Emergency Chemical Restraint of Violent and Agitated Inmates: Why? When? How?

Jeffrey E. Keller MD FACEP

Faculty Disclosure

• “ I do not have any relevant financial relationships with any commercial interests.”

Learning Objectives

1. Understand when Chemical Restraint is appropriate for agitated and violent inmates and how properly to document these encounters. 2. Understand what therapeutic agents are available and the advantages and liabilities of each. 3. Be able to write an evidence-based protocol for the proper use of Chemical Restraint.

Introduction

• My introduction to Emergency Chemical Sedation.

• Emergency Chemical Sedation • NOT Court Ordered Psychiatric Medication• Physical Restraint discussed only briefly.

Definitions

• Psychotropic Medications• Involuntary Medication• Physical Restraint• Chemical Restraint• Rapid Tranquilization

Overall Best Term

• Emergency.• Chemical. • Sedation/Tranquilization vs. Restraint• Involuntary?

Terms

• Emergency Chemical Sedation• Involuntary Chemical Restraint• Involuntary Rapid Tranquilization

Emergency Sedation

• One time event• Not court ordered• Emergency—to rectify an immediate threat• Alternative to Prolonged Physical Restraint• Involuntary

Medico-Legal Questions

• Does the patient need to be restrained?• Which is safer, chemical or physical restraint?• How do I minimize my medical and legal risk in

these cases?

Emergency Sedation Reduces Risk

• I will present a case plus three approaches. You decide:

• Which carries the most medical risk?• Which carries the most legal risk?

Case One

• 26 year old male in booking. Drunk and probably intoxicated on other substances. He is running his head into the wall.

Medical and Legal Risk

1. Do nothing!2. Tie him into a restraint chair for several hours3. Emergency Chemical Sedation

Chemical Sedation is safer than Prolonged Physical Restraint

• Chemical Sedation does carry risk.• Do the benefits outweigh the risks?• How do the risks compare to physical

restraint?

Chemical Sedation is safer than Prolonged Physical Restraint

• Injuries Common in Physical Restrain, both to the patient and staff.

• Death has occurred.

• Injuries uncommon in Chemical sedation.

• Deaths very rare (I am not aware of any).

Chemical Sedation has less Legal Risk than Physical Restraint

• Emergency Medicine – Risk Management Monthly

• Correctional Medicine– Courts take a closer look at physical restraint than

emergency chemical restraint.– Emergent risk of harm– Unaware of any lawsuits related to emergency

chemical sedation that went anywhere

Chemical Sedation has less Legal Risk than Physical Restraint

• Correctional Medicine– Courts take a closer look at physical restraint than

emergency chemical restraint.– Emergent risk of harm– Unaware of any lawsuits related to emergency

chemical sedation that went anywhere

Minimizing Legal Risk

• Right Patient• Right Medication• Right Documentation• Conforms to established protocol• Physician Order (NCCHC requirement)

Right Patient

• Acute Danger to self or others• The danger is immediate and apparent• Other treatment modalities did not work• The patient should refuse voluntary sedation• NOT to be used as a disciplinary measure

Right Patient

• Two reversible medical conditions that can cause agitation– Hypoglycemia– Hypoxia

• Other Causes: – Delirium– Brain Injury

Right Agent--Antipsychotics

• Haloperidol 5-20mg IM. Overall Best Agent• Other Possibilities– Droperidol.– Ziprosidone (Geodon)– Olanzapine (Zyprexa)

Right Agent--Haloperidol

• “Haloperidol has been evaluated in a large number of clinical trials alone and in combination with benzodiazepines. These studies demonstrate that intramuscular haloperidol is both safe and effective in the treatment of agitation caused by virtually any etiology”

• Roberts: Clinical Procedures in Emergency Medicine, 5th ed.

Antipsychotics Advantages

• No Respiratory depression.• Safe, safe, safe.• “How much Haldol can you safely give IV

push?”

Antipsychotic Potential Adverse Event

• QT prolongation– Dysrhythmia exceedingly rare

• Seizure threshold– Controversial

• Neuroleptic Malignant Syndrome– Exceedingly rare

• Dystonia. – Common but trivial

Right Agent--Benzodiazepines

• Lorazepam 2-4mg IM. Best Agent.• Other possibilities:– Midazolam– Diazepam

Lorazepam--Advantages

• “Antidote” to stimulant overdose• Works well in concert with Haldol• Recommended for use in children

Lorazepam--Disadvantages

• Respiratory depression• Hypotension

Haldol-Ativan combination

• Works better in most cases than either agent alone

• Allows for lower doses of each agent• “The Spaghetti Sauce Theory of Combination

Dosing”

Experimental Agent

• Ketamine

Cases

• Standard Jerk• Haldol 10mg , Ativan 2mg IM

Case 2

• Alcohol intoxication• Haldol 5-10mg IM

Case 3

• Methamphetamine High• Ativan 2-4mg IM

Case 4

• Psychosis, Mania• Haldol 10, Ativen 2mg IM

Case 5

• “Undifferentiated Agitation”• Haldol 10mg (+/- Ativan 2mg) IM

Excited Delirium

• Speed of onset critical• Ativan 2-4mg, Haldol 5-10mg IV if possible• Ketamine has rapid onset IM

Documentation

• Need for Emergency Sedation• No reversible medical conditions• Refusal of less invasive alternatives• Physician order• Medication(s) given• Safe Onset of sedation• Retrospective review

Step By Step Procedure

• Establish Need– Danger to self or others– Refuses alternative treatment

• Get order

Step By Step Procedure

• Prepare Agents• Haldol and Ativan in same syringe• Haldol and Valium PO if patient consents to

oral treatment.

Step By Step Procedure

• Prepare restraint team

Step By Step Procedure

• Restrain and medicate

Step By Step Procedure

• Monitor Post Sedation progress– Vitals– Document onset of sedation

Step By Step Procedure

• Insure Follow up– Deputy watch for 12 hours– Mental Health evaluation next day– Medical evaluation next day– Administrative review within one week