chemical restraint

[boingo]

Anyone work in a system with a chemical restraint policy in place for combative patients? I would be interested in seeing your protocols and the system you work for. You can feel free to PM if you don't want to post publicly. Much appreciated.

 

[Farmer2DO]

We have a protocol in place. I will email you the link to our protocols.

We have a standing order for midazolam 2.5 mg, IM or IV. With medical control, we can either repeat it or double it.

We used to have haldol, 5 mg IM, with a benzo, either the midazolam as stated above, or diazepam, 5 mg IM or IV.

My opinion is that the combination worked much better. 2.5 midazolam by itself, most of the time accomplishes nothing but pissing off the patient for stabbing them with a needle. 5 mg often sedates them well, but it wears off quickly.

One of our local EDs sedates all their psychs with IM zyprexa. Those guys are snowed for hours. I wish we had our haldol back, or geodon, or zyprexa. Oh well.

 

[fast65]

Our protocols state that for chemical restraint we can five 2.5-5 mg of Inapsine, and repeat until we've reached the desired effect. Versed is only allowed for sedation of pt's with DT's, however, medical control is usually pretty lenient about allowing it for chemical restraint as well.

 

[MrBrown]

Yes, we have midazolam

 

[usalsfyre]

I believe it's 2-5 of Midazolam x2 for sedation of the agitated patient. If you can get someone to get hold of their head for long enough, IN works great.

 

[Melclin]

If its safe for you AND causes other than being a nut or an arse have been excluded AND aggression is not responsive to verbal de-escalation techniques then: Midazolam 0.05-0.1mg/kg IM q10 (IV route, q5 also an option for Intensive Care medics) (maximum of 4 doses, reduced doses in elderly and hypotensive pts).

I think it would be nice to have some other options. IM midaz is generally for dangerously violent pts. It might be good to have something we could do for anxiety and also the kind of agitation that might become dangerous. You know, that pt that you need to keep the police around for, you need security at the hospital and its a matter of when, not if they're ganna arc up. It might be nice to be able to pop a little diaz in just to bring things down a notch and make things a bit more pleasant for all involved. Olanzapine or oral diazepam might be nice.

 

[Iceman26]

If its safe for you AND causes other than being a nut or an arse have been excluded AND aggression is not responsive to verbal de-escalation techniques then: Midazolam 0.05-0.1mg/kg IM q10 (IV route, q5 also an option for Intensive Care medics) (maximum of 4 doses, reduced doses in elderly and hypotensive pts).

I think it would be nice to have some other options. IM midaz is generally for dangerously violent pts. It might be good to have something we could do for anxiety and also the kind of agitation that might become dangerous. You know, that pt that you need to keep the police around for, you need security at the hospital and its a matter of when, not if they're ganna arc up. It might be nice to be able to pop a little diaz in just to bring things down a notch and make things a bit more pleasant for all involved. Olanzapine or oral diazepam might be nice.

I agree on the diazepam, where I used to work we carried it and it was nice to have. Both there and where I'm working now we do have it in our protocols to use midazolam. I've lucked out so far and have yet to need to use it for this purpose but I suppose now that I just said that it'll happen next shift!

 

[truetiger]

Our protocols allow for up to 2mg of ativan or 5mg of versed

 

[STXmedic]

How well does Zyprexa work? I just found out my FT system will be getting it soon, but I have ZERO experience with it?

As far as standing orders right now: FT has up to 10mg Diazepam without calling, the PT is up to 20mg Diazepam without calling or 10mg Versed. Have actually had to take advantage of that several times recently; had a rash of EDS pts recently.

 

[Farmer2DO]

I see the zyprexa used a lot in one ED, a large, busy, urban ED (>100,000 visits annually) and they have very good luck with it. Snows them with no bad side effects that I've seen.

 

[dmiracco]

We have the option of versed or ketaminegreat option

 

[mikie]

Maryland uses Haldol - Page 234 of MD Protocols

Chemical-restraint guidelines: Sedative agents may be used to provide a safe method of restraining violently combative patients who present a danger to themselves or others, and to prevent violently combative patients from further injury while secured with physical restraints.

Dosage (May combine with midazolam in same syringe)
(1) Adult a. Patient 15-69 years of age:
5 mg IM or IV b. Patient greater than 69 years of age:
2.5 mg IM or IV (2) Pediatric
a. Child less than 6 years of age: Contraindicated
b. Child 6-11 years of age: 0.05 mg/kg IM or IV, max of 2.5 mg
c. Patient 12-14 years of age: 2.5 - 5 mg IM or IV

Benadryl is usually given as well to prevent dystonic reactions/EPS.

 

[jwk]

Our protocols state that for chemical restraint we can five 2.5-5 mg of Inapsine, and repeat until we've reached the desired effect. Versed is only allowed for sedation of pt's with DT's, however, medical control is usually pretty lenient about allowing it for chemical restraint as well.

I didn't realize anyone was using droperidol (Inapsine) for anything anymore except treatment/prophylaxis for perioperative N&V. We abandoned it's use in the OR 20+ years ago for any other indications.

 

[NomadicMedic]

I've worked in several systems with different choices. My last full time job was up to 5mg of Droperidol. I've also had the option of 5 to 10mg of Versed IN/IV/IM.

I prefer the IN versed. It's safer than trying to harpoon a combative patient. The MAD makes it a LOT easier.

 

[325Medic]

P.A. SOP's: 2.5-5mg Versed, should / try to contact med. comm if able to but can use w/o med comm. if needed. Go to P.A. DOH ALS protocols / under combative pt.

325.

 

[JeffDHMC]

Droperidol and versed. Not together, mind you, though I imagine that would do the trick.

Jeff

 

[Epi-do]

Here's our chemical restraint protocol.

Chemical restraint is to be used only where the patient can be adequately and repeatedly monitored by EMT-P providers. It is to be reserved for patients who cannot otherwise be restrained or restrained only at the risk of significant harm to the patient, law enforcement, and EMS providers.
1. Consider other causes of combative or irrational behavior, including but not limited to hypoxia and hypoglycemia.

2. Administer midazolam IV, IM, or via intra-nasal spray

a. If patient > 50 kg, administer 10 mg (5 mg in each nostril)
b. If patient < 50 kg, administer 5 mg
​

3. Patient should be isolated and placed in an ALS ambulance as soon as possible.

4. Airway, mental status, and vital signs (including pulse oximetry and heart rhythm) must be examined and documented every 5 minutes.

5. All patients will be transported to the closest most appropriate facility for further evaluation, and released to law enforcement thereafter.

If chemical restraint is used, a copy of the run record must be made available to the Medical Director through the CQI Coordinator within 24 hours.

 

[bigbaldguy]

2.5 midazolam by itself, most of the time accomplishes nothing but pissing off the patient for stabbing them with a needle.

Amen to that. Like giving a Valium to a grizzly bear rectally.

 

[Trevor]

We have Versed and Haldol.

5 mg Versed IM/IN for "presumed" drug related issues. OR 2.5 mg IV. Each can be repeated.
5 mg Haldol can be given for patient's without "Suspected Substance Abuse". This can be repeated as well.

 

[NomadicMedic]

Here's my old protocols...