Restraint Options for the Agitated Patient

1. David Moore
CME April 2015

2.  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.

3.  Verbal de-escalation
 Chemical restraint
 Physical restraint

4.  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.

5.  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.

6.  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

7.  Benzodiazepines
 Neuroleptics
 (Ketamine)
 (Clonidine)
 (Propofol)

8.  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

9.  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.

10.  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 individual
variability

11.  Oversedation
 Hypotension
 Airway or ventilatory compromise
 Paradoxical reactions
 Delirium
 Tolerance

12.  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.

13.  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.

14.  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

15.  Oversedation
 Hypotension
 Acute dystonia
 Anticholinergic delirium
 (seizures)
 (QT prolongation)

16.  Dissociative anaesthetic agent.
 A good back-up option in cases of extreme benzo
tolerance 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.

17.  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)

22.  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

23.  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).

24.  Reason for restraint.
 Alternative therapies attempted.
 Assessment of potential injuries and any
complications of restraint.
 Monitoring plan.
 Ongoing sedation options.
 Discussion with psychiatry team.

25.  Risk of harm
 Usually combined with chemical restraint.
 Secure large joints.
 Medical instability is a contraindication to
physical restraints.

26. 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’).

27.  One person for each limb.
 One person controls the head (has airway
skills)
 One person to administer pre-prepared meds

28.  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.

29.  Pulse
 RR
 Pulse oximetry
 ECG
 BP
 Monitor conscious state and airway adequacy.
 Neurovascular observations distal to restraints.

30.  Reason for restraint.
 Alternative therapies attempted.
 Assessment of potential injuries.
 Monitoring plan.
 Thresholds for further interventions.
 Ongoing sedation options and sedation chart.

31.  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.

32.  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.