Emergency chemical restraint Medication options

This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

Principles:
Chemical restraint is one modality of control in the management of acute behavioural disturbance. Chemical restraint should be used within the local violence management framework. Also see:

Emergency Restraint & Sedation - Code Grey RCH Code grey policy and procedure RCH Mechanical restraint policy and procedure If at all possible the patient should be given the option of taking an oral medication. Benzodiazepines are generally the medication of first choice, particularly in cases of known intoxication If the patient has a known psychiatric disorder, consider using top-up doses of their regular medication Give one option from choices below, wait for effect (see Drug specific information) and then consider further medication (oral may become an option after initial IM / IV). If a drug from one group has had a poor therapeutic response after 2 doses, try a drug from another group (e.g. - poor response to diazepam, try olanzapine).

At this point reconsider your diagnosis ( eg: Underlying organic pathology) and indications for using emergency sedation

If the patient can tolerate oral medications:

Diazepam - oral 0.2mg - 0.4mg/kg (Max 10mg/dose if benzodiazepine naive) Lorazepam - oral 0.5mg - 1mg (<40kg)

OR

OR

1mg - 2.5mg (>40kg) Olanzapine wafer - sublingual (SL) 2.5mg - 5mg (<40kg) 5mg - 10mg (>40kg) Midazolam - IM / IV 0.1mg - 0.2mg/kg (Max 10mg/dose) Olanzapine - IM only 5mg (<40kg) 10mg (>40Kg) Haloperidol - IM / IV 0.1mg - 0.2mg/kg (Max 5mg/dose, usually 2.5mg 5mg/dose) Midazolam / Haloperidol Combination (IM) Give above doses combined in one syringe Drug Time to review clinical effect before 2nd med IM: 10 - 20 mins IV: almost immediate Olanzapine Oral: 20 - 30 mins IM: 15 - 30 mins

If oral medication not possible:

Drug specific Information:

OR

OR

OR

Adverse effects

Midazolam

Respiratory depression1 and airway compromise, paradoxical reactions4

Respiratory depression1, hypotension, HR. Do not use if history suggestive of prolonged QTC,

Extra-pyramidal reactions2, Neuroleptic Malignant Syndrome3, may reduce seizure threshold Haloperidol IM/IV: 15 - 30 mins Respiratory depression1, hypotension, HR. Do not use if history suggestive of prolonged QTC, Extra-pyramidal reactions2, Neuroleptic Malignant Syndrome3, may reduce seizure threshold Diazepam Lorazepam Oral: 30 - 60 mins Oral:20 - 40 mins Respiratory depression1 (unlikely to see immediate complications as longer half lives) and paradoxical reactions4

Adverse effects - details

1

Respiratory depression - More commonly seen with benzodiazepines but can also occur

with olanzepine and haloperidol.

2

Extrapyramidal reactions - more commonly seen with haloperidol but may be seen with

olanzapine after only 1 dose. Reactions include; dystonia, dyskinesia, oculogyric crisis and akathisia (restlessness). Reversible with benztropine.
3

Neuroleptic Malignant Syndrome - A rare complication of typical and atypical

antipsychotics characterised by hyperthermia, muscle rigidity, autonomic dysfunction and altered mental status. Call hospital emergency team (ie: MET call) if suspected and check serum CK as it is invariably elevated. Immediately inform consultant and Psychiatry team.
4

Paradoxical reactions - Administration of a benzodiazepine results in increasing agitation

and anxiety as opposed to its normal sedating effect. This is more commonly seen in patients with developmental delay and / or a history of aggressive behaviour.

The following antidotes should be readily available for reversal of potential side effects Benztropine - 0.02mg/kg (Max 2mg/dose) given IV or IM for reversal of dystonic reactions associated with haloperidol and olanzepine. Repeated doses may be required.

Flumazenil - 10 micrograms/kg (Max 200micrograms/dose) repeated at 1 minute intervals prn for up to 5 doses, for reversal of respiratory depression associated with benzodiazepines only. Do not give unless you are sure the patient is not on long term benzodiazepines. Consider flumazenil infusion if more than 5 doses are required.

Post sedation care:

Vigilant monitoring, particularly for signs of airway obstruction, respiratory depression, hypotension and extrapyramidal reactions is mandatory. Monitoring should be performed in a safe environment within the clinical setting. Some flexibility in observations is acceptable, so as not to unnecessarily wake or irritate the patient further and to permit sufficient patient rest. Patient with decreased level of consciousness

Require one to one nursing Continuous oxygen saturation monitoring Vital signs (temp, HR + rhythm, BP, resp rate) and neurological observations should be performed every 15 mins until stability is clinically evident

Patient calm but alert

Half-hourly observations for 2 hours after last sedation medication

Agitated patients

Need continuous clinical observation

Procedure for administration:

Information Specific for RCH

If IM or IV medication is required the Code Grey team will provide assistance. Medication will be delivered by medical / nursing staff in the particular clinical area. see RCH Code Grey Procedure

Team leader will designate roles before approaching patient All members should ensure own safety, with gloves and goggles Draw up medication

Secure the patient quickly and calmly using the least possible force. At least 5 people are required - see Figure: Code Grey Procedure The patient should be initially held supine. In highly agitated patients, a face down technique may be used at the discretion of the team leader, but be aware of the increased risk of asphyxiation

Administer the drugs by intramuscular injection into the lateral thigh (Other options ventrogluteal or dorsogluteal). Beware of the risk of needle stick injury. Further titrated doses of medication may be required depending on clinical response (If medication can be given IV this may be an option if the patient is safe to cannulate)

Patients who have needed emergency restraint and sedation may also require mechanical restraint, although chemical restraint is preferred. Mechanical restraint should be provided by trained personnel only. See mechanical restraint RCH policy

Post sedation care (See above)

Consider consultation with local paediatric team:

Any child requiring emergency chemical restraint. Any child with severe behavioural or psychiatric crisis.

When to consider transfer to tertiary centre:

Complications from chemical sedation -respiratory depression, hypotension, extrapyramidal reactions. Child requiring care beyond the comfort level of the hospital.

The Medical Use Of Restraints

What are restraints?
The Medical Use Of Restraints Care Guide

The Medical Use Of Restraints The Medical Use Of Restraints Aftercare Instructions The Medical Use Of Restraints Inpatient Care En Espanol

Restraints are methods used to limit or restrict the movement of a patient. They are used to protect the health and safety of the restrained patient, other patients, and caregivers.

What are the types of restraints?

Physical and mechanical restraint: A caregiver may handle or hold the patient to limit movement or to apply a restraint. This type of restraint includes wrist or ankle ties, locked chairs, and side rails on beds. Chemical restraint: This is the use of medicines to calm a patient, limit his movement, or both. The medicines used are not part of the patient's regular treatment. Chemical restraint may also be called rapid tranquillization. It may allow the patient to talk with caregivers, be examined, and receive treatment without harming himself or others. Chemical restraint may be used alone. It may also be used along with physical restraints. Types of chemical restraints include sedatives and anti-anxiety medicines.

Environmental restraint: This means putting a patient into a limited area, such as a locked room, for a period of time. Environmental restraint is also called seclusion. It may be used to remove a patient from a stressful situation and give him a chance to calm down.

Why may restraints be needed?

When behavior is violent or self-destructive: A patient is restrained because he may be dangerous to himself or others. Restraints may help control harmful behavior caused by problems such as drug abuse, head injury, or mental illness. When behavior is non-violent or non-self-destructive: A patient is restrained to allow caregivers to provide medical treatment. Restraints may help keep a patient from removing a feeding tube or a tube that helps him breathe. A patient may also be restrained to prevent other behaviors that may be harmful to him. For instance, seclusion may keep a patient with dementia (a disease that causes problems with memory and thinking) from wandering.

Are there guidelines for the medical use of restraints?

Yes. The Joint Commission (TJC) is one of many medical organizations that provide guidelines for the medical use of restraints. General guidelines for the use of restraints include:

Restraints are used only when other methods to control behavior have not worked. Restraints are used only when there is a risk of a patient harming himself or others. Restraints are not used for punishment, to make a patient easier to care for, or to make a patient do something. They are not used because of a patient's past restraint use, or his behavior history.

What must be tried before restraints are used?

Caregivers may ask about the patient's health history and do a physical exam. Caregivers will try to learn the cause of a patient's behavior and work with him to help avoid the use of restraint. However, if the patient is at risk of harming himself or others, caregivers may need to apply restraints first. Caregivers may do any of the following:

Violent or self-destructive behavior management: De-escalation is when caregivers use methods to help calm a patient and help the patient better control his behavior. Caregivers will work with the patient to learn what may cause him to become upset and possibly violent. De-escalation can begin as soon as signs that a patient may lose control of his behavior are noticed. Caregivers may do the following:

o o o o o o

Speak to the patient calmly and with respect. Caregivers may also offer the patient food or drink. Listen to the patient's concerns and try to understand them. Caregivers may ask what is bothering the patient or making him anxious (nervous) or agitated (easily angered). Explain what may occur if the patient cannot calm himself, and help the patient identify ways to avoid the use of restraints. Direct the patient's attention away from what is causing him stress. Put the patient in a time-out. This is when the patient stays in an unlocked room for 30 minutes or less. Ask a patient with dementia what his needs are, such as if he needs food or drink. This may help keep hunger or thirst from making him agitated and violent. Caregivers may also provide a calm environment

to help prevent agitation in patients with dementia. This may include lowering noise levels and providing music or massage. It may also include allowing patients to keep familiar items, such as photos of loved ones.

Non-violent or non-self-destructive behavior management: Caregivers may do the following to avoid the use of restraints: Explain to the patient why certain treatments are needed. For instance, explain why a feeding tube is used and when it will be removed. This may help prevent the patient from removing the tube on his own. Observe the patient to learn his needs. This may help prevent behaviors that can require restraint. For instance, a toileting schedule may help keep the patient from wandering to the bathroom on his own and risking a fall.

What must be done when physical and mechanical restraints are used?

Caregivers will tell the patient the type of restraint that may be used and the reason for it. Caregivers will tell the patient what he needs to do to avoid the use of restraint. When the restraint process begins, a caregiver explains to the patient what will happen. This caregiver protects the patient's head while other caregivers each manage an arm or leg. The patient may be restrained on his back or side. If the patient is restrained on his stomach, he is positioned so he can move his head to the side to make breathing easy. Caregivers will monitor the restrained patient at all times. Caregivers will do an assessment of the restrained patient every 15 minutes. This includes checking the patient's vital signs, such as blood pressure, pulse (heart rate), and breathing. Caregivers will check to make sure the restraints are on the patient correctly and that they are not too tight. Caregivers will check whether the patient needs to change positions. This helps prevent skin sores. Caregivers also will check whether the patient needs food, water, medical care, or to use the toilet. An order of restraint can last up to four hours. Restraint use will be stopped as soon as the patient behaves as required by caregivers. This may include the patient agreeing to act in a safe manner or no longer making threats against others. When the restraint order ends, a caregiver will examine the patient.

What must be done when chemical restraints are used?

Caregivers need to know what medicines a patient currently takes. They need to make sure these medicines are safe for use together with medicines used for restraint. Medicines used for chemical restraint are commonly offered to the patient in pill form first. If the patient refuses, medicines may be given as a shot or in an IV. An IV is a small tube put into a vein to give medicines or liquids. After the medicine is given, the patient's health is monitored. Heart function may be checked using an EKG (electrocardiogram). Vital signs are checked often until the medicine wears off.

What must be done when environmental restraints are used?

The patient will be observed constantly by caregivers. This may be done in person or with a video camera. Caregivers will make sure the seclusion room is safe and calm. Furniture in the room is heavy and not easy to move. There should be windows with unbreakable glass so caregivers can monitor the patient. The space should have clear exits. It may have panic buttons (buttons to press for immediate help). The patient may keep personal objects if they do not increase the risk of harm to the patient or caregivers. These personal objects may include clothing and jewelry. Caregivers will review the need for seclusion every two hours. Seclusion ends as soon the patient behaves as caregivers have requested. This may include stopping violent behavior that risks harm to others.

Does a patient need to agree to the medical use of restraints?

Trained caregivers usually decide when the use of restraints is needed. Caregivers will always tell the patient what is going to happen before they apply restraints. In some cases, a patient may give permission for restraint use. This may occur when a patient understands the need for treatment and how restraints can help keep him safe. Some patients may have a behavioral health advance directive. This is a document that describes how the patient wants his care or restraint to be handled when he acts out violently.

What must caregivers do after restraints are removed?

Within 24 hours, caregivers meet with the patient to talk about the restraint event. They discuss why restraint was needed and how restraint use could have been avoided. They also discuss how restraint use can be avoided in the future. During this meeting, caregivers ask if the patient's physical and mental needs were met while restrained. If needed, a mental health caregiver helps the patient cope with the restraint event.

How should the patient's family or significant others be involved when restraints are considered or used?
Caregivers ask the patient if he wants his family to be told about or involved with the use of restraint. If the patient says yes, the patient's family is asked if they want to be involved. With consent from the patient and his family, caregivers:

Tell the family when restraints are used. Explain to the family the rules on the use of restraint.

Ask family members about any physical disability that may increase the patient's risk if restraints are used. Caregivers may ask about past health care, health problems, or physical abuse. They may also ask about ways to help the patient control his behavior. Ask family members to help calm the patient and help him understand how he can avoid restraint. Involve the family in the discussion that takes place after the restraint use.

What are the risks of using restraints?

A patient who is restrained will not be able to do his normal daily tasks. He may feel isolated (alone), rejected (unwanted), anxious, or depressed (deeply sad). He may not be able to control when he urinates. This may increase his risk for a urinary tract infection. Physical restraints may cause skin sores and bruising. Frequent restraint and lack of movement may lead to loss of muscle strength. The patient may have problems with balance and be at risk for falling. Lack of movement can also lead to a lung infection. If the restraints move out of the right position, he may have decreased blood flow to his arms and legs. He may also have trouble breathing. A struggle against physical restraints may lead to an increase in the patient's body temperature. He may become dehydrated (not having enough body fluid). He may also have skin and muscle damage. Struggling may lead to lactic acidosis. This is a buildup of lactic acid in the muscles. Too much lactic acid can lead to heart problems. Rarely, an injury from restraint use can lead to death. The medicines used for chemical restraint may cause nausea (upset stomach). The patient may become confused, restless (cannot relax), and agitated. Medicines may cause low blood pressure. They may not work well with other medicines the patient takes. The patient may have movements that he cannot control and be at risk for falling. Certain medicines can decrease how well he breathes. He may also be at risk for seizures (convulsions) and loss of consciousness. Talk with caregivers about questions or concerns about the medical use of restraints.

Where can I find more information about the medical use of restraints?
If you or a family member has been placed in restraints, you may feel frustrated, angry, or sad. These are normal feelings. It may help to find out all you can about the use of restraints. For more information, contact:

Joint Commission on Accreditation of Healthcare Organizations One Renaissance Blvd. Oakbrook Terrace , IL 60181 Phone: 1- 630 - 792-5000 Web Address: http://www.jointcommission.org

Care Agreement
A patient has the right to safe care and to be treated with respect when restraints are used. Restraints should not cause the patient pain or harm. Patients have the right to help plan their care. To help with this plan, patients must learn about their health condition, how it may be treated, and when restraints may be needed. Treatment options should be discussed with caregivers. Patients and caregivers can work together to decide what care may be best.

Thiopental sodium, a short-acting barbiturate anaesthetic, is a CNS depressant inducing hypnosis and anaesthesia. Color: yellow color due to the presence of sulphur molecules.