This document provides guidance on managing aggressive or violent patients in healthcare settings. It outlines non-physical interventions like verbal de-escalation and recommends physical restraint only as a last resort with adequate staff. Chemical sedation options are discussed, including benefits of different drugs like midazolam, droperidol and ketamine. Close monitoring of sedated patients is emphasized along with documenting restraint use.

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.