In this episode, I discuss the takedown and restraint of the violent, agitated delirium patient. This is a team sport and requires a coordinated approach for the safety of the patient and staff.
Update
My buddy Reub Strayer has a fantastic lecture on this topic that became Podcast 185
How to apply restraints in the ED
This video by Gary Marks, DO is the best instructional source for the proper way to restrain a patient in the ED
This image shows good restraint:
If you have ideas of your own and how to accomplish safe takedown of these patients, please put your comments below.
Some Evidence
Haldol vs. Droperidol
- J Clin Psychiatry. 1984 Jul;45(7):298-9. Droperidol vs. haloperidol in the initial management of acutely agitated patients.
- Ann Emerg Med. 1992 Apr;21(4):407-13. Droperidol versus haloperidol for chemical restraint of agitated and combative patients.
Droperidol vs. Midazolam
10 mg IM droperidol was not associated with greater QTc prolongation than the midazolam group. The DORM Study. Ann Emerg Med 2010;56:392-401.
Droperidol Safety
Article froms Peds literature looked at safety of high doses in patients aged 15-21 (Peds Emerg Care 2010;26(4):248)
The DORM Study
Randomized Controlled Trial of Intramuscular Droperidol Versus Midazolam for Violence and Acute Behavioral Disturbance: The DORM Study(Annals of Emergency Medicine Volume 56, Issue 4 , Pages 392-401.e1, October 2010)
This study showed that 10mg of IM droperidol was safe and more effective than midazolam or a combination of the two at half does of each.
New Ketamine Takedown
Efficacy of Ketamine for Initial Control of Acute Agitation in the Emergency Department: A Randomized Study. Am J Emerg Med. 2020 Apr 11;S0735-6757(20)30241-2. doi: 10.1016/j.ajem.2020.04.013.
Update
- Duh!!! Droperidol is still safe and effective [PMID: 35063889]
Additional New Information
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Chris writes:
I have heard of ‘old skool’ ED guys using sux to restrain patients also and heard the term:
“No one fucks with a 100 of sux.”
Hi Scott great discussion of a neglected EM topic Firstly Sux as restraint. What can I say? Why don’t you just use a TASER on theM instead? But really, I think we can do better. We took an oath to. Secondly acute sedation is tricky. I agree haldol and ativan can be too slow. Midazolam is ok but not always ideal. I am sure you have run into tolerance and paradoxical agitation as I have. I had one speed freak still playing fight club with the police after IV 60 mg midazolam over 20 minutes early in my career Midazolam… Read more »
As usual, we agree on most of this. Unless there is coincident pulmonary pathology, if these patients are desaturating the only reason is hypoventilation. I’m sure in your setting, you are monitoring these folks wonderfully and it would be safe to give them O2. However, in most EDs, if these patients are put in the general mix, or worse an iso room, they will be ignored until they perish. I’d much rather have the sat alarm beeping.
acute sedation should be practised to the same standard as any other ED procedural sedation. Nursing should be one to one and oxygen should be provided.
I appreciate in a busy ED that is not always a priority but it is best practice. the key as you point out is maintaining a safe sedation level. This is in the unintubated patient of course..but even in the intubated you need to be careful about sedation level monitoring. We have had two cases of reported awareness during intubation when it was used for restraint.
Preaching to the choir, brother
As to ketamine, I agree I think it is probably the ideal agent. I need someone to either publish or show me some numbers on what happens to hyperdynamic vitals (and I mean scary high) when we give the drug. Until then, I can’t publicly say it is a good idea on the podcast regardless of what I may do in my own personal practice.
Ketamine’s 2011 ACEP Clinical practice guidelines: Absolute contraindications (risk essentially always outweighs benefits) = age < 3mo and known or suspected schizophrenia. Wait, what now? (sighs) No idea what this is about.
Oh and about martial arts and trying to pull moves on agitated patients..I totally agree with Scott on this one. No place for heroics and yes I have seen people bitten, spat at, all kinds of nasty stuff. You don’t train for that in your air conditioned dojo. even in UFC you are not allowed to bite! the key to safety is numbers . bring your gang..its a team effort as Scott says. I talked to Master Cliff Reid about this when I met him ( we both have a Wing Chun background)..he retells the story of when the agitated… Read more »
Amazing! If you didn’t know better, you might tried to mug Bruce Lee as well–just looks like a scrawny dude. But that mugger would have been in for a big surprise.
Hi Scott Thanks for your podcast on sedation / restraint – this is one of those areas that is done very poorly and never talked about. Couldn’t agree more re: psych ward strategy in ED – this is a highway to nowhere but failure. I have posted a lot of stuff on this topic and have some resources that I have created myself at the Broome Docs site. I would like to hear your take on my “matrix” of care. Check out: http://wacdocs.csp.uwa.edu.au/2011/08/clinical-case-024-livin-the-ketamine-dream/ http://wacdocs.csp.uwa.edu.au/2011/06/psych-sedation-and-transfer-update/ As you can read – I am very passionate about this topic. Way too many unnecessary… Read more »
Casey, As Minh alludes this is specifically a podcast on the take-down of the acutely violent, agitated patient. I have yet to see old ladies in this scenario, though I am certainly not ruling it out.
I don’t have a single sedation recipe as the previous podcasts have gone through and I think are matrices would probably overlap in this regard.
However the takedown recipe is pretty much pt independent as it is titrated, safe and effective to start with a reasonable dose of drop/midaz in any patient exhibiting agitated delirium.
Casey, I think Scott is talking about that situation before you have IV access..in those cases, you have little choice but to go IMI. I agree when you need to give rapid IMI sedation that is risky and you have to pretty much set it up like as for procedural sedation…if you got the time. As Scott cites, these cases you often got no time. I understand why some have gone to the extreme of IMI Sux. The coroner up here has recently finished an inquiry into the sedation death last year of a mental health patient in a psychiatric… Read more »
Hi Scott — great podcast! Just out of curiosity, is there any reason for your preference of droperidol over haloperidol (or any other typical antipsychotic)? Is it an evidence-based reason, or simply a formulary consideration?
Added evidence above in the post. Droperidol is quicker and more sedating.
Ok guys, here’s my take: A patient that is so agitated to require this degree of intervention is in the class of “Excited Delirium”. This is a medical EMERGENCY! And in my opinion, requires rapid, complete sedation. We have two drugs that work well in this situation. Propofol and Ketamine. In my shop, these folks get the team approach. Two people on each extremity, RT at the bedside with the RSI box, nurse with RSI meds and IV start kit. Doc with syringe full of 100mg of propofol. Ready…….GO! Pt restrained, Doc at groin, femoral vessel ID’d and 50mg propofol… Read more »
Hi Mike I half agree with you! At least you choose more effective sedation agents and have a total control approach. Scott’s approach is evidence based..a couple of RCT comparing droperidol vs midazolam demonstrate greater safety and faster control http://www.ncbi.nlm.nih.gov/pubmed/20868907 http://onlinelibrary.wiley.com/doi/10.1197/j.aem.2005.07.017/abstract Of Course some agitated patients who are at one end of the spectrum and lives are in danger, do require urgent sedation and airway control. Your approach is valid in them. Many do not. The goal should always be a calm cooperative patient. We do not need to intubate everyone with delirium. BUt yes some we do. OUr current… Read more »
Minh and Scott, I agree that there are probably two populations to deal with. Excited Delirium=Rapid and total control Agitation alone=more measured response. How you differentiate those is challenging in the heat of battle. I would disagree with the sentiment that “some will die of oversedation”. This is usually a well planned and coordinated management strategy. RT at the bedside, enough hands to make it safe (by enough I mean at least 2 people per extremity, one at the head and 2-3 on the torso). The plan is immediate control, intubation, IV Access and continued heavy sedation. Given the adrenergic… Read more »
Hi Mike I appreciate the concern regarding adrenergic crisis and ketamine making things worse. There is little evidence base to guide us here. The case reports from mainly the US and my own case series is that there are no obvious adverse outcomes apart from transiennt worsening of hypertension, that requires generally observation only. The Hennepin county case report was in someone with cocaine intoxication and a hefty dose of ketamine did not lead to cardiovascular adverse events. I have found this to be the case in my own series. What we know from other published literature such as the… Read more »
I think Minh will turn out to be right about hemodynamics not being a bid deal with ketamine in these players> I just need someone to put a nice case series in the lit demonstrating this fact.
Mike- I never condemn anything that works, but mainlining propofol would seem very scary to me. I wouldn’t want to have to maintain a needle in the femoral vessel while a patient is thrashing around. Just judging by how femoral art or vein placements go during cpr, I’m not sure how much of the prop is actually getting in the vessel and how much in the sub-q. I’d also think that the degree of sedation without resp depression is lower with prop than the benzo class. I think your IM ketamine is fine for the takedown and then hefty doses… Read more »
yeah Scott thats a fair point about mainlining propofol being risky.
if your intention is to rapidly intubate them, you might as well go old school and give them IMI SUX plus IMI ketamine…prob safer than mainlining propofol
you can mix in one syringe but depending upon size of patient that might be 8mls worth..less for smaller people. Or you can divide into two syringes
but I think that is rarely necessary
Clonidine for the adrenergic crisis. 100-150mg ketamine has worked fine in the ward I worked at where a 5’9 140lb man came in who was very violent and was demanding us to give him ketamine or he will get violent. Initially I denied his request but as his violence continued to escalate the 5 and 2 was suggested but he said it would make him much worse, paradoxical agitation. Needless to say we didn’t go the usual 5 and 2 route we gave him 150mg of ketamine IM and 0.6mg clonidine orally for hypertension, he settled down but when it… Read more »
I forget to mention he was not excited delirium but he was combative due to the nature of the psychiatric problems he had on top of serious life threatening circumstances in his living environment. This was the only patient we used ketamine out of the hundreds we used haloperidol and Ativan.
One thing I’ve learned is empathy for the patient will go a long way if you listen to them.
Just to be clear with the 5 & 5 method, you are using the 5 mg/ml midazolam for a total volume of 3 ml, correct? Sorry just the pharmacist in me, in the heat of the moment I would hate for somebody to give a 7 ml IMI. Silly to point out, but just a med safety point. Thanks for the great podcast, I spread your gospel whenever/where ever possible.
If you have the more concentrated form–great. If not, then 7cc it is, the arm will be sore, but it will work.
Great discussion here guys.
Some of you have discussed the difficulties of getting and IV in these patients, would any of you consider going down the intraosseous path?
Be interested in your thoughts.
Kane
doing an IO in a struggling patient is only slightly easier than doing an IV in a combative patient.
firstly restraining someone safely to expose an IO site is challenging. tibial site I haeve seen people kneed in the groin or kicked in the face
humeral site I have seen people bitten.
IMI into the buttocks is safer if you hold someone down..not ideal restraint position but ok for a IMI shot then get them onto side whilt awaiting effect.
IMI into thigh is also safer but you are exposed to being punched
Minh as usual took the words right out of my mouth. I see no reason not to give all these folks their first round IM and then work on the IV or IO. It can only make your life easier. If you are worried about excess sedation and think you can get a line then just give the droperidol and then try your IV. Save the benzos for when you get the line.
Scott,
Thanks for the great exposure of this issue! I look forward to your discussion of agitated delirium as this needs a fuller discussion than it has had in the past. As I said earlier I am a firm believer in rapid, complete sedation in these folks. Death in this situation is not as uncommon as we would like and rapid sedation is paramount.
Mike
just to pay respect where its due
this was the original case report that sparked my interest into researching ketamine as chemical restraint
kudos to the Hennepin County EM dept folks!
http://www.ncbi.nlm.nih.gov/m/pubmed/16036834/
DR SCOTT, Thanx for covering such a neglected area that was quite informative,just two days we had faced similar kind of situation in our ED.Patient presented with complaints of respiratory distress,severe body ache and started shouting suddenly.Vitals were absolutely normal,Spo2 100% on air,when we started digging into history and medical records it was found he was taking injections of pentozacine and promethazine at least 20 times a month meaning he was addicted to it.We tried to convince him and when we said no to his request he started shouting,abusing and what not.Lot of medazolam toatal 10mg in intermittent doses was… Read more »
The Hypocritic Corpus
As I stand over this
Screaming
(human?)
Patchwork
Scarred
Scared
Amphetamine fuelled
Pulsing rage
With a syringe of midazolam
(fantazaslam!)
Invoking the Mental Health Act
(the gospel according to psychiatry!)
As if I believe in it
I realise this does not rest easy
With the mumbled Greek of Hippocrates,
Sworn in a marbled hall in another life
When I believed in it
beautiful, my friend!
Scott, in addition, I’d like to say thanks for your blog and especially the podcasts. They were a vital tool for me in passing my Australian ED fellowship exam a few weeks ago…somehow made studying a bit less like a chore!
We have intranasal midazolam with a mucosal atomization device, as an option. 10 mg doses.
No needles, but watch out for teeth 🙂
Mike
yep, I’m not going anywhere near the face without my demo gloves on
believe it or not, at some point in recent years the US military researched the use of ketamine nasal spray for soldiers in lieu of other prehospital analgesics
So you can give ketamine intranasally as well!
but in this case of severely agitated patient I am not confident it is best approach due to risk of being bitten as cited already.
choosing between a needle stick vs a human bite injury is challenging decision.
Mike , I have to ask. Have you ever used intranasal midazolam this way to sedate an agitated patient?
Minh, I’ve used IN midazolam on pediatric and adult patients with seizures and have found it very effective. However, as I was lamenting recently, since we added the IN midazolam for adults I have not had the chance to use it on a combative patient. I suspect it would be best to have both a needle and an atomizier available, and use the appropriate technique based on what part of the body you end up having access to. I work prehospital, so likely there will either be a taser or significant brutane applied prior to my attempting to sedate the… Read more »
Minh, Scott, I frequently use the MAD atomizer on these patients. I still use the 5+5 technique you mentioned with the nurse pushing 5 mg of IM droperidol, the guards securing the extremities, and myself pushing the midazolam in the nares. We usually have one guard on the head which makes the process a lot smoother. Just make sure to use the 5mg/mL solution if you can because you don’t want to push more than 2-2.5 mL per nare. Thanks for the great post. The strapping method makes complete sense having tried it just last night. We’ll have to retrain… Read more »
Rob, I agree, the restraint video is excellent. big thankyou to Scott for posting it.
I am unclear why you give droperidol IMI and midazolam IN, Rob. Why not both IMI as Scott suggests?
Do you think the INmidazolam works faster?
Not to put words in Rob’s mouth, but I think IN midaz would be markedly quicker…but I’m still not going there. Nebulized midaz wouldn’t be the worst idea as an augmentation to the IM meds and to keep the team from being spit upon at the same time.
IN is very fast. I had one patient calmly sedated in about 60 seconds. It helped that the patient snorted the midazolam as I was administering it. I suppose they thought I was giving them something else they’d enjoy. . . As mentioned, you need one person on the head as the patient tend to flail. We have a decent security force and when the police bring us a patient, they often stay and help too, so there is a lot of manpower available to restrain the patient.
thanks mate for the tip. I am aware IN is faster than IM midaz but just was not sure why you gave one IN and the other IM..but it seems to make sense. IN works for rapid onset whilst IM starts to kick in for added sedation. yes that sounds sensible now. Despite the problems with biting, spitting and holding someones head still for IN, you at least dont have to inject through clothes or try to get some clothing off…that was one thing I was wondering about Mike J’s suggestion of mainlining propofol via the fem vein…how do you… Read more »
Interesting conversation. I’m currently working at the Mater Hospital Newcastle which is the main centre here for both toxicology and mental health. Our practice is largely based on a study of 90 patients (http://www.ncbi.nlm.nih.gov/pubmed/20868907) completed at the hospital in 2010. Conclusion: Intramuscular droperidol and midazolam resulted in a similar duration of violent and acute behavioral disturbance, but more additional sedation was required with midazolam. Midazolam caused more adverse effects because of oversedation, and there was no evidence of QT prolongation associated with droperidol compared with midazolam. Our procedure is, in a step wise fashion, the patient is ‘code blacked’, offerred… Read more »
thanks Dan
I read a recent study from your department on dexmedetomidine sedation in ED
http://emj.bmj.com/content/early/2011/12/08/emermed-2011-200849.short?rss=1
sounds like it has been stopped due to safety concerns?
time to do that ketamine sedation in ED study?
Dan, great study to add to the list. We used to use droperidol 110 mg at a time until the black box warning (a warning which all of us in the States know is ridiculous). 10 mg worked very, very well as you say. I imagine if I was able to repeat the 10 mg a second time, most anyone could be chilled out. I’m surprised Dex is in the protocol. I have been using it extensively for proc sedation and I am unimpressed with its ability to blunt agitation.
First; Scott, you are redefining my residency experience and appreciation thereof. Your lectures are game-changers here and our generation of docs is implementing the kind of interventions that are saving lives. Awesome. Keep it coming.
Second: Anything I should know about giving it IV vs. IM? Had to put down a combo cocaine and tylenol OD with 5 droperidol IM, but when I ordered it we already had an IV so that’s how I gave it. Pharmacy was nonplussed. Quicker to the fabled QT elongation (which I did not see)? Worked like a charm.
Thanks, Gabriel! Nope IV and IM are the same gig.
Gabriel,
The QT effect isn’t a fable, plenty of literature out there demonstrating the effect. It’s just not as clinically significant as the FDA would have you believe. Theres a great Annals of EM article that does a nice deep dive that I read before I jumped in with both feet and began happily using droperidol. Problem is, I’m pretty much the only faculty member at our shop that uses it and many of my residents are still afraid of it. The nurses however, have become big fans.
Check out the Annals article here: http://www.annemergmed.com/article/S0196-0644(03)00059-3/fulltext
Rob, much obliged for the reminder and reference; I’ve read it and printed it to pass around our droperidol-hungry residents. I didn’t mean to imply a disbelief in the existence of prolongation, just a recognition that we’re unlikely to hit it with these take-down doses. Pharmacy is in the process of re-writing some of our sedation caresets to include droperidol and I do appreciate the cautious approach, as my favorite method is still the verbal de-escalation. As impressed (relieved) as I am with the efficacy of droperidol, I think that any of these chemical approaches need to be applied with… Read more »
Hi Scott I’ve just revisited this podcast and was wondering what your current thoughts are on the management of the agitated ICU patient; ICU delirium. I managed a lady on my last night shift with 5mg Haldol IV who has OSA and obesity hypoventilation syndrome. I think her delirium was exacerbated by her problems sleeping ( she’d desaturate on falling asleep ) and the nursing staff were waking her. She lost it and went crazy, speaking in tongues and needed to be restrained. She became unresponsive after the Haldol and tolerated BiPAP well. Any thoughts on the latest best meds… Read more »
check out this site:
http://www.mc.vanderbilt.edu/icudelirium/overview.html
Sometimes it´s worth it to look over the fence and see what veterinarians do. I use Ketamine mainly to position patients with hip fractures for spinal anesthesia. A lot of them are hypertensive and tachycardic, often in AF. Ketofol (which I call Ketacolada) sometimes leads to respiratory depression in patients > 80 y. So I started mixing Ketamine with Clonidine, to counteract the sympathomimetic effects and for additional sedation and analgesia. When I researched this idea, guess what I found? It´s called the “Hellabrunn Mixture” (after the Munich Zoo) and it´s a favorite to bring down animals via blow gun.… Read more »
Patrick, I always love to hear what the vets are doing, they are usually a decade or so ahead of the curve. Ketamine/dexmed combo has been in the adult literature as well. When it comes off patent, it should get some play.
great discussion… I had patient with postictal agitation who received total of midazolam 20mg iv with increasing agitation… finally we tried diazepam increments of 5mg, he regain full consciousness within two hours and asked to leave hospital 🙂 .. in seizure/postictal, the choices are limited (avoiding antipsychotics)… then you play with sedation trying to avoid intubation due to lack of ICU beds and high rate of infection related outbreaks. One friend suggested Thiopental 50mg!! what do you think ?
After an adequate dose of benzos, I’d have no problem giving droperidol in these cases. Theoretical seizure threshold stuff doesn’t worry me so much. Ketamine is always an option and will lower recurrent seizure risk, but they may wake up even more agitiated, though doubtful if benzos are on board.
Hi. I found this site while looking for info on alternatives to tasers being used in the ER In Maine we have two hospitals who are now using them. I am hoping to get this policy changed. I understand that staff needs to be kept safe, so I am looking for other alternatives than just the normal ones usually used. If any of you have ideas for me I would appreciate it. Currently ,I am including faster triage time, changing the color and atmosphere of the ER ,possibly offering a wait room with out as many people and calming music..… Read more »
As a retired cop and not a Doc this site was very informative though at times a little hard to follow. (not knowing all your lingo) I have been teaching a class in arrest related deaths (ExDS) and preaching the gospel (field sedation for the extremely aggitated) to law enforcement and EMS for years. Of course there is considerable resistance from some medical directors to allow ALS the flexability to do so in the field, but the numbers speak for themselves. Many lives saved due to early sedation. I agree the trick is to give enough. The big difference is… Read more »
Jerry,
Thanks so much for the comments! One thing they have done in NYC is to use what they call the “burrito bag” for EDP in addition to the handcuffs. Completely wraps the body, but allows the patients to be transported supine with safety to crew and officers.
Is that an official product or just a name you have given to the procedure? If it is a product I will include it on my list of restraints that agencies need to look at when preparing to deal with this issue. I now suggest looking at the Body Cuff and The Wrap. Both specifically designed to handle extremely aggtitated patients in the field.
These pt’s Absolutely need constant monitoring if we physically or chemically restrain the agitated patient. I think it is essential to have a plan of how to care for these patients before hand so it can be implemented quickly. If chemical restraint is to be used (my preference would be droperadol and Midazolam) it should be delivered quickly. Important to note that physical restraints used in conjunction with chemical restraint is a dangerous combination. Physical restraint should be removed (be that manpower of devices) after the pt is restrained chemically. I feel the physical restraints are sometimes used because we… Read more »
Thanks Scott. Hi ED gurus, I’m an emergency physician in a base rural hospital which has a low socioeconomic population in Australia. High rates of ice addiction. It’s interesting how a fairly common occurrence has a fairly wide variation in practice. We had a tragic sudden death in a patient with excited delirium from supposedly LSD. First time he tried it; a 23yM with stable job and no drug addiction problems. Thankfully I wasn’t involved directly and I’m just trying to deal with the repercussions. He was the classic case of agitated, running around in street naked, prolonged struggle with… Read more »
fantastic comments, Andre
You medical people are the scum of the earth, rapist and deviants. Hopefully many of you will get covid and die.
At my institution there is quite a bit of pushback on putting patients in the “split arm” position, with one arm by the head and the other at the patient’s side. We have had situations where the patient has been nearly able to flip the stretcher over because they are able to get momentum from sitting upright. Nurses have brought up concerns that the arm up position can cause neurovascular compromise. Is there any truth to this? Is anyone aware of any literature on the safety of the “one arm up” position? I had been doing it throughout my career… Read more »
until someone does a study, we will never be able to overcome these viewpoints