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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 ...

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