# chemical restraint



## boingo (Jul 19, 2011)

Anyone work in a system with a chemical restraint policy in place for combative patients?  I would be interested in seeing your protocols and the system you work for.  You can feel free to PM if you don't want to post publicly.  Much appreciated.


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## Farmer2DO (Jul 19, 2011)

We have a protocol in place.  I will email you the link to our protocols.

We have a standing order for midazolam 2.5 mg, IM or IV.  With medical control, we can either repeat it or double it.

We used to have haldol, 5 mg IM, with a benzo, either the midazolam as stated above, or diazepam, 5 mg IM or IV.  

My opinion is that the combination worked much better.  2.5 midazolam by itself, most of the time accomplishes nothing but pissing off the patient for stabbing them with a needle.  5 mg often sedates them well, but it wears off quickly.

One of our local EDs sedates all their psychs with IM zyprexa.  Those guys are snowed for hours.  I wish we had our haldol back, or geodon, or zyprexa.  Oh well.


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## fast65 (Jul 19, 2011)

Our protocols state that for chemical restraint we can five 2.5-5 mg of Inapsine, and repeat until we've reached the desired effect. Versed is only allowed for sedation of pt's with DT's, however, medical control is usually pretty lenient about allowing it for chemical restraint as well.


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## MrBrown (Jul 19, 2011)

Yes, we have midazolam


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## usalsfyre (Jul 19, 2011)

I believe it's 2-5 of Midazolam x2 for sedation of the agitated patient. If you can get someone to get hold of their head for long enough, IN works great.


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## Melclin (Jul 19, 2011)

If its safe for you AND causes other than being a nut or an arse have been excluded AND aggression is not responsive to verbal de-escalation techniques then: Midazolam 0.05-0.1mg/kg IM q10 (IV route, q5 also an option for Intensive Care medics) (maximum of 4 doses, reduced doses in elderly and hypotensive pts). 

I think it would be nice to have some other options. IM midaz is generally for dangerously violent pts. It might be good to have something we could do for anxiety and also the kind of agitation that might become dangerous. You know, that pt that you need to keep the police around for, you need security at the hospital and its a matter of _when_, not _if_ they're ganna arc up. It might be nice to be able to pop a little diaz in just to bring things down a notch and make things a bit more pleasant for all involved. Olanzapine or oral diazepam might be nice.


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## Iceman26 (Jul 19, 2011)

Melclin said:


> If its safe for you AND causes other than being a nut or an arse have been excluded AND aggression is not responsive to verbal de-escalation techniques then: Midazolam 0.05-0.1mg/kg IM q10 (IV route, q5 also an option for Intensive Care medics) (maximum of 4 doses, reduced doses in elderly and hypotensive pts).
> 
> I think it would be nice to have some other options. IM midaz is generally for dangerously violent pts. It might be good to have something we could do for anxiety and also the kind of agitation that might become dangerous. You know, that pt that you need to keep the police around for, you need security at the hospital and its a matter of _when_, not _if_ they're ganna arc up. It might be nice to be able to pop a little diaz in just to bring things down a notch and make things a bit more pleasant for all involved. Olanzapine or oral diazepam might be nice.



I agree on the diazepam, where I used to work we carried it and it was nice to have. Both there and where I'm working now we do have it in our protocols to use midazolam. I've lucked out so far and have yet to need to use it for this purpose but I suppose now that I just said that it'll happen next shift!


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## truetiger (Jul 19, 2011)

Our protocols allow for up to 2mg of ativan or 5mg of versed


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## STXmedic (Jul 19, 2011)

How well does Zyprexa work? I just found out my FT system will be getting it soon, but I have ZERO experience with it? 

As far as standing orders right now: FT has up to 10mg Diazepam without calling, the PT is up to 20mg Diazepam without calling or 10mg Versed. Have actually had to take  advantage of that several times recently; had a rash of EDS pts recently.


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## Farmer2DO (Jul 19, 2011)

I see the zyprexa used a lot in one ED, a large, busy, urban ED (>100,000 visits annually) and they have very good luck with it.  Snows them with no bad side effects that I've seen.


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## dmiracco (Jul 19, 2011)

We have the option of versed or ketaminegreat option


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## mikie (Jul 19, 2011)

Maryland uses Haldol - Page 234 of MD Protocols



> Chemical-restraint guidelines: Sedative agents may be used to provide a safe method of restraining violently combative patients who present a danger to themselves or others, and to prevent violently combative patients from further injury while secured with physical restraints.





> Dosage (May combine with midazolam in same syringe)
> (1)    Adult a. Patient 15-69 years of age:
> 5 mg IM or IV b. Patient greater than 69 years of age:
> 2.5 mg IM or IV (2) Pediatric
> ...


Benadryl is usually given as well to prevent dystonic reactions/EPS.


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## jwk (Jul 19, 2011)

fast65 said:


> Our protocols state that for chemical restraint we can five 2.5-5 mg of Inapsine, and repeat until we've reached the desired effect. Versed is only allowed for sedation of pt's with DT's, however, medical control is usually pretty lenient about allowing it for chemical restraint as well.



I didn't realize anyone was using droperidol (Inapsine) for anything anymore except treatment/prophylaxis for perioperative N&V.  We abandoned it's use in the OR 20+ years ago for any other indications.


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## NomadicMedic (Jul 19, 2011)

I've worked in several systems with different choices. My last full time job was up to 5mg of Droperidol. I've also had the option of 5 to 10mg of Versed IN/IV/IM. 

I prefer the IN versed. It's safer than trying to harpoon a combative patient. The MAD makes it a LOT easier.


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## 325Medic (Jul 19, 2011)

P.A. SOP's: 2.5-5mg Versed, should / try to contact med. comm if able to but can use w/o med comm. if needed. Go to P.A. DOH ALS protocols / under combative pt.

325.


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## JeffDHMC (Jul 19, 2011)

Droperidol and versed. Not together, mind you, though I imagine that would do the trick.

Jeff


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## Epi-do (Jul 19, 2011)

Here's our chemical restraint protocol.



> Chemical restraint is to be used only where the patient can be adequately and repeatedly monitored by EMT-P providers. It is to be reserved for patients who cannot otherwise be restrained or restrained only at the risk of significant harm to the patient, law enforcement, and EMS providers.
> 1.  Consider other causes of combative or irrational behavior, including but not limited to hypoxia and hypoglycemia.
> 
> 2.  Administer midazolam IV, IM, or via intra-nasal spray
> ...


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## bigbaldguy (Jul 20, 2011)

Farmer2DO said:


> 2.5 midazolam by itself, most of the time accomplishes nothing but pissing off the patient for stabbing them with a needle.



Amen to that. Like giving a Valium to a grizzly bear rectally.


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## Trevor (Jul 22, 2011)

We have Versed and Haldol. 

5 mg Versed IM/IN for "presumed" drug related issues. OR 2.5 mg IV. Each can be repeated. 
5 mg Haldol can be given for patient's without "Suspected Substance Abuse". This can be repeated as well.


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## NomadicMedic (Jul 22, 2011)

Here's my old protocols...


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## reaper (Jul 23, 2011)

We have 2mg of Ativan and 10mg of Geodon, followed by 10mg of geodon, if needed.


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## Shishkabob (Jul 23, 2011)

Non-intubated
Ativan 0.5-2
Versed 0.5-2
Both can be repeated

Intubated
Ativan 2-4
Versed 2-5
Both can be repeated


If need be, they buy themselves some Roc/Etomidate and a tube.


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## usalsfyre (Jul 23, 2011)

Linuss said:


> Non-intubated
> Ativan 0.5-2
> Versed 0.5-2
> Both can be repeated
> ...



Don't forget we can also treat pain as a possible cause of agitation...2 of midaz and 100mcg of fentanyl usually makes for a "comfortable" situation for everyone involved .


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## Shishkabob (Jul 23, 2011)

I love me some conscious sedation!  Only thing I love more is the look on the nurses face when they realize what I did to the patient.  

"That's conscious sedation!"
"Yeah, and?"


Honestly, I'm surprised they don't have Benadryl as a standing chemical sedative for us.  Go to some place like Green Oaks, and you won't touch a patient who doesn't have atleast 50mg running through them at any given point.



I love Jimmy's view... "EVERYONE is agitated!"


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## NomadicMedic (Jul 23, 2011)

Linuss said:


> If need be, they buy themselves some Roc/Etomidate and a tube.



Are you serious? RSIing a merely uncooperative patient would, at least in my old system, get you QIed and probably a vacation. We knocked down and tubed a lot of patients, but each was medically justifiable. We had 100% review on any RSI. 

Let's remember this thread was about chemical restraint, ie: controlling an unruly patient that was dangerous to himself or others, not about sedating and then managing the airway of a medically unstable, possibly combative patient


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## Shishkabob (Jul 23, 2011)

Yes, I'm serious.  No, the OP never made a distinction between a combative psych, and a combative head injury... just chemical restraints for combative patients.



You will NOT see me RSIing someone who's simply unruly.  Period.  And I doubt 99% of the medics at my agency will either.  The other 1% need not be Paramedics to begin with.  It's the 'use of force' continuum, only for EMS.  RSI is to us like a gun is to LEOs... your last step, but if you need it you better have it.  Better to start off low like physical restraints, but sometimes that's simply not enough... which apparently our clinical department and med control agree with.  




Hell, if someone is already intubated, and you've tried more Etomidate / Fent / Benzos but they're still bucking the tube, guess what?  Paralysis... and from what I've seen, that's used in EMS, the ER, OR, ICU, etc etc.  Some people simply cannot be sedated enough with normal means.




Shoot, have you ever fought someone high on PCP?  They break handcuffs for Gods sake.


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## usalsfyre (Jul 23, 2011)

n7lxi said:


> Are you serious? RSIing a merely uncooperative patient would, at least in my old system, get you QIed and probably a vacation. We knocked down and tubed a lot of patients, but each was medically justifiable. We had 100% review on any RSI.
> 
> Let's remember this thread was about chemical restraint, ie: controlling an unruly patient that was dangerous to himself or others, not about sedating and then managing the airway of a medically unstable, possibly combative patient



The line starts to get blurry with extremely agitated, hypermetabolic patients. I have RSI'd patients who were extremely agitated/combative and unresponsive to benzodiazepines. We have 100% QA of RSI as well, as did the last program I worked for.

That said, where I worked before was an airmedical program and we currently share clinical guidelines with our HEMS program. Airframe safety is paramount and takes precedence.


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## thegreypilgrim (Jul 23, 2011)

Our protocol is 2-5mg Versed IV or 5mg IN/IM and can only be repeated once.

Like everything else, however, it requires a base hospital order.


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## NomadicMedic (Jul 23, 2011)

Oh, I agree that combative patients need to be sedated for their safety and the safety of the crew transporting or caring for them, and yes, I'd not hesitate to RSI a combative head injury.

That being said, the statement "...they buy themselves...a tube" seems a bit cavalier. 

...but that's the internet, isn't it?


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## socalmedic (Jul 23, 2011)

versed 5mg im for agitation with out an order, i can repeat with an order.


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## ah2388 (Jul 26, 2011)

Ive heard of RSI in hospital to facilitate CT or other invasive testing.  I am not sure I agree with it prehospital, however if the physicians in control of your guidelines believe it to be necessary, then I would assume that the quality control process is in place well enough to make it safe practice.

We carry Ativan/Valium(lol), Versed, Haldol...

4mg/20mg/10mg/10mg respectively


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## cruiseforever (Jul 27, 2011)

ADULT BEHAVIORAL EMERGENCIES
Standing Orders
A. Assess the severity of the patient’s agitation.
B. Consider manpower necessary to adequately and safely restrain the patient.

C. SEVERE AGITATION
1. If the patient is severely agitated and poses an immediate threat to himself/herself
or others, consider giving one or both medications (may be mixed together in one
syringe):
 Versed 5 mg IV/IM/IO; AND/OR
 Haldol 5-10 mg, IV/IM/IO (dosage based on the patient’s age and/or
weight).
OR
 Ativan 2 mg IV/IM/IO; AND/OR
 Haldol 5-10 mg, IV/IM/IO (dosage based on the patient’s age and/or
weight).
2. For continued agitation, contact a medical control physician for further orders
After Obtaining Verbal Orders
3. Consider additional Versed 1-5 mg IV/IM/IO OR Ativan 1-2 mg IV/IM/IO.

D. PROFOUND AGITATION
1. If the patient is profoundly agitated with active physical violence to
himself/herself or others evident, and usual chemical or physical restraints
(section C) may not be appropriate or safely used, consider:
 Ketamine 5 mg/kg IM (If IV already established, may give 2 mg/kg
IV/IO).
 DO NOT attempt to place an IV in a severely combative patient.
2. If Ketamine is administered, rapidly move the patient to the ambulance and be
prepared to provide:
a. Respiratory support including suctioning, oxygen, and intubation.
b. Monitoring of the airway for laryngospasm (presents as stridor, abrupt
cyanosis/hypoxia early in sedation period). If laryngospasm occurs perform
the following in sequence until the patient is ventilating, then support as
needed:
i. Provide jaw thrust and oxygen.
ii. Attempt Bag Valve Mask (BVM) ventilation.
iii. Intubate over gum bougie/tracheal tube introducer with appropriate RSI
medications as needed (per applicable service protocols). Cords likely to
be closed if not paralyzed thus the need for introducer.
 If hypersecretion is present, consider Atropine IV/IO 0.1-0.3 mg IV or 0.5 mg
IM.
 If emergence of hallucinations/agitation after administration of Ketamine,
consider Midazolam 2-5 mg IM/IV/IO.
3. Consider IV access once sedation occurs (if no IV access previously established
and Ketamine given IM) then administer Normal Saline wide open up to 1 liters.
4. Consider Sodium Bicarbonate 1 amp IV/IO push.
5. Rapid transport at earliest opportunity.


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## boingo (Jul 29, 2011)

Appreciate all the responses!


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## McGoo (Aug 8, 2011)

We have midazolam and haloperidol for sedation, both only used IM. 10mg of each if required, more available with phonecall approval.


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## Wes (Aug 26, 2011)

SEDATION/CHEMICAL RESTRAINT
PARAMEDIC
MILD SEDATION (i.e. Anxiety)
• Versed 1-2 mg IV/IN, or
• Ativan 0.5-2 mg IV/IM
MODERATE SEDATION (Cardioversion, painful procedures, potential harm to self or others without
psychiatric history)
• Versed 2-5 mg IV/IN
CHEMICAL RESTRAINT (Potental harm to self or others, psychiatric history) except Excited Delirium)
IV (Must be administered in separate syringes)
• Haldol 5 mg
• Versed 2-5 mg and/or Ativan 2 mg
IM (Must be administered in separate syringes)
• Haldol 5-10 mg
• Versed 5 mg and/or Ativan 2 mg

EXCITED DELIRIUM
ALL KETAMINE USAGE MUST HAVE PRIOR
MEDICAL CONTROL APPROVAL
INDICATIONS
• Sedation of combative or violent patients
SYMPTOMS
• Agitation
• Aggressive, threatening, or combative behavior
• Amazing feats of strength
• Presured, loud, incoherent speech
• Sweating (or loss of sweating late)
• Dilated pupils/less reactive to light
• Rapid breathing
• Stripping of clothes
FIRST-LINE TREATMENT MAY BE MEDICATION ADMINISTRATION
MEDICAL CONTROL CONSULT (Only Paramedic In-Charge Can Perform this Guideline)
• CABCs, Oxygen
• Vital signs including temperature – With hyperthermia perform immediate cooling
• NS 250 mL may repeat 4-8 times if no evidence of pulmonary edema
• ECG, SpO2, ETCO2
Options
• Ketamine 1-2 mg/kg IV over 1 minute or 4-5 mg/kg IM
• Versed 2-5 mg IV/IN (to prevent emergence) and/or
• Ativan 2 mg IV/IM (to prevent emergence)
• Zofran 4-8 mg IV (to prevent emesis)


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## MrBrown (Aug 26, 2011)

ZOMG somebody in the US is using ketamine woohoo 

*Brown jumps around doing the very happy dance


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## Wes (Aug 26, 2011)

Mr. Brown -- our medical director absolutely loves Ketamine and encourages its use when appropriate, of course.


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## usafmedic45 (Aug 26, 2011)

Ketamine if given in sufficient doses (and chased with either a drip or some form of benzo to avoid the emergence reaction) is a good drug for putting someone out.


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## epipusher (Aug 28, 2011)

usafmedic45 said:


> Ketamine if given in sufficient doses (and chased with either a drip or some form of benzo to avoid the emergence reaction) is a good drug for putting someone out.



and who is using this?


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## LondonMedic (Aug 28, 2011)

epipusher said:


> and who is using this?


Most of Europe and Australasia...


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## IBleedJDM (Aug 29, 2011)

This is copy and pasted directly from our standing orders


*Restraints -Mechanical/Pharmacological *

INDICATIONS
Patients with actual or potential threat to self or others.Patients at risk or exhibiting S/S of the excitable phenomenon known as excited delirium.

APPLICATION
1.The senior personnel on scene is to evaluate the need for restraints. Restraints should be considered only as a last resort after verbal techniques have failed. They are never to be used for disciplinary reasons or for the convenience of EMS personnel
2.Request law enforcement assistance and Contact Medical Control for restraint order. When the patients and/or safety of othersis in jeopardy, the senior personnel on scene shall use his/her best judgmentto use mechanical and/or chemical restraints if a physicians order cannot be immediately obtainedor if, in their opinion,the time lapsein obtaining those orders would be detrimental to any individuals safety. In such cases, the senior personnel will contact medical control and the Shift Captain as soon thereafter as time permits. 
3.Contact Shift Captain regarding the situation.
4. The least amount of restraint necessary to accomplish the desired purpose should be used. The restraints used may includepadded leather devices, additional nylon straps, cravats, towels, additional sheets or Haloperidol/Haldol, 5mg IM injectionin conjunction with Midazolam/Versed 2 mg IV or 5 mg IM or IN.
5.The restraints should not be limiting to the patient's peripheral or central circulation or respiratory status.
6.Soft restraints such as cravats or roller bandages can be used for extremity restraints.
7.Sheets may be used to limit upper body or lower extremity movement.
8.The restraints should be frequently monitored during transport. Breathing, circulation and neurovascular status of restrained parts must be monitored for impedance from the restraint. Care should be taken to insure that injuries to the patient are not aggravated by the restraints. The patient should never be left without at least one EMT or EMT-P in attendance.
9.Place pt. supine, fowlers or on side. Placing pts. prone/face down has been found to increase the incidences of sudden cardiac arrest
10. Raise the head of the patient slightly in order to prevent aspiration unless contraindicated by the possibility of spinal injury. In that incidence, the head of backboard may be elevated. 
11. If using chemical restraint, an EMT-P must be in attendance providing continuous cardiac and SPO2 monitoring. ConsiderETCO2 monitoring if applicable. With some medications there is a tendency for a patient to develop seizure activity as well as hyper/hypotension.
12. If transport occurs from a medical facility to a mental health facility or from one mental facility to another and transport timewill exceed 45 min., a written order for a chemical agent must be obtained prior to the transport from the evaluating physician.A copy of the written order is to be attached to the patient care report.
13. In circumstances where law enforcement personnel are present and their handcuffs/shackles are used to restrain the patient, an officer with a key to the locks will remain with the patientuntil those particular restraints are removed. If the handcuffs/shacklesare to be left on the patient during transport, the law enforcement personnel must accompany patient inside the EMS unit. Documentation on call report should include reason, type of restraints, time restraints were placed and removed.
14. Any time EMS personnel use any of the above mentioned restraining methods, the facts will be documented in the P C R and an Incident Report will be filled out in detail with one copy to the Shift Captain and one copy to the Operations Director. Documentation shall include the reason for use, type used and time placed and removed from pt.


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