Search The Royal Children's Hospital Melbourne Search

Clinical Practice Guidelines

RCH>Division of Medicine>General Medicine>Clinical Practice Guidelines>Emergency Restraint and Sedation- Code Grey

Emergency Restraint and Sedation- Code Grey

  • Also see:

    Principles

    • A key principle of medical ethics is that a patient's autonomy should be respected.
    • Physical restraint is only used for safety and/or treatment.
    • As physical restraint and sedation deprives the patient of autonomy, it should only be contemplated as a last resort.  A patient who is 'acting out' and who does not need acute medical or psychiatric care should be discharged from the hospital to a safe environment rather than be restrained.
    • When physical restraint is required a coordinated team approach is essential, with roles clearly defined and swift action taken.  See Code Grey procedure. RCH staff members should never attempt to restrain the patient without the Code Grey response team resource on hand.
    • Unless contraindicated, sedation should usually accompany physical restraint.

    Alternative means of calming a patient

    • Crisis prevention.  Anticipate and identify early irritable behaviour (and past history).  Involve mental health expertise early for assistance (intake worker; after hours - on call psychiatry registrar).
    • Provide a safe 'containing' environment.  This includes a confident reassuring approach by staff without added stimuli.
    • Listen and talk simply and in a calm manner.
    • Offer planned 'collaborative' sedation (e.g. ask the patient if they would take some oral medication to regain some control of their behaviour).

    Indications for restraint

    • Other methods to control the behaviour have failed such as de-escalation techniques; and
    • The patient displays aggressive or combative behaviour which arises from a medical or psychiatric condition (including intoxication); and
    • The patient requires urgent medical or psychiatric care; and
    • The behaviour involves a proximate risk of harm to the patient or others, or risk of significant destruction of property.

    Cautions and contraindications to physical restraint and emergency sedation:

    • A patient who is 'acting out' and who does not need acute medical or psychiatric care should be discharged from the hospital to a safe environment (home, police, DHS) rather than be restrained.
    • Be aware of previous medications and possible substance use.
    • Safe containment is possible via alternative means (including voluntary, collaborative oral sedation).
    • Inadequate personnel/unsafe setting/inadequate equipment.
    • Situation judged as too dangerous e.g. patient has a weapon (call a Code Black)

    Emergency chemical restraint

    • If at all possible the patient should be given the option of taking an oral medication. 
    • Benzodiazepines are generally the medication of first choice, particularly in cases of known intoxication
    • If the patient has a known psychiatric disorder, consider using top up doses of their regular medication
    • Give one option from choices below, wait for effect (see Drug specific information) and then consider further medication (oral may become an option after initial IM / IV).
    • If a drug from one group has had a poor therapeutic response after 2 doses, try a drug from another group (e.g. - poor response to diazepam, try olanzapine).
      • At this point reconsider your diagnosis (e.g:  Underlying organic pathology) and indications for using emergency sedation  

    If the patient can tolerate oral medications: 

    Diazepam - oral
    0.2mg - 0.4mg/kg (Max 10mg/dose if benzodiazepine naive)

    OR

    Lorazepam - oral
    0.5mg - 1mg (<40kg)
    1mg - 2.5mg (>40kg)


    OR

    Olanzapine wafer - sublingual (SL)
    2.5mg - 5mg (<40kg)
    5mg - 10mg (>40kg)

     


    If oral medication not possible:

    Midazolam - IM / IV
    0.1mg - 0.2mg/kg
    (Max 10mg/dose)


    OR

    Olanzapine -   IM only 
    5mg (<40kg)
    10mg (>40Kg)

    OR  

    Haloperidol - IM / IV
    0.1mg - 0.2mg/kg (Max 5mg/dose, usually 2.5mg - 5mg/dose)


    OR
      

    Midazolam / Haloperidol Combination (IM) 
    Give above doses combined in one syringe 

     


     Drug specific information:

    Drug

    Time to review clinical effect before 2nd med

    Adverse effects

    Midazolam

    IM: 10 - 20 mins

    IV: almost immediate

    Respiratory depression1 and airway compromise, paradoxical reactions4 

    Olanzapine

    Oral: 20 - 30 mins

    IM: 15 - 30 mins

    Respiratory depression1, hypotension, ↑HR.

    Do not use if history suggestive of prolonged QTC, Extra-pyramidal reactions2, Neuroleptic Malignant Syndrome3, may reduce seizure threshold

    Haloperidol

    IM/IV: 15 - 30 mins

    Respiratory depression1, hypotension, ↑HR.

    Do not use if history suggestive of prolonged QTC, Extra-pyramidal reactions2, Neuroleptic Malignant Syndrome3, may reduce seizure threshold

    Diazepam

    Lorazepam

    Oral: 30 - 60 mins

    Oral:20 - 40 mins

    Respiratory depression1 (unlikely to see immediate complications as longer half lives) and paradoxical reactions4 

       

    1Respiratory depression - More commonly seen with benzodiazepines but can also occur with olanzepine and haloperidol.

    2Extrapyramidal reactions - more commonly seen with haloperidol but may be seen with olanzapine after only 1 dose.  Reactions include; dystonia, dyskinesia, oculogyric crisis and akathisia (restlessness). Reversible with benztropine.

    3Neuroleptic Malignant Syndrome - A rare complication of typical and atypical antipsychotics characterised by hyperthermia, muscle rigidity, autonomic dysfunction and altered mental status. Call hospital emergency team (ie: MET call) if suspected and check serum CK as it is invariably elevated. Immediately inform consultant and Psychiatry team.

    4Paradoxical reactions - Administration of a benzodiazepine results in increasing agitation and anxiety as opposed to its normal sedating effect. This is more commonly seen in patients with developmental delay and / or a history of aggressive behaviour.

    The following antidotes should be readily available for reversal of potential side effects

    Benztropine - 0.02mg/kg (Max 2mg/dose) given IV or IM for reversal of dystonic reactions associated with haloperidol and olanzepine. Repeated doses may be required.

    Flumazenil - 10 micrograms/kg (Max 200micrograms/dose) repeated at 1 minute intervals prn for up to 5 doses, for reversal of respiratory depression associated with benzodiazepines only. Do not give unless you are sure the patient is not on long term benzodiazepines.  Consider flumazenil infusion if more than 5 doses are required. 

    Post sedation care

    Vigilant monitoring, particularly for signs of; airway obstruction, respiratory depression, hypotension and extrapyramidal reactions is mandatory.

    Monitoring should be performed in a safe environment within the clinical setting.

    Some flexibility in observations is acceptable, so as not to unnecessarily wake or irritate the patient further and to permit sufficient patient rest.

    Patient with decreased level of consciousness

    • Requires one to one nursing
    • Need continuous oxygen saturation monitoring 
    • Vital signs (temp, HR + rhythm, BP, resp rate) and neurological observations should be performed every 15 mins until stability is clinically evident

    Patient calm, but alert

    • Half-hourly observations for 2 hours after last sedation medication

    Agitated patients

    • Need continuous clinical observation 

    Procedure

    1. The Code Grey team should perform this procedure.
    2. Team leader will designate roles before approaching patient (Code grey procedure).
    3. All members should ensure own safety, with gloves and goggles.
    4. Draw up medication See table above
    5. Secure the patient quickly and calmly using the least possible force. At least 5 people are required.
    6. The patient should be initially held supine. In highly agitated patients, a face down technique may be used at the discretion of the team leader, but be aware of the increased risk of asphyxiation
    7. Administer the drugs by intramuscular injection into the lateral thigh (Other options - ventrogluteal or dorsogluteal). Beware of the risk of needle stick injury.  Further titrated doses of medication may be required depending on clinical response (If medication can be given IV this may be an option if the patient is safe to cannulate)
    8. Post sedation care (See below)
    9. Patients who have needed emergency restraint & sedation may also require mechanical restraint, although chemical restraint is preferred. Mechanical restraint should be provided by trained personnel only. See Mechanical restraint policy and procedure.

    Figure: Code Grey Procedure

     clip_image001

    Post sedation care

    Vigilant monitoring, particularly for signs of airway obstruction, respiratory depression, hypotension and extrapyramidal reactions is mandatory.

    Monitoring should be performed in a safe environment within the clinical setting.

    Some flexibility in observations is acceptable, so as not to unnecessarily wake or irritate the patient further and to permit sufficient patient rest.

    Patient with decreased level of consciousness

    • Requires one to one nursing
    • Continuous oxygen saturation monitoring 
    • Vital signs (temp, HR + rhythm, BP, resp rate) and neurological observations should be performed every 15 mins until stability is clinically evident

    Patient calm, but alert

    • Half-hourly observations for 2 hours after last sedation medication

    Agitated patients

    • Need continuous clinical observation

    Complications of emergency restraint include

    • Complications from medications (above)
    • Injury to patient or staff
    • Traumatic asphyxiation

    Complications of mechanical restraints include

    • Escape from mechanical restraints
    • Pressure effects of mechanical restraints
    • Complications of being held supine, such as inability to clear vomitus from airway
    Explain
    • Explain the procedure to the parents/carers if possible.

    Ongoing care

    • Following restraint the patient must undergo a detailed medical and mental health assessment to guide subsequent management.
    • In some cases recommendation and transfer to an inpatient mental health facility may be required (Section 9 of the Victorian Mental Health Act, 1986).
    • The need for restraint and sedation should be reviewed on an ongoing basis and the patient should be cared for in the least restrictive modality so as to provide safety.
    • In most cases, mechanical restraints should be removed once patient control is gained and this should be done in a stepwise fashion (one limb at a time).
    • As the sedation wears off, the patient's risk status should be carefully monitored throughout the entire process.  Adjuncts to safe care may include the use of the Emergency Behavioural Assessment Room (EBAR), further sedation (oral, IV, IM) or possible use of mechanical restraints.

    Document

    Document fully in the patient's medical record and medication chart when appropriate:

    • The indication for restraint, noting times
    • Patient's response to sedation and complications thereof
    • On-going observations documented at least 15 minutely, including limb observations if mechanically restrained
    • Use code grey reporting form (in Code Grey folder)

    Defusing and Debriefing

    • The need to physically restrain an aggressive patient can be extremely distressing for staff involved.  A critical incident stress debriefing session may be required. It is ideally chaired by an objective facilitator who was not involved in the restraint process.  See Human Resources Employee Assistance Program (EAP).
    • An operational debriefing may also be useful as a quality improvement tool.

    Please remember to read the disclaimer.

     

    Last Updated May 2013

     


Donate now Support us

Support The Royal Children's Hospital