Chemical Restraint in the ED

Sudden violence in the emergency department (ED) remains a common problem. Psychiatric disturbance, uncontrolled pain, intoxication, de-robing, and long wait times all contribute to the eruption of violence. Assaults involving health care workers in the United States occur at 4 times the rate seen in other industries1. Those predisposed to violent behavior include males, prisoners, intoxicated patients, or those with psychiatric illness¹. When a patient begins to exhibit dangerous behavior, the emergency physician must be prepared to control the situation in a safe and effective manner.

Chemical restraint via antipsychotic and benzodiazepine medication, used in an effort to facilitate medical workup and patient safety, enjoys a long standing safety and efficacy record. Chemical restraint avoids adverse consequences associated with physical restraint, which include hyperthermia, dehydration, rhabdomyolysis, and lactic acidosis. Chemical restraint is indicated when a patient poses a danger to himself, others, or hospital property. Techniques involving verbal de-escalation and provision of patient comfort always should be attempted prior to employment of forceful measures. Before receiving medications, the patient should be placed into physical restraints by appropriate security staff in an effort to avoid injury to the patient, staff, or environment.²

The most appropriate drug regimen for combative ED patients has been the subject of much study. Haloperidol and lorazepam “5 and 2” combination therapy for the violent medically undifferentiated patient enjoys overwhelming support; however, rapid acting IM formulations of atypical antipsychotics are gaining popularity. Orally dissolving (ODT) risperidone, intramuscular (IM) olanzapine, and IM ziprasidone, have found a new role in the treatment of agitated and violent patients. Atypical antipsychotics provide more tranquilization and less sedation than typical antipsychotics, while additional serotonergic activity lowers the incidence of extra pyramidal signs (EPS).1 Atypical antipsychotics offer a seamless transition from IM to oral dosing, a reduced side effect profile, and a faster onset of action than typical antipsychotics.^3,4

The widespread use of haloperidol and lorazepam in the ED for all chemical restraint is multifactorial. Together, haloperidol and lorazepam block dopaminergic transmission and enhance GABA receptor binding to reduce agitation quickly – usually within 30 minutes. Known disadvantages regarding haloperidol/lorazepam combination therapy include: EPS, prolonged QT, ataxia, sedation, additive CNS depression, geriatric over-sedation, slower onset, and longer duration of action when compared to newer atypical antipsychotic regimens.