A few weeks ago, I received a request from a psychiatry resident working at a state prison about the use of restraints with patients who engage in severe self-injury. He was looking for guidance on the use of physical restraints with this population in prison. He noted that his role of ordering and monitoring patients in restraints caused him to feel more like a provider for the facility, rather than for the patient. I shared with him with the best resources I know – Resource Document on the Use of Restraint and Seclusion in Correctional Mental Health Care (http://jaapl.org/content/35/4/417) as well as Dr. Applebaum’s commentary on the same (http://jaapl.org/content/jaapl/35/4/431.full.pdf). As I sat down to write this, I intended to discuss the rules and regulations surrounding restraint (e.g., Center for Medicare and Medicaid Services (CMS) 42 CFR § 482.13) but I stopped myself.
The inquiry was not about regulations and requirements for the use of restraints. The question was about patient care.
This article was first published here on MedPage Today.
How safe is correctional medicine?
People naturally assume that working in a jail or prison is dangerous. “Aren’t you nervous about working there?” they ask me. What people have seen of jails on TV looks pretty rough! After all, that’s where they put the violent criminals, right? The problem is, it just isn’t so!
Jails and prisons are not dangerous places to work; to assume so is just one of many misconceptions people have about correctional facilities. In fact, my jail medical clinics have been a much safer work environment than where I worked before.
Remember our patient? He was the guy who repeatedly ran his head into the wall. Probably everyone in corrections (if you have worked in the field long enough) has seen someone like this guy , who is working hard to harm himself.
Of course, once the patient has been given Haldol and Ativan IM, we cannot just walk away. Most of the time, chemical sedation occurs without incident. Well within an hour, most patients are asleep and can be removed from physical restraints. But as with everything in medicine, problems sometimes occur. Therefore, following the administration of involuntary chemical sedation, the medical team must ensure and document the safe and effective onset of sedation. Then, there must be appropriate follow-up. Chemical sedation is an unusual occurrence that has both medical and legal implications. Follow up visits investigate why the patient became so unmanageable as to need chemical sedation and make sure that the sedation was administered correctly.
Safe Onset of Sedation
Generally, most patients who have received an IM injection of Haldol and Ativan will be asleep well within an hour. In the normal course of events, the nurse caring for this patient should observe him long enough to document that the patient has become sedated and has been removed from physical restraints. Once the patient is out of restraints, the nurse should take vitals signs and document that the patient is sedated but arousable and is in good shape.
Problems sometimes occur, however. The single most common problem is that the first shot was not enough and the patient is still awake, thrashing and agitated, an hour after the IM injection. When this happens, the proper course is to start over from the beginning. Does the patient have an unrecognized medical cause of the agitation, like hypoglycemia or hypoxia or delirium? Have the vitals signs improved or deteriorated? Is the patient just as agitated as before or is he (more likely) partially, but incompletely, sedated? After this re-evaluation, most patients in this situation just need a second dose of Haldol and Ativan to complete the sedation process. Rarely, though, the appropriate call is to send them to the ER.
All patients who have received involuntary chemical sedation should have two follow-up check ups, preferably within 24 hours. The reason for these visits is twofold:
To investigate the question of why the patient was so agitated in the first place, and
Whether the patient needs further interventions, like further work up (labs, say), changes in his maintenance medication regimen, or commitment.
The first of these visits should be in the medical clinic with a medical practitioner. The practitioner should document absence of harm from the procedure and, if possible, pinpoint a medical reason for the agitation, if there was one. The two most common medical reasons for agitation of this severity are amphetamine or alcohol intoxication. Confusional states, like dementia and delirium, are also possible.
The patient should also normally be seen by the mental health. The purpose of this visit is to determine if there was a psychiatric reason for the agitation. The three most likely possibilities are:
Misbehavior as a manifestation of a personality disorder, especially the “Big Three: Borderline, Antisocial and Narcissistic Personality Disorder.
Questions that should be specifically addressed in the mental health visit are whether the threat of aggressive behavior is over (usually it is), whether the patient is a candidate for commitment to a psychiatric facility (usually not) and whether changes should be made in the ongoing psychiatric medication regimen.
Finally, each and every case of involuntary sedation should be reviewed in a quality assurance capacity. This can be done by the facility medical director or within a CQI committee. Chemical sedation can be misused and overused. Once the medical and security staff see how much easier and better involuntary chemical sedation is than physical restraint, there is a tendency to want to use it all the time—in patients who really are not a danger to self or others–just for the convenience of the staff. The purpose of the CQI review of all instances of involuntary chemical sedation is to ensure that this extraordinary therapy is not misused or overused.
Involuntary Chemical Sedation Checklist
Involuntary chemical sedation tends to be a high adrenaline affair. When you are in a situation involving a yelling, agitated patient and correctional staff amped up on adrenaline, it is hard to remember everything you are supposed to document. The charting of these incidents often contains important omissions, at least in my experience.
The solution to this problem is to borrow a procedure from airline pilots, who have a written checklist of everything they must remember to do before they take off. Without the checklist, something will be missed eventually. The documentation of involuntary chemical sedation is likewise made easier by using a checklist that contains the following sections:
Reversible medical causes.
Safe and effective onset of sedation.
I have attached below a PDF file of a Sample Involuntary Chemical Sedation Form. You are welcome to download it and use it to develop one for your own facility!
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.
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:
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.
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.
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.
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.
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?
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).
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.
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.
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.
“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 etiology” Roberts: 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!
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.
First, let’s define what we are talking about here. The key concepts in Chemical Sedation-Restraint are:
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.
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.
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.
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:
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.
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.
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.
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
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!