The document discusses guidelines for the emergency chemical restraint of violent and agitated inmates, including definitions, appropriate situations for use, recommended medication options and dosages, importance of proper documentation, and steps for safely administering chemical restraint. The overall message is that emergency chemical restraint can be a safer alternative to physical restraint for reducing risk of injury when an inmate is an acute danger to themselves or others.

1. Emergency Chemical Restraint of
Violent 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 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.

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 Risk
1. Do nothing!
2. Tie him into a restraint chair for several hours
3. 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