Most of us will have seen patients like this – agitated, aggressive and often with police or security pinning them down.

1. High risk of Cardiovascular Collapse/Death – likely due to adrenaline surge, heat exhaustion and injury. It can happen very suddenly.
2. Keep physical restraint to a minimum – Don’t allow patient to forced face down, it’s the most likely way of killing them.
3. Sedation – if you’re restraining you will almost certainly need to sedate. IV is best but if access is too risky IM will have to do.
4. Aggressive management of underlying issues – esp. hyperthermia and acidosis and look out for rhabdomyolysis and DIC

Refusing treatment = Mental Capacity Assessment [LINK]

Order	Drug	Route	Typical Dose (mg)	Onset (min)	Duration (hr)	Warning
First Line	Lorazepam - Adult	IV	1mg IM/IV (max dose 4mg/24hrs)	2-5	1-2	Respiratory depression, IM unpredictable onset
		IM		15-30
	Lorazepam-Elderly	IV	0.5mg IM/IV (max dose 2mg/24hrs)	2-5
		IM		15-30
Second Line - Adult	Olanzapine (not within 1hr of IM Lorazepam)	IM	5mg (max dose 20mg/24hr)	15-45	>10	Arrhythmia Risk: Only if previously used OR ECG
Second Line - Elderly	Promethazine	IM	10mg	15-30	>10
Sedation ST4+ involvement required	Ketamine	IV	1-2mg/kg	1	20-30	Theoretical risk of worsening cardiovascular instability
		IM	2-4mg/kg	3-5	60-90

RCEM –abd

Trust Guide