Tag Archives: Restraint

Involuntary Chemical Sedation–The Right Medications

Let’s start by setting the stage:  Our patient is a 35 year-old man who is angry that he has been arrested in a domestic dispute case.  He cooperated with the booking process, but then, several hours later, began to repeatedly ram his head full force into the wall.  There is blood on his face and on the wall.  The word “uncooperative” does not do him justice.  He is agitated and belligerent and wants to fight.  He is screaming offensive obscenities. 

Of course, he cannot be allowed to continue to hurt himself.  The deputies take him down and strap him to a restraint chair.  A spit mask is required.  Nobody really expected him to calm down after he is placed in the restraint chair and they are not disappointed.  30 minutes later, he is still screaming.Restraint

This patient certainly meets the criteria for chemical sedation.  He is an acute danger to himself.  He is an acute danger to others.  He has refused voluntary sedation.  He is not hypoxic or hypoglycemic (but if there is a suspicion of this, it is easy enough to get a pulse oximetry reading or a finger stick blood sugar).

What medications should be used to sedate this patient? 

Remember that our goal is to sedate the patient so that he can be released from physical restraints.  We would like him to be sedated and drowsy and even go to sleep, but to be easily arousable.  We do not want respiratory depression or other serious side effects.

The two main drug classes that have been traditionally used for this type of chemical sedation are the benzodiazepines and the antipsychotics.  I was taught in my Emergency Medicine residency that the benzos were “minor sedatives” and the antipsychotics were “major sedatives.”  However, there have been several studies comparing the two when sedating agitated patients, including this 2010 Cochrane Review, and, in fact, both work well.  They may work even better when given together.  Each has advantages and disadvantages that should be considered.

 Antipsychotics for Sedation–Haloperidol

The best overall antipsychotic for rapid sedation of agitated patients in a correctional setting, in my opinion, is good, old haloperidol.  Haldol has been safely used for this indication (probably) millions of times world-wide.  It is “tried and true.”  It is Vitamin H.  The Velvet Hammer.

The main advantage of haloperidol is that it is so safe.  It does not cause respiratory depression and so can be given to intoxicated patients.  It has no dose limit for safety reasons.  This means that it can safely be given to patients who are already taking antipsychotics.  The dose is the same whether po or IM, so if a patient changes his mind and accepts oral meds, it is easy to change course.  It can be given IV as well as IM (though we would seldom give haloperidol IV in a correctional facility as is done routinely in ERs).

 “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.

Any other antipsychotic that can be given IM can also be used for rapid sedation.  Possibilities include Inapsine (droperidol), Geodon (ziprasidone), and Zyprexa (olanzapine).  There is nothing wrong with any of these agents, and if you already use them and are comfortable with them, that is great.  They offer no advantages to Haldol, however.  None are more effective and none are safer.

The major potential adverse effects of acute one-time dose Haldol administration are exceedingly rare.  One of these is Q-T prolongation that can, potentially, cause dysrythmias.  Another is Neuroleptic Malignant Syndrome. Both of these are very rare, however, and the risk is far less than the risk of prolonged physical restraint.  Haldol has also been reported to lower the seizure threshold, but this is controversial.

The one reasonably common adverse effect of acute IM Haldol administration is a  dystonic reaction.  Dystonic reactions involve involuntary muscle contractions  usually in the neck, shoulders or face, but also elsewhere.  It can also manifest as akesthesia, which can be thought of as a case of restless legs from hell.  We are not talking here about Tardive Dyskinesia. Tardive Dyskinesia is also involuntary muscle contractions but these occur after years of neuroleptic medication use and are irreversible.  Acute dystonic reactions are easily reversible, using an antihistamine, like Benadryl.  Unlike tardive dyskinesia, dystonic reactions are a nuisance, trivial and easily treated.

Because of the possibility of a dystonic reaction to IM Haldol, some practitioners give Benadryl 50mg IM at the same time as the Haldol.  I do not do this for the following reasons:

  1. The dystonic reactions from Haldol tend to occur the day following the IM injection.  Benadryl is so short acting that it is gone by then.  Theoretically, then, it may not be effective in reducing dystonic reactions.  This has never been studied, as far as I know.
  2. Only 1 in 6 or 7 patients who receive a single Haldol injection will develop dystonia.  If you give Benadryl to everyone, you are treating the majority of patients needlessly.  Benadryl has its own set of ill effects and side effects.
  3. If a patient does develop dystonia the next day, 50mg of Benadryl given orally will solve the problem quickly at that time.  That is when I prefer to treat these nuisance reactions.

The standard adult dose of Haldol for rapid sedation is 5-20 mg IM.DSC01310

Benzodiazepines for Sedation–Lorazepam

Any benzodiazepine that can be given IM can be used for chemical sedation.  I like to use Ativan (lorazepam), myself.  Valium can be used but is not as good because it is not well absorbed from an IM injection.  Versed (midazolam) is an acceptable alternative to Ativan.

The main disadvantage of Ativan as a chemical sedative is that it can cause respiratory depression, especially when combined with other sedating drugs.  For example, it should be used cautiously in the obnoxious drunk.  Haldol alone is a better choice for him.  It also reportedly can cause hypotension, though I have never seen this.

On the other hand, lorazepam is an excellent choice for stimulant overdoses.  It almost can be thought of as an “antidote” to stimulant “poisoning.”  So the patient who is agitated while “tweaking” on meth would do well receiving lorazepam.

The standard dose of lorazepam for chemical sedation is 1-4mg IM.

Combination Therapy

One cool thing about Haldol and Ativan is that they play well together.  The medical term for this is that they are synergistic—they increase each other’s effectiveness.  In practical terms, this means that if they are combined, you can use a smaller total dose of each agent.  Instead of needing 4mg of lorazepam IM to sedate a patient, if you combine it with Haldol, you only may need 1 or 2 mg  and vice versa. The two drugs are so compatible that you can mix them together in the same syringe.

The standard dose of the combination used for chemical sedation of the agitated patient is “ten and two” meaning 10mg of Haldol and 2mg of Ativan.  You can reduce this to “five and one” or increase it depending on the circumstances.  You can also vary the ratio or use just Haldol or just lorazepam depending on a particular case.  For example, what would you use in these cases?

  1.  The Standard Jerk.  This is the patient who is agitated and belligerent not because of drugs or alcohol,  but because of frustration, manipulation or whatever.  Chemical Sedation:  “Ten and Two” (Haldol 10mg and lorazepam 2mg IM).
  2. The “Mean Drunk.” This patient is still intoxicated, so you might not want to use lorazepam since it potentially could cause respiratory depression in combination with the alcohol.  Chemical Sedation:  Haldol 10mg IM.  It will not cause respiratory sedation and can be used safely in an intoxicated patient.
  3. The Acutely Psychotic or Manic Patient.  Chemical Sedation?  “Ten and two.”  Sometimes these patients need a second dose in an hour.  Should we be worried that the patient is already taking antipsychotics (let’s say Abilify, for example)?  The answer is no.  You can still safely give Haldol.
  4. Methamphetamine Intoxication.  Lorazepam is the “antidote” for the patient who is tweaking on meth or cocaine.  Chemical Sedation?  Lorezepam 4mg IM.  You can add 5mg of Haldol, as well if you want.
  5. “Undifferentiated.”  If you just do not know why the patient is agitated and belligerent, remember that “intramuscular haloperidol is both safe and effective in the treatment of agitation caused by virtually any etiologyRoberts: Clinical Procedures in Emergency Medicine, 5th ed.  If you are reasonably sure the patient is not drunk, add the lorazepam, as well.

 Next installment in the series:  Chemical Sedation:  Right Documentation and Right Follow –Up.

What medications do you use for Involuntary Chemical Sedation at your facility?  Please comment!

 

 

 

 

 

Involuntary Chemical Sedation–The Right Patient

In my last blog post, I argued that chemical sedation was safer that prolonged physical restraint for patients who represent an acute threat to themselves or others.  Today, I would like to explore who is an appropriate candidate for involuntary chemical sedation—and who is not.  This is the first part of the Four Rights of Chemical Sedation:  Right Patient, Right Medication,  Right Follow-Up and Right Documentation.

RestraintFirst, let’s define what we are talking about here.  The key concepts in Chemical Sedation-Restraint are:

  1. It is an urgent situation.  Consider again the patient who is running his head into the wall.  We have to stop him now.  There is no time to consult with superiors or obtain a court order.  The patient is harming himself now and we must stop him–now.
  2. It is an alternative to prolonged physical restraint.  We are restraining patient behavior using medication because this is safer for the patient than is prolonged physical restraint.  In fact, we are using chemical sedation precisely so that we can release the patient from physical restraints.
  3. It is involuntary.  The patient does not want it to be done.  Sometimes, when a patient is in a restraint chair and you say, “Would you like something to help you calm down?”  They will say “Yes.”  The sedation there is not involuntary anymore.  We are talking here about someone who is refusing any type of medication.
  4. We are using sedating psychotropic medications.  There are many medications that can be used for sedation but they all have in common that the patient will be sedated at the end.  The end goal is that the patient will be asleep (but arousable) and no longer requires any type of physical restraints.

There are many terms we could use to convey these concepts.  We could say: Urgent or Emergency for the first concept, Restraint or Sedation for the second, Involuntary or Forced  for the third, and Chemical or Psychotropic for the last concept.  This could lead to some cumbersome terms like “Emergency Involuntary Psychotropic Restraint” or “Urgent Forced Chemical Sedation.” The emergency medicine literature tends to use the more concise term “Chemical Sedation” for this procedure.  Since the overall goal is to get the patient out of physical restraints, I prefer the term “Chemical Sedation” instead of “Chemical Restraint.”

Who Is A Candidate for Emergency Involuntary Chemical Sedation?

There are four indications for Chemical Sedation in a correctional facility:

  1. The patient is a danger to himself.  The patient who is running his head forcibly against the wall is an obvious example.  I once had a patient who kept climbing up onto the sink in his cell and doing a swan dive onto the floor.  Head-bangers, I think, would qualify as would those patients who pull out fist-fulls of hair or gouge at their eyes.  I also would include poop-eaters, since as a trained medical professional, I know that eating poop is considered bad for one’s health.  Poop-smearers probably qualify, as well.  On the other hand, screamers may not qualify since screaming obscenities, even for prolonged periods of time does not represent a danger to self.
  2. The patient is a danger to others.  There is an element of a judgment call here in assessing the level of danger involved with those inmates who threaten others with violence. For example, if you happened to have John “Bones” Jones (world champion mixed martial arts fighter) in your facility and he were to say “I will kill anyone who comes into my cell,” you should believe him.  Mr. Jones would represent a true danger to others and probably should be chemically sedated.  On the other hand, a frail 90-year old man who makes the same threat might not be a real danger to others and chemical sedation based on that statement alone might not be warranted.  Other examples of inmates who pose a true threat to others might include poop-throwers, biters, and maybe even spitters.
  3. The inmate represents a threat to the integrity and security of the institution.  For example, an inmate who is tearing apart his cell, damaging the door or plexiglass, might qualify for chemical sedation.  Another example would be an inmate who screams racial taunts at other inmates, inciting them to anger and a potential riot, also could qualify for sedation.
  4. To assist in the medical assessment and management of the patient.  Sometimes, I don’t know for sure why an inmate is being aggressive and threatening.  An example here would be a newly booked inmate who is acting bizarrely.  Let’s say he is not talking coherently.  He will not cooperate even with getting vitals signs.  Is he high on meth?  Delirious?  Drunk?  Psychotic? Sometimes, the only way to be able to assess this patient is to chemically sedate him so that we can examine him..

Two Reversible Medical Conditions Can Cause Agitation

When deciding to chemically sedate someone, we need to keep in mind that there are two easily reversible medical conditions that can cause agitation.  These are

  1. Hypoglycemia
  2. Hypoxia

Fortunately, both can be quickly and easily assessed if there is any question in a particular patient (say the patient described above, who is acting bizarrely in booking and we do not know why).  Once a patient is physically restrained, and before injecting the chemical sedating agents, it is simple to check a blood sugar and an oxygen saturation in appropriate patients.  It is embarrassing to sedate a patient and then find out later that he had a blood sugar of 20.  Oops.

Other medical conditions can potentially cause a patient to be agitated, such as brain tumors, delirium, and being post-ictal after a seizure.  However, these are not easily reversible as are hypoglycemia and hypoxia.  If a patient has one of these, they usually will be sedated and then the underlying medical cause will hopefully be sorted out thereafter.

Chemical Sedation Should Never Be Punitive!

Always remember that the goal of restraining and sedating patients is for their benefit, not ours.  I have found that when jail deputies find out how much better chemical sedation is than prolonged restraint, both for the patient and for them, they sometimes want to chemical sedate everyone who is a management problem.  However, most jail management problems are not candidates for chemical sedation.

Even patients who are appropriate candidates for chemical sedation should always be offered less restrictive means of calming down.  Sometimes, just putting a patient in a restraint chair preparatory to getting chemical sedation is enough for them to settle down.  More often, however, patients facing a cell extraction, or who are already in a restraint chair  will accept oral medications rather than receive an injection.

Summary.  Is This the Right Patient for Chemical Sedation?

1.   Is he a danger to himself?

2.  Is he a danger to others?

3.  Is he a danger to the safety and security of the facility?

4.  Is sedation the only way he can be medically assessed?

5.  Does he have a reversible medical condition?

6.  Will he accept a less restrictive form of sedation?

What is your experience with chemical sedation?  Please comment!

 

Chemical Sedation is Safer than Prolonged Physical Restraint

Here is the clinical scenario:  You have an inmate in your facility who is running his head into wall, bull-like, at full speed.  He then backs up and does it again.  He may be suicidal.  He may be high on meth.  He may just be a jerk throwing a tantrum.  But he will not stop just because you have asked him to.

How should we stop this patient from hurting himself?

How should we stop this patient from hurting himself?

What would you do in this situation?  It seems to me that there are only three options for how to deal with this inmate.

  1.  Do nothing!  Let him hurt himself if he wants.
  2. Physically restrain him in a restraint chair or on a board.
  3. Administer sedating medications as a form of chemical sedation.

These three responses clearly are different in the risk of a bad outcome.  And there are two possible bad outcomes to consider.  The first is the medical risk.  Which approach is most likely to result in a serious injury to the patient?  The second is the legal risk.  Which approach is least likely to result in a successful lawsuit?

I hope that no one reading this would opt to do nothing.  You simply cannot continue to let this inmate run his head against the wall.  The risk of a bad outcome, both medical and legal is just too high.  On the medical side, I personally am aware of three cases where inmates running their heads into the wall of their cells fractured their necks. One was left a quadriplegic.  The risk of legal action is also high.  In fact, this could be Deliberate Indifference:  You knew that running his head into the wall could potentially result in serious injury and yet you did nothing to stop him.  I will leave the Deliberate Indifference question to the lawyers, but even without this, the threat of a nasty lawsuit following such an injury is almost inevitable.

So the prudent action, both medically and legally, is to restrain this patient in some way.  But which method of restraint is safer for the patient?  Which method of restraint is safer legally?

In my strongly held opinion, restraint by chemical sedation is safer than prolonged physical restraint for those who are a threat to injuring self or others.  I have several reasons for believing this.

  1. Chemical Sedation is the community standard of care in the other two areas of medicine that also routinely restrain patients who are a threat to self or others.  Those two areas are Emergency Medicine and Inpatient Psychiatric medicine.
  2. Prolonged physical restraint, for example in a restraint chair or board, carries significant risks of injury, including death.  Chemical sedation is much safer.
  3. As long as the chemical sedation is done properly, there is less risk of successful legal action with chemical sedation than with prolonged physical restraint.

Chemical Sedation is the Community Standard of Care

I practiced in a busy emergency department for many years before I came to correctional medicine.  There, chemical sedation is routinely practiced.  Every Emergency Department does chemical sedation routinely.  It is not controversial in ERs at all.  I was taught how to do chemical sedation in my ER residency.  It is an Emergency Medicine “Core Competency.”  Chemical Sedation is discussed in every major Emergency medicine textbook.  As a matter of fact, physical restraint is viewed in Emergency Medicine as a tool to facilitate chemical sedation rather than a viable option on its own.

It is a similar situation in inpatient psychiatric hospitals.  I have asked several psychiatrists whether they leave dangerous inmates in a psych hospital physically restrained for long periods of time.  The typical response is to laugh and say “No.  They get sedated.”

I’m not sure why chemical sedation has such a bad reputation in some quarters of the correctional medicine world, because it is the Standard of Care for patients who are an acute danger to self or others elsewhere in medicine.  Why is this so?  It is because:

Chemical Sedation is Safer than Prolonged Physical Restraint

Unfortunately, I cannot point to any published studies that show that chemical sedation is safer than prolonged physical restraint.  That is because there are none.  However, I personally know of at least five cases of death from physical restraint.  The mechanism of death in these cases has ranged from suffocation to acute pulmonary embolism to “excited delirium.”  The point is that prolonged physical restraint carries substantial risks that range from minor (contusions, abrasions, broken bones) to serious (death, loss of limbs from too-tight restraints).

On the other hand, I am not aware of any deaths from chemical sedation, whether in an Emergency Department setting or in corrections.  I actually have never heard of any serious complications from chemical sedation.  There may have been one somewhere and I am just not aware of it.  If you know of such a case, please contact me!

Chemical Sedation Carries Less Legal Risk Than Does Prolonged Physical Restraint

Again, there are no published studies on the incidence of lawsuits after restraints.  I have spoken to several different Risk Management experts on the subject, both in Emergency Medicine and Correctional Medicine,  and they have unanimously agreed that chemical sedation of a dangerous patient carries less legal risk than does prolonged physical restraint.

Here is one example.  I contacted Rick Bukata and Greg Henry, who together publish Risk Management Monthly, a publication on how to reduce medico-legal risk in Emergency Departments.  I asked them about the legal risk of administering chemical sedation to a dangerous patient against his will.  This was their response:

“Jeff Keller has malpractice concerns about the patient who is sedated against his/her will.  This situation is not likely to be problematic if the patient is being sedated because he or she poses a danger to self or others, and if the reason for sedation is meticulously documented.  A physician might be at greater medicolegal risk if he or she fails to sedate a problematic patient who is placing the staff in jeopardy.”

After talking to several Risk Management experts in Correctional Medicine about this subject, I am unaware of any successful lawsuits arising from chemical sedation of an incarcerated inmate who was an acute danger to self or others.  Once again, if you are aware of such a lawsuit, I want to know about it!  Please contact me!

I believe that the legal risk of restraining an inmate depends on two factors.  The first is harm.  If a patient has been harmed by the restraints, he is more likely to sue and is more likely to be successful.  So the method of restraint least likely to injure the patient is the safest legally.  Chemical sedation is safer than prolonged physical restraint and so is safer legally as well.

The second factor is that the sedation was done on the right patient (one who is an acute danger to himself or others) and that this was documented properly.

In fact, chemical sedation is very like administering any medication.  You must have the right patient, give the right medications in the right dosages, do the right monitoring and follow-up care, and document in the right way.  If you do all of that, your legal risk will be low.  More details on that later.

What does your facility do for out-of-control inmates who are a threat to themselves or others?  Chemical sedation or prolonged physical restraint?  Please comment!