When are pharmacological restraints (medications used to restrict patient movement) indicated and what medications, such as haloperidol (antipsychotic) or lorazepam (benzodiazepine), can be used?

Pharmacological Restraints: Indications and Medication Options

Pharmacological restraints are indicated only to prevent dangerous behavior to self or others and to prevent serious disruption of treatment programs when less restrictive options have failed or are impractical. 1

Indications for Pharmacological Restraints

• Pharmacological (chemical) restraint is defined as the involuntary use of psychoactive medication in crisis situations to help contain out-of-control aggressive behavior 1
• Chemical restraint should be used only after less restrictive interventions have failed, including verbal de-escalation techniques 1
• The only legitimate indications are:
  • Prevention of dangerous behavior to self or others 1
  • Prevention of serious disruption to the treatment program including serious property damage 1
  • Management of acute agitation that poses immediate safety risks 1

Contraindications and Inappropriate Uses

• Chemical restraint should never be used:
  • As punishment for patients 1
  • For the convenience of staff or the program 1
  • To compensate for inadequate staffing patterns 1
  • Where prohibited by state guidelines 1
  • By untrained staff 1

Medication Options for Chemical Restraint

First-Line Options

• Benzodiazepines:

  • Lorazepam: Preferred due to fast onset, rapid absorption, and no active metabolites 1
  • Typical dose: 2 mg oral or intramuscular 1, 2
  • Particularly useful when the cause of agitation is unknown or related to substance withdrawal 1

• Antipsychotics:

  • Haloperidol: Most evidence-based conventional antipsychotic for agitation 1
  • Typical dose: 0.5-5 mg depending on age and symptom severity 3
  • More appropriate when psychosis is suspected as the underlying cause 1

• Combination therapy:

  • A benzodiazepine plus an antipsychotic is frequently recommended for acutely agitated patients 1
  • Example: Lorazepam 2 mg plus haloperidol 5 mg 2
  • This combination may provide more rapid control of severe agitation 1

Alternative Options

• Antihistamines:

  • Diphenhydramine or hydroxyzine can be used for their sedative effects 1
  • May be preferred in children or when antipsychotics are contraindicated 1
  • Risk of paradoxical increase in agitation exists 1

• Atypical antipsychotics:

  • Limited evidence for use in emergency chemical restraint 1
  • Limitations include lack of injectable forms for many agents and longer onset of action 1
  • Ziprasidone (when available in injectable form) has shown efficacy with fewer movement disorders 1

Administration Protocol

• Before administration:

  • Review the patient's medical and psychiatric history 1
  • Consider potential drug interactions with current medications or substances 1
  • Obtain parent/guardian consent when possible 1

• During administration:

  • Offer oral medication before resorting to intramuscular injection 1
  • Ensure patient is sitting or standing when giving oral medication to prevent aspiration 1
  • Administer on a stat or emergency basis 1

• After administration:

  • Continuous monitoring by trained nursing personnel is required 1
  • Monitor for adverse effects including allergic reactions, paradoxical reactions, dystonia, and extrapyramidal symptoms 1
  • Continue monitoring until the patient is awake and ambulatory 1

Regulatory and Documentation Requirements

• A licensed independent practitioner must have face-to-face contact with the patient within 1 hour of the initial order 1
• The treating physician must be consulted as soon as possible 1
• Document the rationale for medication choice and the impact on other medications the patient is taking 1
• Orders are time-limited based on patient age (1 hour for children under 9,2 hours for ages 9-17) 1
• The patient's family should be informed of the use of chemical restraint 1

Common Pitfalls and Cautions

• Benzodiazepines may cause respiratory depression, especially when combined with other CNS depressants 1, 4
• Antipsychotics can cause QT prolongation, extrapyramidal symptoms, and dystonic reactions 1
• With anxiolytics and antihistamines, there is a risk of paradoxical increase in agitation 1
• Chemical restraint should be terminated once the patient has regained self-control 1
• Medications used for restraint often cause sedation that persists longer than necessary for the patient to regain control 1
• Always consider the ethical implications of using chemical restraints, as they restrict a patient's autonomy and dignity 5