data demonstrated a favorable QTc profile for olanzapine in the treatment of schizophrenia, dementia, and bipolar mania.46 However, studies have showed significantly higher rates of orthostatic hypotension in patients receiving IM olanzapine and ACEP guidelines recommend orthostatic vital signs to be taken if repeated dosing occurs.19,20,47,48 Of note, olanzapine has been affiliated with a number of fatalities. Cardiopulmonary depression, bradycardia, and hypotension were noted in these cases.5,20,23 Review of the fatalities demonstrated that patients tended to have significant comorbidities and often received concomitant benzodiazepines or excessive olanzapine dosing. The combination of a benzodiazepine and olanzapine should not be given concomitantly as a result of this evidence.5,20,23

Consensus guidelines endorse calming without sedation or with mild sedation to the point of drowsiness (without sleep) as the most appropriate goal.5,15,49 This allows the resumption of a more normal patient–physician relationship, the ability to obtain informed consent, and ensures the safety of both the patient and the staff. Such an approach may be associated with fewer injuries, shorter length of stay in the ED, and a quicker transition to the next appropriate level of care.4 Sleep has been previously treated as an endpoint of chemical restraint. However, it eliminates the potential for patient participation in decision making and is not a guarantee of safety. The desired therapeutic objective of reduction in agitation or aggression with minimal sedation to allow for a timely assessment and treatment of any medical condition that requires acute intervention.

If success is not achieved, further dosing or an alternative medication may be required. Though timing of repeated doses depends upon the pharmacokinetics of the medications employed, most of the agents should exert their effects by 30 to 60 minutes. If there is no improvement in agitation or violent behavior, administer another similar or higher dose of the initial medication. Consider administering lorazepam unless olanzapine was used. If a combination of an antipsychotic and benzodiazepine was used, this may be repeated. Switching medications is only advised after three to four doses of the medication were given with insufficient effect or two doses of medication had no effect. Switching from one antipsychotic to another antipsychotic is generally not advised due to the different adverse effect profiles of the separate antipsychotics.5,50 However, if a conventional antipsychotic was administered that resulted in EPS, an atypical antipsychotic may be used if further dosing is needed.51

After chemical restraint is employed, the staff must continue to interact with the patient in a calm, nonjudgmental, and noncondescending manner. Patients still require a staff member to observe them throughout their ED stay. As with any other ED patient, the issues of elimination and hydration should be anticipated and addressed. If the patient is calm and alert, the degree and frequency of vital sign and cardiopulmonary monitoring is dictated upon medical concerns and the patient's clinical status. If the patient is sedated, they should have frequent cardiac, neurologic, and pulmonary monitoring, as well as frequent vital sign and respiratory assessments. Additionally, initiate aspiration precautions and the changing of positions to prevent pressure sores. The chemically restrained patient must be evaluated for side effects and adverse reactions, such as orthostasis, dystonic reactions, akathisias, EPS, and NMS.

Document the indication and description of the chemical restraint process, the outcome, and any complications. It is also prudent to document the less restrictive alternatives that were considered or performed prior to chemical restraint. If during the interaction with the patient, it is discovered that a specific person(s) is in danger, they should be warned and the local police notified, especially if there is a situation where it is not possible to prevent a violent patient from leaving the ED (Tarasoff v. The Regents of the University of California, Supreme Court of California, 1976).

Psychiatric consultation should be a part of the evaluation of the violent patient. Standard medical clearance should be documented, including resolution of abnormal vital signs, resolution of mental status and behavioral abnormalities, stability of ambulation and mobility, and ability to understand and follow discharge instructions.

The management of the patient exhibiting dangerous behavior usually requires several techniques that are used sequentially or in concert with other techniques. Though some of these techniques may be used as alternatives, they are generally used in conjunction with chemical restraint.

As stated above, verbal de-escalation is usually the first approach to the violent patient and may be the only intervention necessary. The overarching principle with verbal de-escalation is that staff convey their professional concern for the well-being of the patient.11,14,15 Though a full description of verbal de-escalation techniques is not in the scope of this chapter, there are a few critical points to note. During the interaction with a violent patient, use a nonjudgmental, calm, and neutral approach. Give assurance that they will not be harmed and use empathic statements. Healthcare providers should be clear with limits on dangerous and violent behavior and the actions that will be taken to mitigate such behavior and actions. One should avoid lying to or arguing with the patient as these can represent a challenge to the patient to justify violent behavior and actions.14

A “show of force” is intended to deter dangerous behavior by having a daunting number of staff and security present in front of the violent patient. Ideally, personnel in the show of force should remain neutral and not provoke the patient, while a single team leader interacts with the patient to de-escalate the behavior.11,14

Physical restraint is another alternative that may be employed in place of, or temporarily in conjunction with chemical restraint. Both CMS and TJC have standards for use of physical restraints. The use of physical restraints is discussed in Chapter 194.

The safety, efficacy, and fetal outcome of using isolated doses of an antipsychotic medication and/or a benzodiazepine during pregnancy have not been directly studied and there is no strong evidence of any teratogenic effects from their use.52,53 Benzodiazepines are considered fairly safe to use during pregnancy, as no definitive association between benzodiazepines and teratogenicity has been shown. Given the lack of evidence proving or disproving teratogenicity, the benefits of administering short-term doses of benzodiazepines generally outweigh the risks in emergent situations.54,55 Though most benzodiazepines cross into breast milk, this is not usually a concern in the agitated ED patient who typically receives short-term therapy.

A consensus panel of expert Emergency Psychiatrists recommends using haloperidol as a first-line agent in the agitated pregnant patient.30 Successful use of haloperidol and risperidone, with and without lorazepam, have been described.56 There is limited experience with the use of ziprasidone, olanzapine, and quetiapine in the medical management of the agitated pregnant patient.56 Atypical antipsychotic use has thus far not been linked to congenital malformations.56,57

Monitor women in their second and third trimester for inferior vena cava obstruction if chemically restrained and placed in the supine position. Place them in the left lateral decubitus position. They may be at an increased risk of aspiration due to lower esophageal sphincter relaxation during pregnancy. The pregnant patient's respiratory status must be carefully monitored. The normal increase in respiratory rate and decrease in tidal volume can be effected if the patient is oversedated or somnolent.

In general, chemical restraint of the pediatric patient should follow the overarching themes of chemical restraint in the adult. Every reasonable attempt possible should be made to obtain parental consent for the medical management of a violent pediatric patient. If an emergent situation precludes parental consent, further communication attempts and early discussion with the patient's parent(s) must be pursued. The child should be offered the option of taking the medication orally prior to the IM or IV routes of administration. This may help instill trust and help engage a likely frightened child, as even the idea of a needle may increase the agitation of a child and family members.58–60 If minors are discharged, they should be in the care of a responsible adult who understands and agrees with the discharge plan.

The agents most commonly used for the chemical restraint of the pediatric patient are lorazepam, haloperidol, risperidone, and antihistamines.5,61 Intranasal administration of midazolam has been studied for conscious sedation, but not for chemical restraint. Thus, use of intranasal midazolam cannot be recommended until there is further experience with this route of administration.62,63 Benzodiazepines may cause paradoxical disinhibition, in which there is increased agitation. This is more common in children with developmental delay and organic brain syndromes.60 For children with established attention deficit disorder, there is no data to support the use of stimulants to control behavior.64

The use of haloperidol and droperidol in pediatric patients should follow the same guidelines as in adults and are viewed as generally safe in children. Atypical antipsychotic use in pediatric patients is becoming more frequent. Olanzapine is approved for pediatric use and available in IM and orally disintegrating tablet form (Table 195-5). Risperidone is an effective and safe alternative.64 Experience with ziprasidone use in the ED for pediatric patients is extremely limited and there is no available pediatric dosing for this medication. Diphenhydramine can be an effective agent due to its sedative effect. Extrapyramidal side effects may be treated with diphenhydramine (1.25 mg/kg/dose IV or IM) or benztropine (0.02 to 0.05 mg/kg/dose IV or IM).

Acute agitation and violent behavior may be due to a variety of medical and psychiatric etiologies and is not an uncommon finding in ED patients. At times it may be appropriate to use pharmacologic intervention to calm the agitated patient in order to facilitate the appropriate diagnostic and therapeutic workup while ensuring patient and staff safety. Typical antipsychotics and benzodiazepines have been the traditional options, but the use of atypical antipsychotics is expanding with the development of new rapid-acting formulations with less adverse effects. Given the medical, ethical, and legal complexities involved in the treatment of acute agitation, it is advisable to review CMS, TJC, and hospital policies regarding chemical restraint. Emergency Physicians should be aware of the indications, as well as the risks and benefits, of chemical restraint.