Chemical Restraints

1
Chemical Restraints

• Marc L. Martel, MD
• Program Director
• Hennepin County Medical Center
• Assistant Professor
• University of Minnesota

2
Goals of Chemical Restraint

• Morbidity / Mortality
• Patient
• Provider
• Limit physical restraints
• Facilitate
• Evaluation diagnosis
• Cooperation without excessive sedation
• Intervention

3
Chemical Restraints

• Ideal CR medications
• Parenteral
• Rapid onset
• Non-addictive
• Minimal tolerance
• Low side-effect profile
• Short duration of action

4
MedicationsOverview

• Antipsychotics
• Haldol
• High potency
• Lengthens QT interval
• FDA Warning
• Droperidol
• Non-traditional antipsychotic
• Lengthens QT interval
• FDA Warning
• BP, anticholinergic, EPS, NMS

5
Overview

• Benzodiazepines
• Midazolam
• Short acting
• Lorazepam
• Longer acting
• Respiratory depression, hypotension

6
Overview

• Ketamine
• Dissociative anesthetic
• Rapid acting, short duration of action
• EBM
• ED CS - Substantial
• Out of hospital None
• Hick 2005 Jumper
• Future?
• Airway reflexes, htn, laryngospasm, emergence rxn

7
Overview

• Atypical Antipsychotics
• Ziprasidone
• Short acting, Lengthens QT interval, Cost
• Olanzapine
• No QT changes, slower onset, gt need 2nd meds,
  Cost
• Risperidone
• Oral, Rapid dissolving, slower onset, Cost

8
Evidence for ED Use

• Haldol (Now FDA warning)
• Extensive ED experience
• Agitation improved _at_ 30 in 851
• 15 suboptimal, Ø effect 2
• Need lorazepam?2
• No difference in sedation
• More rapid onset with combination

1. Clinton, JE, et al. Haloperidol for sedation
of disruptive patients in the emergency patients.
Ann Emerg Med 1987163219-322. 2. Battaglia, J,
Moss, S, Ruch, J, Et al Haloperidol, lorazepam
or both for psychotic agitation? A multicenter,
prospective, double-blind, emergency department
study. Am J Emerg Med 1997 15335-340.
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Evidence for ED Use

• Droperidol
• Less agitation at 10 301
• 2500 patients, all indications2
• Minor AEs Serious AEs
• 96 transient hypotension - 2 resp depression
• 40 dystonic reactions - 3 seizures
• - 1 cardiac arrest

1. Thomas, et al. Droperidol versus haloperidol
for chemical restraint of agitated and combative
patients. Ann Emerg Med 1992 21407-413. 2.
Chase, PB, Biros, MH A retrospective review of
the use and safety of droperidol in a large,
high-risk, inner-city emergency department
patient population Acad Emerg Med
200291402-1410.
10
Evidence for ED Use

• Atypical Agents Limited data
• Ziprasidone
• Effective FDA approved for psych d/o
• 39.1 decr in agitated pts at 15(60 Drop), Ø
  RD1
• Olanzapine
• No pub EM studies, effective FDA approved for
  psych d/o
• 53.5 at 15, 78.9 at 302
• ¼ needed additional sedatives, 4 multiple meds
• Risperidone (rapid dissolving oral)
• No pub EM studies, effective FDA approved for
  psych d/o
• 33.3 at 30, 44.4 at 60, 77.8 at 120 2

1. Martel M, et al. Management of acute
undifferentiated agitation in the ED a
randomized double-blind trial of droperidol,
ziprasidone, and midazolam. Acad Em Med. 2005,
121167-1172. 2. Martel M, 2005. Unpublished data.
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Newer Agents
12
Advantages of the New Medications

• Little hypotension
• Less sedation
• Few dystonic reactions
• Replacement for Black Boxed medications?
• FDA warning associated with increased mortality
  in elderly patients with dementia
• Europe cardiac and respiratory depression