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]

Drug	Route	Typical Dose (mg)	Onset (min)	Duration (min)	Warning
Midazolam	IV	2-5	1-5	30-60	Respiratory depression, IM unpredictable onset
	IM	5	10-15	120-360
Lorazepam	IV	2-4	2-5	60-120
	IM	4	15-30	60-120
Haloperidol	IV	5-10	10	180-360	Arrhythmia Risk: Only if previously used OR ECG
	IM	10-20	15-30	180-360
Ketamine	IV	1-2mg/kg	1	20-30	Theoretical risk of worsening cardiovascular instability
	IM	2-4mg/kg	3-5	60-90

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