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. Medications Overview 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, > 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 @ 30’ in 85%1
15% suboptimal, Ø effect 2%
Need lorazepam?2
No difference in sedation
More rapid onset with combination
9. Evidence for ED Use Droperidol
Less agitation at 10’ & 30’1
~2500 patients, all indications2
Minor AEs •Serious AEs
96 transient hypotension - 2 resp depression
40 dystonic reactions - 3 seizures
- 1 cardiac arrest
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 30”2
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
11. 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
