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chemical restraints

Goals of Chemical Restraint. Morbidity / MortalityPatientProviderLimit physical restraintsFacilitate Evaluation

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chemical restraints

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    1. Chemical Restraints Marc L. Martel, MD Program Director Hennepin County Medical Center Assistant Professor University of Minnesota

    2. Goals of Chemical Restraint Morbidity / Mortality Patient Provider Limit physical restraints Facilitate Evaluation & diagnosis Cooperation without excessive sedation Intervention

    3. Chemical Restraints Ideal CR medications Parenteral Rapid onset Non-addictive Minimal tolerance Low side-effect profile Short duration of action

    4. Medications Overview Antipsychotics Haldol High potency Lengthens QT interval FDA Warning Droperidol Non-traditional antipsychotic Lengthens QT interval FDA Warning BP, anticholinergic, EPS, NMS

    5. Overview Benzodiazepines Midazolam Short acting Lorazepam Longer acting Respiratory depression, hypotension

    6. Overview Ketamine Dissociative anesthetic Rapid acting, short duration of action EBM ED CS - Substantial Out of hospital – None Hick 2005 – Jumper Future? Airway reflexes, htn, laryngospasm, emergence rxn

    7. Overview Atypical Antipsychotics Ziprasidone Short acting, Lengthens QT interval, Cost Olanzapine No QT changes, slower onset, > need 2nd meds, Cost Risperidone Oral, Rapid dissolving, slower onset, Cost

    8. Evidence for ED Use Haldol (Now FDA warning) Extensive ED experience Agitation improved @ 30’ in 85%1 15% suboptimal, Ř effect 2% Need lorazepam?2 No difference in sedation More rapid onset with combination

    9. Evidence for ED Use Droperidol Less agitation at 10’ & 30’1 ~2500 patients, all indications2 Minor AEs •Serious AEs 96 transient hypotension - 2 resp depression 40 dystonic reactions - 3 seizures - 1 cardiac arrest

    10. Evidence for ED Use Atypical Agents – Limited data Ziprasidone Effective & FDA approved for psych d/o 39.1% decr in agitated pts at 15’(60% Drop), Ř RD1 Olanzapine No pub EM studies, effective & FDA approved for psych d/o 53.5% at 15”, 78.9% at 30”2 Ľ needed additional sedatives, 4% multiple meds Risperidone (rapid dissolving oral) No pub EM studies, effective & FDA approved for psych d/o 33.3% at 30’, 44.4% at 60’, 77.8% at 120’ 2

    11. Newer Agents

    12. Advantages of the New Medications Little hypotension Less sedation Few dystonic reactions Replacement for Black Boxed medications? FDA warning – associated with increased mortality in elderly patients with dementia Europe – cardiac and respiratory depression

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