II. Indications
- Dangerous and uncontrolled Violent Behavior (e.g. Agitated Delirium)
III. Precautions
- Refer to these procedures as "Sedation of the Violent Patient"
- Joint Commission views "Chemical Restraint" as an inappropriate term
- Evaluate for other causes of Agitation (see Agitated Delirium)
- Hypoglycemia (obtain bedside Glucose)
- Hypoxia
- Sepsis
- Intracranial Bleeding (if preceding Head Trauma)
IV. Monitoring
- Sedation requires 1:1 monitoring
- Vital Signs should include Pulse Oximetry, End-Tidal CO2
- Reassess every 15 minutes including Vital Signs
- Document the indications, monitoring, reassessment and the indications to continue sedation
- Agitation rating scales
V. Management
-
General approach in all cases
- Be prepared with strong, large, burly security guards at the ready in case of dangerous Agitation
- Consider alternatives to sedation or restraints
- Approach Agitated Patients with plans for each of three presentations (see below)
- Agitated but cooperative
- Disruptive, but not dangerous
- Agitated Delirium
- Verbal De-escalation approach (for agitated, but non-dangerous patients)
- One person initiates de-escalation
- Maintain a safe distance for both patient and provider (2 arms lengths)
- Stand with hands visible and at an angle to patient (less confrontational)
- Introduce yourself and call the patient by their preferred name
- Maintain a calm voice and ask open-ended questions
- Speak in clear, concise sentences and use simple vocabulary
- Tell the patient you wish to help them
- Agree with the patient when possible
- Listen patiently and approach with kind demeanor
- Avoid a confrontational, demeaning, coersive approach
- Do not threaten the patient (e.g. with restraints)
- Set clear limits of what behaviors will not be tolerated
- Tell the patient that their behavior is frightening to the staff and others
- Agitated but cooperative patients (Agitation in Dementia, or drunk teen)
- Assign a volunteer to talk to the patient and distract them
- Provide a calm, quieter, comfortable setting with dimmed lights to help de-escalate Agitation
- Offer food, drink, warm blanket, phone call and other comforts to those able to reason
- Offer Nicotine Replacement as needed
- Benzodiazepines for Alcohol Withdrawal protocol or anxiety
- Apologize for delays (in some cases, days for boarding psychiatric patients)
- Express empathy and compassion
- Disruptive patients who are not dangerous (agitated drunk, acute Psychosis)
- Have staff available in case of escalation and need for Physical Restraint
- Consider non-medication options used above for cooperative patients
- Common calming agents (adult doses), primarily if concurrent Psychosis (see descriptions below)
- Midazolam 5 mg IM
- Olanzapine (Zyprexa) 10 mg ODT or IM
- Ziprasidone (Geodon) 10-20 mg IM
- Risperidone 2 mg orally
- Haldol 5 mg with Midazolam 2 mg and Benadryl 25 mg IM (may be repeated once in 30 minutes)
- Alcohol Withdrawal (B52)
- Droperidol 5 mg with Midazolam 2 mg IM (and may be repeated once in 3-5 minutes)
- Dangerously combative patients or Agitated Delirium
- Physical Restraint allows access to patient for IM Injection
- Requires at least 5 strong responders (one for each limb and one for head)
- Consider applying an oxygen mask at face to block spit and supply oxygen
- Intramuscular Chemical Restraint (see agents below)
- Ketamine 2 mg IV or 5 mg IM
- Allows for Intravenous Access and maintained chemical sedation
- Then administer Benzodiazepines after IV Access is available
- Consider Rapid Sequence Induction and intubation for a sick or injured, Agitated Patient
- Physical Restraint allows access to patient for IM Injection
- References
- Strayer in Herbert (2017) EM:Rap 17(6):10-11
VI. Approach: Initial Agent Selection by Cause
-
Excited Delirium
- Ketamine 5 mg/kg IM
-
Sympathomimetic
Intoxication (Methamphetamine, Cocaine, Synthetic Marijuana)
- Benzodiazepines (e.g. Midazolam IM)
-
Alcohol and Psychosis
- Benadryl 50 mg, Haloperidol 5 mg, Midazolam 2 mg given IM (B52)
- Also consider other Alcohol related causes (Wernicke's Encephalopathy, hepatic encaphalopathy, Trauma)
-
Alcohol Withdrawal and Agitation
- Benzodiazepines
- Phenobarbital (consider as alternative or adjunct to Benzodiazepines, see below)
-
Agitation with Psychosis
- Second generation Antipsychotic (e.g. Olanzapine, Risperidone, Ziprasidone)
- Benzodiazepine (Exercise caution when used in combination with Olanzapine; see below)
- Dexmedetomidine Sublingual approved in 2022 for Agitation in Schizophrenia and Bipolar Disorder
VII. Preparations: Adults (lower doses in the elderly)
-
Ketamine
- Excellent choice for prehospital sedation of an agitated Trauma child or adult on long transport
- Minimal ABC suppression, and may bridge to RSI as induction agent
-
Ketamine Bolus
- IV/IO: 0.5 to 1 mg/kg
- IM: 3-5 mg/kg (typically 5 mg/kg)
-
Ketamine maintenance
- Dose: 1 to 1.5 mg/kg/hour IV
- Duration
- Recovery within 10-15 minutes of discontinuing the infusion
- Safe in prehospital use (including non-intubated patients)
- Ketamine at high dose (4-5 mg/kg) results in GCS 3, but typically maintained respiratory drive (GCS-3K)
- Ketamine sedated patients may be safely, closely monitored without intubation, despite low GCS
- Iwanicki (2014) Clin Toxicol 52:685-6 [PubMed]
- Swaminathan and Perlmutter in Herbert (2018) EM:Rap 18(7): 15-6
-
Benzodiazepines
- Preferred fall-back agent
- Safest agent when potential Drug Interactions, allergies, QT Prolongation or other patient risk factors
- Preferred agents in Overdose patients with toxin or Unknown Ingestion (offers additional Seizure Prophylaxis)
- Also preferred first line agent in Agitated Delirium
- Consider as adjunct in patients using Sympathomimetics (e.g. Cocaine or Amphetamines)
- Risks
- Unpredictable effects (especially in tolerant drug and Alcohol Abusers) and effect may subside quickly
- Risk in elderly and in respiratory conditions for Hypotension and hypoventilation
- Maintain arway management, End-Tidal CO2 monitoring with Advanced Airway at the ready
- Lorazepam (Ativan)
- Standard Dosing
- Adult: 1-2 IM/IV/PO every 6 hours prn
- Agitated Delirium or ICU sedation
- Advanced Airway management as needed
- Dose: 0.02 to 0.4 mg/kg up to 2-4 mg IV every 2-6 hours as needed
- Agitated Delirium (e.g. Methamphetamine) may require 4 mg IV repeated every 10 min prn
- Also may be used in combination with Haloperidol (see below)
- Standard Dosing
- Midazolam (Versed)
- Preferred Benzodiazepine in short procedures due to shorter duration of action
- Preferred Benzodiazepine for Intramuscular Injection (most rapid absorption)
- Very effective with 15 min, but short-half life often requires additional doses or adjunctive agents
- Intravenous
- Child: 0.05 to 0.1 mg IV (up to 2-4 mg IV for teen) over 2 minutes
- Adult: 1 to 2.5 mg IV over 2 minutes and may be repeated once after 2-5 minutes
- Intramuscular
- Child: 0.1 to 0.15 mg IV (up to 5 mg IM for teen) over 2 minutes
- Adult: 5 mg IM and may repeat in 3-5 minutes prn
- Larger patients may require 10 mg IM
- Smaller patients or elderly may be adequately sedated with 2.5 mg IM
- Preferred fall-back agent
- Butyrophenones
- Precaution: Risk of QT Prolongation
- Risk with Haloperidol, Droperidol as well as all Atypical Antipsychotics
- Avoid these agents in higher risk comorbidities
- Unknown Ingestion
- Hypokalemia
- Hyomagnesemia
- Bradycardia
- Combination with other agents causing QT Prolongation
- Generally considered safe with low Torsades risk (despite the FDA black box warning)
- Haloperidol (Haldol)
- Haloperidol alone
- Child: 0.05 to 0.15 mg/kg PO/IM/IV (up to 2-5 mg for teen)
- Adult: 5 to 10 mg PO/IM/IV prn
- Consider with Benadryl 50 mg or Cogentin 1 mg to prevent Dystonic Reaction
- Haloperidol with Midazolam and Benadryl q30 minutes prn (Mnemonic: B52)
- Benadryl 50 mg (prevents Dystonia)
- Haloperidol 5 mg (up to 10 mg)
- Midazolam 2 mg (up to 4 mg) - Midazolam is preferred over Ativan for IM Benzodiazepine)
- Draw up the 3 agents into same syringe and deliver IM
- May repeat once with additional 5 mg Haloperidol and 2 mg Midazolam
- Haloperidol alone
- Droperidol (Inapsine)
- Unfortunately was unavailable in most regions of U.S., but is once again available as of 2020
- Preferred over Haloperidol due to better sedation, faster action, and shorter Half-Life
- Very effective in psychotic patients and those unresponsive to Benzodiazepines
- QT Prolongation risk appears to be very low (occurs at much higher dose than is typically used)
- Droperidol (use with Cogentin 1 mg)
- Intravenous dose: 2.5 to 5 mg IV prn (up to 5-10 mg IV, with maximum of 20 mg IV)
- Intramuscular dose: 5 to 10 mg IM prn
- Common Combinations
- Droperidol (Inapsine) 5 mg with Cogentin 1 mg IV
- Droperidol 5 mg with Midazolam 2 mg mixed in same syringe (1.5 inch needle) IM
- May repeat once in 3-5 minutes
- Faster onset sedation (10 min compared with 30 min) than Droperidol or Olanzapine alone
- Minor airway management needed, but no intubations required
- Taylor (2017) Ann Emerg Med 69(3): 318-26 +PMID: 27745766 [PubMed]
- Precaution: Risk of QT Prolongation
-
Atypical Antipsychotics
- Olanzapine (Zyprexa)
- Preferred in Psychosis (Bipolar Disorder, Schizophrenia)
- Contraindications
- Dosing
- Child<12 years: 2.5 mg PO/IM
- Adults: 10 mg ODT sublingual wafer or 10 mg IM
- Diphenhydramine 1.25 mg/kg PO/IM/IV up to 50 mg prn Dystonia
- Ziprasidone (Geodon)
- Age <12 years old: 5 mg IM
- Teen or Adult: 10-20 mg IM
- Aripiprazole (Abilify)
- Child <12 years: 1-2 mg IM
- Teen: 2-5 mg IM
- Adult: 5-10 mg IM
- Risperidone (Risperdal)
- Child <12 years: 0.5 mg orally
- Teen: 1 mg orally
- Adult: 2 mg orally
- Olanzapine (Zyprexa)
- Miscellaneous agents (older agents)
- Fluphenazine (Prolixin) 5 mg IM q6h prn
- Chlorpromazine (Thorazine) 50 mg IM q6h (or 0.25 mg/kg IM prn in children and adolescents)
- Thiothixene (Navane) 5 mg PO or 10 mg IM prn
- Dexmedetomidine (Precedex) Sublingual
- IV form used in ICU for sedation on Mechanical Ventilation and in Alcohol Withdrawal
- Sublingual form FDA approved in 2022 for Agitation in Schizophrenia and Bipolar Disorder
- Mild to moderate Agitation (maximum 240 mcg in 24 hours)
- Start 120 mcg sublingual or buccal and repeat 60 mcg SL every 2 hours prn for up to 2 doses
- Severe Agitation (maximum 360 mcg in 24 hours)
- Start 180 mcg sublingual or buccal and repeat 90 mcg SL every 2 hours prn for up to 2 doses
- Phenobarbital
- Consider in Alcohol Withdrawal as an alternative or adjunct to Benzodiazepines
- Avoid IV infusion >60 mg/min
- Phenobarbital 5-10 mg/kg IBW up to 130 to 260 mg every 20-30 minutes titrating to light sedation
- Nisavic (2019) Psychosomatics 60(5):458-67 [PubMed]
- Nelson (2019) Am J Emerg Med 37(4):733-6 [PubMed]
- Tidwell (2018) Am J Crit Care 27(6):454-60 [PubMed]
VIII. Preparations: Children
- Precautions
- Avoid combining intramuscular Olanzapine with Benzodiazepines
- Risk of Hypotension and Bradycardia
- Limit Antipsychotic doses to half dose or less for children under age 9 years old
- Avoid combining intramuscular Olanzapine with Benzodiazepines
-
Benzodiazepines (esp. Lorazepam)
- Preferred agents in suspected ingestion or Intoxication
- Paradoxical Agitation may occur
- Lorazepam 0.05 mg/kg IV/IM/PO up to 2 mg per dose
-
Olanzapine (Zyprexa)
- Contraindicated in Unknown Ingestion, liver disease, Neuroleptic Malignant Syndrome and Seizure Disorder
- Dose for age 6-10 years old: 2.5 mg ODT or IM Injection
- Dose for age >10 years old: 5 mg ODT or IM Injection
- Dose for adult weight: 10 mg ODT or IM Injection
- Observe for Dystonic Reaction
- Diphenhydramine 1.25 mg/kg PO/IM/IV up to 50 mg prn Dystonia
- Haloperidol
- Other agents that may be considered longer term (reactive children)
- Clonidine
- Guanafacine
IX. References
- Glauser and Peters (2016) Crit Dec Emerg Med 30(4): 17-27
- Mason, Mallon and Colwell in Herbert (2018) EM:Rap 18(10): 11-2
- Orman in Herbert (2012) EM: Rap 12(8): 3-5
- Orman and McCollum in Herbert (2016) EM:Rap 16(1): 12-14