Restraint Options for the Agitated Patient

David Moore

CME April 2015

To prevent harm to the patient.

To prevent harm to other patients.

To prevent harm to staff.

To assist in assessing and managing the patient.

Restraints should never be used for ease of convenience.

Verbal de-escalation

Chemical restraint

Physical restraint

Aggressive behaviour (verbal or physical) and no evidence of an acute medical or psychiatric illness that is impairing their cognition.

Patient should be escorted out by security rather than be restrained.

Police assistance can be sought.

A drug is considered a restraint when used as a restriction to manage the patient’s behaviour or restrict the patient’s freedom of movement and is not a standard treatment for the patients condition.

Goal is to rapidly and safely sedate the patient.

Should only be administered once all available alternative treatment options have been considered.

Attempt verbal de-escalation first. Assemble sufficient and appropriate security staff. Consider factors that affect doses and dosing

interval:-level of agitation-body size-age-medical history-medication history (e.g. drug dependence)-previous response to sedative drugs

Choose route of administration- IV route more rapid, more predictable, easily

titratable

Benzodiazepines

Neuroleptics

(Ketamine)

(Clonidine)

(Propofol)

Midazolam - Rapid, effective, short acting

- IM 2.5-5mg or IV 2.5-5mg q3min

titrated to response up to 30mg

(half dose in frail elderly)

- In tolerant patients >100mg may

be needed. 10mg boluses may

need to be given.

- Max effect 10 mins, lasts ~ 2 hrs

Diazepam - PO or IV (erratic absorption IM)

- Painful when administered IV

- Slower onset but longer acting

than midazolam

- IV dose 5mg q3min, titrated to

response, up to 30mg.

Lorazepam – Only available as PO/SL

- Dose is 1-2mg q2-6hrs titrated to clinical response, up to maximum of 10mg in 24 hours.

-Rapid onset. Longer duration than midazolam

- No CYP450 metabolism (undergoes conjugation), so compared to midazolam and diazepam, no active metabolites, less drug interactions an less individualvariability

Oversedation

Hypotension

Airway or ventilatory compromise

Paradoxical reactions

Delirium

Tolerance

Used in combination with midazolam or when patients are tolerant of benzodiazepines or if there is failure of midazolam.

Effect is synergistic.

Patients may respond to low doses of antipsychotic.

Options include droperidol, haloperidol, olanzapine, risperidone.

Droperidol (Haloperidol)

-Droperidol is more sedating than haloperidol

- Can be given IM or IV

- Droperidol 2.5-5mg IV q3min, titrated to response, up to 20mg

- Droperidol IM 5-10mg

-Haloperidol IV titratable dose : 2.5-5mg repeated every 2 to 3

minutes, titrated to clinical response, up to 10mg per sedation

event.

- Halve these doses in the frail elderly patient.

- Obtain ECG to monitor QT prolongation once sedated.

Olanzapine- An atypical antipsychotic- IM or SL or PO- IM dose is longer acting e.g. 10mg IM- Max 30mg/24 hours- Not licensed for IV use in Australia, research

supports the use of the IM formulation for IV.

Risperidone-0.25-2mg PO/SL- works well in the elderly-orthostatic hypotension common

Oversedation

Hypotension

Acute dystonia

Anticholinergic delirium

(seizures)

(QT prolongation)

Dissociative anaesthetic agent.

A good back-up option in cases of extreme benzotolerance or previous reaction to neuroleptics.

Limited deleterious effects on haemodynamic and respiratory function.

As a guide, use 1mg/kg IV or 5mg/kg IM.

Can give titrated midazolam in addition.

Centrally acting alpha-2 adrenergic agonist.

Administered as bolus doses (50-150 micrograms) or as an infusion.

Principle adverse effect is hypotension.

Also causes bradycardia and headache (dose-dependent)

One-to-one nurse special.

Pulse and respiratory rate.

End-tidal CO2 monitoring

Oxygen saturations

ECG

BP check 5 minutely for 20 mins post-sedation dose then half-hourly.

Close monitoring of conscious state and airway adequacy

Over-sedation

Bladder care – bladder scans every 3-4 hours.

IDC to be inserted if bladder volume >400mls

Pressure areas – turn every 2 hours to prevent pressure areas.

BSL checked 2-hourly

Temperature control.

Extra-pyramidal side-effects (consider benztropine).

Reason for restraint.

Alternative therapies attempted.

Assessment of potential injuries and any complications of restraint.

Monitoring plan.

Ongoing sedation options.

Discussion with psychiatry team.

Risk of harm

Usually combined with chemical restraint.

Secure large joints.

Medical instability is a contraindication to physical restraints.

1. Exclude other therapeutic options.

2. Do not attempt if inadequate staff available.

3. Activate ‘Code Black’ to assemble team.

4. Requires 6 trained staff.

5. Personal protective equipment: Gloves, facemasks etc.

6. Allocate roles and state plan of action.

7. Give patient a final chance to comply with requests with restraint team in attendance (‘show of force’).

One person for each limb.

One person controls the head (has airway skills)

One person to administer pre-prepared meds

Administer chemical restraint when safe to do so.

Supine position.

Elevate head of bed to 30 degrees once physical restraints in-situ (decrease aspiration risk).

Perform cyclical limb release if possible.

Ensure appropriate fluid maintenance, bladder care and pressure care.

Pulse

RR

Pulse oximetry

ECG

BP

Monitor conscious state and airway adequacy.

Neurovascular observations distal to restraints.

Reason for restraint.

Alternative therapies attempted.

Assessment of potential injuries.

Monitoring plan.

Thresholds for further interventions.

Ongoing sedation options and sedation chart.

As soon as possible.

Once patient is calm and/or sedated.

Remove restraints from one limb at a time –start with a leg and then contralateral arm.

Not all patients need to be sedated.

Midazolam is not the only way –

Droperidol is very useful and in some ways a

better choice than midazolam.

Become familiar with Ketamine (+Clonidine)

Sedative drug choices and routes of administration dependent upon setting and resources.

Post-sedation care.