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

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  • 1. Emergency Chemical Restraint ofViolent and Agitated Inmates: Why? When? How? Jeffrey E. Keller MD FACEP
  • 2. Faculty Disclosure• “ I do not have any relevant financial relationships with any commercial interests.”
  • 3. Learning Objectives1. Understand when Chemical Restraint isappropriate for agitated and violent inmatesand how properly to document theseencounters.2. Understand what therapeutic agents areavailable and the advantages and liabilities ofeach.3. Be able to write an evidence-basedprotocol for the proper use of ChemicalRestraint.
  • 4. Introduction• My introduction to Emergency Chemical Sedation.• Emergency Chemical Sedation• NOT Court Ordered Psychiatric Medication• Physical Restraint discussed only briefly.
  • 5. Definitions• Psychotropic Medications• Involuntary Medication• Physical Restraint• Chemical Restraint• Rapid Tranquilization
  • 6. Overall Best Term• Emergency.• Chemical.• Sedation/Tranquilization vs. Restraint• Involuntary?
  • 7. Terms• Emergency Chemical Sedation• Involuntary Chemical Restraint• Involuntary Rapid Tranquilization
  • 8. Emergency Sedation• One time event• Not court ordered• Emergency—to rectify an immediate threat• Alternative to Prolonged Physical Restraint• Involuntary
  • 9. 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?
  • 10. 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?
  • 11. Case One• 26 year old male in booking. Drunk and probably intoxicated on other substances. He is running his head into the wall.
  • 12. Medical and Legal Risk1. Do nothing!2. Tie him into a restraint chair for several hours3. Emergency Chemical Sedation
  • 13. 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?
  • 14. Chemical Sedation is safer than Prolonged Physical Restraint• Injuries Common in • Injuries uncommon in Physical Restrain, both Chemical sedation. to the patient and staff.• Death has occurred. • Deaths very rare (I am not aware of any).
  • 15. 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
  • 16. 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
  • 17. Minimizing Legal Risk• Right Patient• Right Medication• Right Documentation• Conforms to established protocol• Physician Order (NCCHC requirement)
  • 18. 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
  • 19. Right Patient• Two reversible medical conditions that can cause agitation – Hypoglycemia – Hypoxia• Other Causes: – Delirium – Brain Injury
  • 20. Right Agent--Antipsychotics• Haloperidol 5-20mg IM. Overall Best Agent• Other Possibilities – Droperidol. – Ziprosidone (Geodon) – Olanzapine (Zyprexa)
  • 21. 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.
  • 22. Antipsychotics Advantages• No Respiratory depression.• Safe, safe, safe.• “How much Haldol can you safely give IV push?”
  • 23. Antipsychotic Potential Adverse Event• QT prolongation – Dysrhythmia exceedingly rare• Seizure threshold – Controversial• Neuroleptic Malignant Syndrome – Exceedingly rare• Dystonia. – Common but trivial
  • 24. Right Agent--Benzodiazepines• Lorazepam 2-4mg IM. Best Agent.• Other possibilities: – Midazolam – Diazepam
  • 25. Lorazepam--Advantages• “Antidote” to stimulant overdose• Works well in concert with Haldol• Recommended for use in children
  • 26. Lorazepam--Disadvantages• Respiratory depression• Hypotension
  • 27. 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”
  • 28. Experimental Agent• Ketamine
  • 29. Cases• Standard Jerk• Haldol 10mg , Ativan 2mg IM
  • 30. Case 2• Alcohol intoxication• Haldol 5-10mg IM
  • 31. Case 3• Methamphetamine High• Ativan 2-4mg IM
  • 32. Case 4• Psychosis, Mania• Haldol 10, Ativen 2mg IM
  • 33. Case 5• “Undifferentiated Agitation”• Haldol 10mg (+/- Ativan 2mg) IM
  • 34. Excited Delirium• Speed of onset critical• Ativan 2-4mg, Haldol 5-10mg IV if possible• Ketamine has rapid onset IM
  • 35. 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
  • 36. Step By Step Procedure• Establish Need – Danger to self or others – Refuses alternative treatment• Get order
  • 37. Step By Step Procedure• Prepare Agents• Haldol and Ativan in same syringe• Haldol and Valium PO if patient consents to oral treatment.
  • 38. Step By Step Procedure• Prepare restraint team
  • 39. Step By Step Procedure• Restrain and medicate
  • 40. Step By Step Procedure• Monitor Post Sedation progress – Vitals – Document onset of sedation
  • 41. 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