Pharmacological Restraints: Indications and Medication Options

Indications for Pharmacological Restraints

The American Academy of Child and Adolescent Psychiatry indicates that pharmacological restraints are used 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, 2
Chemical restraint should be used only after less restrictive interventions have failed, including verbal de-escalation techniques, as recommended by the American Academy of Pediatrics 3, 4
The legitimate indications for pharmacological restraints include prevention of dangerous behavior to self or others, prevention of serious disruption to the treatment program, and management of acute agitation that poses immediate safety risks 1, 2, 3, 5

The American Academy of Child and Adolescent Psychiatry states that chemical restraint should never be used as punishment for patients, for the convenience of staff or the program, to compensate for inadequate staffing patterns, where prohibited by state guidelines, or by untrained staff 1, 2

Benzodiazepines, such as lorazepam, are preferred due to fast onset, rapid absorption, and no active metabolites, with a typical dose of 2 mg oral or intramuscular, as recommended by the American Academy of Pediatrics 3, 4, 6
Antipsychotics, such as haloperidol, are most evidence-based conventional antipsychotic for agitation, with a typical dose of 0.5-5 mg depending on age and symptom severity 6
Combination therapy of a benzodiazepine plus an antipsychotic is frequently recommended for acutely agitated patients, with an example being lorazepam 2 mg plus haloperidol 5 mg 3, 6

Before administration, review the patient's medical and psychiatric history, consider potential drug interactions, and obtain parent/guardian consent when possible, as recommended by the American Academy of Child and Adolescent Psychiatry 2, 5, 7
During administration, offer oral medication before resorting to intramuscular injection, ensure patient is sitting or standing, and administer on a stat or emergency basis 2, 5, 7
After administration, continuous monitoring by trained nursing personnel is required, with monitoring for adverse effects including allergic reactions, paradoxical reactions, dystonia, and extrapyramidal symptoms 5, 7

A licensed independent practitioner must have face-to-face contact with the patient within 1 hour of the initial order, and the treating physician must be consulted as soon as possible, as required by the American Academy of Child and Adolescent Psychiatry 2
Document the rationale for medication choice and the impact on other medications the patient is taking, with orders being time-limited based on patient age 2, 7

Benzodiazepines may cause respiratory depression, especially when combined with other CNS depressants, and antipsychotics can cause QT prolongation, extrapyramidal symptoms, and dystonic reactions, as warned by the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry 3, 6, 7