What is chemical restraint?
A chemical restraint is a drug, usually a sedative or antipsychotic, administered to control a patient's violent behavior that could harm medical staff or themselves.
Chemical restraint refers to the administration of certain medications to restrain agitated patients from behavior that is harmful to themselves or others, including the medical staff attending to them. The administration of a medication is considered a chemical restraint when used to sedate an agitated patient and not for direct therapeutic reasons.
What are the three types of restraints?
The three types of restraints are
- Physical: Limiting a person’s freedom of movement with physical devices such as waist belts, restraining vests or hand mitts.
- Chemical: Use of medications to moderate behavior.
- Environmental: Restricting a person’s free access to the places or things in their environment, such as locking up a room or keeping a thing in an inaccessible place.
Why and when is chemical restraint required?
A chemical restraint is most often administered in the emergency department, when prompt action is required to avert violence, or manage dangerous and uncontrollable behavior in an agitated patient.
A patient may be agitated due to a combination of several factors such as:
- Substance intoxication or withdrawal
- Significant physical illness
- Mental health crisis
- Confusion and anxiety
A chemical restraint medication is used as a last resort when less invasive options fail. Examples of such less invasive options include verbal reasoning and/or involving trusted family members to calm the patient.
What are the important considerations before administration of chemical restraint?
A chemical restraint is an infringement on a patient’s personal freedom and dignity, and has legal implications. Before administering a chemical restraint, medical staff must carefully assess:
- If the patient is able to make rational decisions
- If the patient poses a serious threat to themselves or others, if restraint is not administered
- If the patient has any health condition that precludes use of chemical restraint due to side effects
- If there are medical causes for agitation, such as
- Low oxygen
- Dementia
- Low blood sugar
- Delirium
Other important considerations are:
- Legal requirements
- Obtaining the patient’s consent if it is possible
- Obtaining the family member’s consent if the patient is not in a condition to comprehend, or is a minor
- Need for extreme caution in use of chemical restraint and its dosage in a pregnant patient
- Use of appropriate medication and dosage in children
What is an example of chemical restraint?
Administration of the right kind of chemical restraint is essential, based on the patient’s condition and the cause of agitation. Examples of chemical restraint include sedatives and antipsychotics.
Three main classes of drugs are used as chemical restraint:
Benzodiazepines: Benzodiazepines are sedative drugs effective in aggression reduction and quick sedation in an agitated patient. This drug class is useful for patients with:
- Alcohol intoxication or withdrawal symptoms
- Seizure disorders or those at risk for seizures
- Agitation from unknown causes
Typical or classic antipsychotics: Butyrophenones and phenothiazines are the main classes of antipsychotic drugs used to control violence in patients with acute psychosis.
Atypical antipsychotics: Atypical antipsychotic drugs are relatively new type of chemical restraints and have a better side effect profile than benzodiazepines and typical antipsychotics. Studies indicate that atypical antipsychotic drugs are effective in controlling acute psychosis in patients with a known psychiatric disorder such as:
Some clinical trials have demonstrated better efficacy in achieving rapid sedation with a combination therapy of one benzodiazepine and one typical antipsychotic drug.
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How is a chemical restraint administered?
Chemical restraints must ideally act rapidly with the least dosage and minimal side effects. Ease of administration is also an important consideration.
A chemical restraint may be administered in three ways:
- Oral medication: The first option is per oral (PO) administration, if the patient is amenable and willing to take the medication. Oral solutions are considered better than tablets as they
- work faster and
- help avoid the possibility of the patient hiding the tablet in their cheek.
- Intramuscular injection: In emergencies, intramuscular injections (IM) may be the best option because of ease of access and rapid action.
- Intravenous injection: Intravenous injections (IV) have the quickest onset time, but accessing the vein may be difficult in an acutely agitated patient.
The vital signs of the patients must be carefully monitored for any serious side effects after administration of chemical restraint.
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What are the drugs used for chemical restraint?
Following is a list chemical restraint drugs, and some of their side effects; also, some drugs are used in combination (for example, lorazepam and haloperidol):
Benzodiazepines
Two benzodiazepine drugs are used for chemical restraint administered PO, IM or IV:
- Lorazepam
- Midazolam
Side effects include:
- Respiratory depression (shallow and ineffective breathing)
- Hypotension (low blood pressure)
- Extreme somnolence (sleepiness)
Typical antipsychotics
The main two antipsychotic drugs administered PO, IM or IV are:
- Haloperidol
- Droperidol
Side effects include:
- Heart rhythm disorders (dysrhythmia)
- Extrapyramidal symptoms from movement disorders such as
- Tardive dyskinesia (jerky movements)
- Dystonia (muscle spasms and contractions)
- Akathisia (restlessness)
- Torticollis (twisted neck from neck muscle contraction)
- Drug-induced parkinsonism (tremors and muscle stiffness)
Atypical antipsychotics
Three atypical antipsychotic drugs are available to administer PO or IM:
Side effects include:
- Extrapyramidal symptoms (for example, akathisia, tardive dyskinesia, acute dystonia)
- Neuroleptic malignant syndrome, a condition that leads to
- High fever
- Muscle stiffness and weakness
- Severe fatigue and confusion
- High heart and pulse rate
- Signs of kidney problems such as dark urine