Advanced Paramedic Practitioners
ADVANCED CLINICAL OPERATING PROCEDURE
TITLE
Emergency Sedation
AUTHOR
Dr Neil Thomson, Assistant Medical Director East
PRINCIPLE
Dr Fionna Moore, Medical Director
REVIEWERS
Mark Whitbread, Director of Paramedic Education & Development
Jaqualine Lindridge, Consultant Paramedic (v1.3)
AUTHORISED BY Dr Fionna Moore, Medical Director
REVISION
Dr Fenella Wrigley
AUTHORISED BY Interim Medical Director
Advanced Paramedic Practitioners
APPLICATION
Consultant Paramedics
Named Paramedics
THIS
DOCUMENT
ACOP 002 V1.0
REPLACES
ISSUE DATE
6th July 2015
REVIEW DATE
May 2016
REFERENCE
ACOP 002
VERSION
1.6
Smith, Scarth and Sasada: Drugs used in Anaesthesia and Critical Care,
4th Edition, 2011
LAS PGDs: Midazolam & Haloperidol
FURTHER
Calver L
et al Droperidol v Haloperidol for sedation of aggressive
READING
behaviour in acute mental health: randomised controlled trial BR J Psychiatry 2015 Mar 206 (3) 223-8
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ACOP 2 – Emergency Sedation
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Ibister GK
et al Randomised controlled trial of IM droperidol v
midazolam for violence and acute behavioural disturbance: the DORM
study Ann Emerg Med 2010 Oct 56(4) 392-401
Mental Capacity Act, (2005) & Mental Capacity Act Deprivation of
Liberty Safeguards (2009)
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Version Number
Revisions
1st April 2014 NT
0.1
Initial Draft
15th April 2014 NT
0.2
Minor amendments following comments from reviewers
24th April 2014 NT
0.3
Minor amendments following review with APP Group
1st May 2015
1.0
Final Version
29 April 2015
1.1
Reviewed and updated
Fenella Wrigley; Neil Thomson; Peter Dalton; Ian Wilmer; Mark Faulkner
15th May 2015
1.2
Detail on haloperidol and case examples added
19th May 2015
1.3
NT, FW: Additional detail on case examples; Deprivation of Liberty Safeguards
17th June 2015
1.4
JL: Wording on Deprivation and Restriction of Liberty adjusted
Final Review & Release
29th June 2015
1.5
Removal of reference to Intranasal Midazolam
6th July 2015
1.6
Review of Cases and reference to Haloperidol
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INTRODUCTION
The agitated, restless or combative patient is relatively rare in prehospital care. However in the APP system
(with targeted dispatch) they are not uncommon. These patients can be immensely challenging to manage,
not least because an altered level of consciousness is often a sign of very serious underlying illness or
injury.
These are also complex and challenging scenes to manage, and often involve a variety of clinical and non-
clinical resources. Non-clinical resources such as the police and in particular security staff may have little
understanding of the medical implications of these incidents, or of the serious risk to life that may threaten
these patients.
Regardless of the circumstances, a person with altered mental state must be considered to be a ‘patient’
with medical needs, rather than a ‘prisoner’. They are unwell, and need urgent hospital assessment. The
clinician is responsible for patient care, and not the police. A custody suite is not a place of safety for an
unwell person.
In all cases consideration needs to be given to whether or not the patient has capacity. It must be believed
that based on the information available to the clinician at the time, sedation is both in the patient’s best
interests and the least restrictive option. Consideration must also be given as to whether a patient is
already subject to a Deprivation of Liberty order, and where possible, seek documentary evidence of this.
The act of sedation in the emergency situation, as a therapeutic intervention and in the least restrictive,
best interests of the patient, is not in itself a Deprivation of Liberty. Sedation in this context will constitute
restraint as a minimum, and may constitute a restriction of liberty. As such, the minimum amount of
restraint should be applied for the shortest period of time and must be justified, and the rationale fully
documented.
This ACOP does not cover sedation to facilitate placement of an advanced airway. Sedation to maintain and
airway that is already in place is covered in the ACOP for ROSC.
LICENSING & RESTRICTIONS
Only paramedics who have been appropriately trained and who are authorised by the Medical
Director may work to these guidelines.
Autonomous use of a medicine not listed in the in the UK Ambulance Service Clinical Practice
Guidelines is restricted to paramedics who are authorised under an appropriate Patient Group
Direction.
ASSESSMENT
It is important to rapidly establish the most likely cause of altered behaviour and to exclude treatable or
reversible causes as quickly as possible.
Agitation, irritability, restlessness and combativeness are terms that are sometimes used interchangeably,
although it is possible to distinguish between them, and to start to consider possible causes based on how
the patient is behaving, and based on the history, mechanism or triggers leading to the incident. Obtaining
this information often requires interviewing multiple witnesses.
Possible Causes can include (but are not limited to):
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Hypoxia
Hypovolaemia
Sepsis
Hypoglycaemia and other metabolic abnormalities
Head injury, and neurological emergencies (post-ictal state, sub-arachnoid haemorrhage,
expanding mass, meningitis and other infections etc.)
Pain – especially in the context of patients who are unable to communicate
Full bladder
Mental illness
Learning difficulties
Fear
Dementia
Drugs and / or alcohol use
Note that it is important to exclude other causes before assuming that alcohol or drugs are the reason
behind altered behaviour, even though these are the most common causes.
In the context of severe injury (without significant head injury), restlessness is an ominous sign. Ensure that
all possible causes of bleeding have been addressed (wounds managed, pelvis and long bones splinted,
femurs in traction etc.), and minimise time on scene. In the profoundly shocked patient, cautious
administration of small boluses of fluid may be more effective.
RISKS OF SEDATION
Sedation of a patient about whom little may be known is not without considerable risk.
Inexperienced Crews, who may have been faced with a challenging patient for some time, may not fully
appreciate the risks involved, or the need to titrate medicines to effect. Managing their expectations can
add a further level of complexity
Risks include
1. Failure, or delay in achieving the desired level of sedation
2. Airway loss
3. Respiratory depression
4. Reduced cardiac output
5. Injury (to patient or crew)
6. Positional asphyxia
7. Cardiac arrest
8. Further disinhibition of the patient
STRATEGY
Assess the situation and the patient, taking control if needed; identify and where possible address
the underlying cause.
Consider consent implications – whilst the patient will almost certainly not be able to demonstrate
capacity, it is often useful to verbalise this with the crew, and if appropriate, log the decision with
EOC. If using powers under the Mental Capacity Act (2005), ensure that the assessment is
documented and sedation is the least restrictive option.
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Discuss options for management with the crew, police and other services. It may be appropriate to
involve close family members in the discussion so that they understand the risks and benefits, and
the need to gain control.
“Doing nothing” is an option. If left alone, patients often settle into a position of comfort, and can
be moved in this position, even if a traumatic mechanism of injury suggests that spinal
immobilisation might be indicated.
If physical restraint is required by police officers, the patient must be placed in a lateral position, to
reduce the risk of positional asphyxia.
Where appropriate, wrapping a patient in a blanket may be sufficient restraint.
Regardless of the method of restraint, the patient must be closely monitored throughout the
procedure, and the APP must remain in control of patient care.
Plan an extrication strategy (including any contingency plan) PRIOR to sedation. The plan must be
understood by everyone on scene (including police if applicable). Equipment must be prepared to
move the patient before sedation.
Consider where the patient is. It may be possible to move, or persuade the patient to move to a
place or room that affords better access.
Use the minimum amount of sedation and restraint needed to achieve the desired effect
The APP MUST travel with the patient.
PREPARATION
Assign roles to the team. This includes airway monitoring and management, IV access and
monitoring of cardio-respiratory status. There should ideally be at least one other paramedic on
scene.
Prepare airway management and resuscitation equipment. Note that unlike rapid sequence
induction (RSI), it may not be possible to set up a formal ‘kit-dump’ as the scene may move with the
patient.
The following equipment must be immediately available:
Bag-Valve-Mask-Reservoir (BVMR), including the appropriate sized mask
Suction (tested and functional) with a range of rigid and flexible catheters
Essential and advanced airway management equipment
Oxygen and a spare oxygen cylinder
The patient must be fully monitored, including EtCO2, as soon as possible. It is accepted that this
may not be possible to achieve prior to sedation.
All drugs should be checked by two clinicians.
When cross checking ask the question “what is this?” which prompts the checker to stop and read the vial
or ampoule, rather than tell the checker what the drug is, which may illicit a positive or confirmatory
response without a proper check.
Drugs must only be drawn up in the stipulated concentrations and syringe sizes. This greatly reduces the
risk of error. Drug preparation must only be done by the APP.
All syringes must be labelled with an approved colour-coded label, with the concentration clearly marked.
Ensure that there is no restriction (handcuffs etc.) to blood flow from the cannula site
“TALK THROUGH” & CHECKLIST
1. Make sure that the crew have agreed on the indication and risk assessment
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2. One clinician must have the sole responsibility of monitoring and maintaining the patient’s airway.
3. Make sure that this plan is communicated to all present, and that specific tasks have been allocated
and understood. This brief should include alternative / ‘Plan B’ options.
Preferred Drug Route
The ideal drug route is dependent upon the clinical condition being treated and a number of patient factors
including size, pre- and co-morbid conditions and the likelihood and safety of obtaining IV access on the
first attempt.
Although the IV route may allow medication to be titrated to effect more closely, and absorbtion through
the IM route is slower, the IM route has the advantage of more gradual absorption and therefore more
gradual sedation with less fluctuation in response. Allow at least 15 minutes before repeating an IM dose.
Haloperidol should be administered by the IM route only.
Midazolam can be given via either route.
Both routes may require a degree of physical restraint. If this is the case it should be measured, justifiable,
and carried out in the least restrictive manner, by people trained to provide restraint. If restraint is used it
is imperative that the patient is closely observed and their airway and ventilation are unimpeded.
IV access should be obtained as soon as it is safe to do so. This should ideally be away from a joint and
firmly secured in place. Using a t-piece or extension and covering the cannula site with a bandage may aid
security.
IO access should not be used in the conscious, semi-conscious or agitated patient
Examples
28 year old male behaving bizarrely following a night out with friends. He is agitated and angry, shouting at random people and objects, and has removed most of his clothes. IV
access is likely to prove impossible due to his size and apparent strength.
1. Ascertain that there is no history of trauma, head injury or pre-existing neurological condition
2. Determine that the patient lacks capacity and that you are acting in his best interests
3. Cautiously restrain the patient and administer (by separate injections):
5mg Haloperidol IM
2mg Midazolam IM
4. Allow 10-15 minutes for the drugs to take effect, during which time the patient should be
monitored from a distance to ensure his safety.
5. If there is no sustained response, the same dose of both drugs can be repeated IM.
6. Once IV access can be obtained IV Midazolam alone should be used to maintain sedation
7. As soon as the patent becomes compliant commence transport to the nearest ED
Maximum total dose without advice from the on-call clinician:
Haloperidol 10mg
Midazolam 10mg
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75 year old lady with an acute confusional state secondary to sepsis from a presumed urinary tract infection
She is confused and irritable, pushing you away every time you try and move her from her chair to a carry
chair. She has a temperature of 39OC is tachycardic and clearly lacks capacity.
1. This represents a significant risk, in that little is known about her background and she is clearly
physiologically compromised. Sedation in this group of patients should be discussed with the on-
call clinician.
2. Consider simple measures – oral paracetamol and fluids, less aggressive persuasion and
involvement of family members to create a calm environment. Minimise the number of people
talking to the patient.
3. Very gentle restraint to allow IV access may be appropriate
4. Administer IV fluid boluses
5. Administer 0.5 – 1mg boluses repeated every 2-5 minutes to a maximum of 5mg
6. If IV access is not easily obtained or appropriate a small dose (1-2mg) of IM midazolam would be
appropriate, followed by IV access at the earliest opportunity.
19 year old boy with significant learning difficulties, a fear of hospitals and a possible abdominal obstruction
He settles nicely with his family and carers, but has resisted any attempts by the crew to obtain
observations or move him to the ambulance.
1. Adopt a slow and friendly approach to the patient and avoid any unnecessary monitoring or
interventions.
2. Consider whether oral analgesia may be of benefit – paracetamol or oramorph
3. Involve the family and carers in moving him out of the house, and consider whether a more familiar
means of transport may be more appropriate than an ambulance.
4. Only if these methods fail should consideration be given to the use of sedatives.
5. If at all possible, IV access should be obtained. Titrate midazolam IV slowly to a level that the
patient cooperates but is not overly sedated.
6. Ensure that the ED is aware of his impending arrival so that arrangements can be made for a
suitable area and prompt senior assessment.
45 year old female with a closed head injury following a fall down stairs in a pub.
She has a fluctuant level of consciousness, intermittently becoming very agitated. There is blood in one of
her ears.
1. Assume that her behaviour is related to a significant brain injury and not alcohol or drugs
2. Request assistance (if available) from an Enhanced Care Team / London’s Air Ambulance
3. Monitor the patient fully and establish IV access
4. Administer 1-2mg boluses of Midazolam IV and 1-2mg boluses of morphine taking care to monitor
her airway and respiration closely.
5. Package and extricate her as soon as possible, and convey to the nearest Major Trauma Centre with
an appropriate priority call.
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MEDICATIONS Midazolam
Presentation
Ampoules containing either 1mg/ml midazolam (for IV use) or 5mg /ml (for IM
use). This is a potential source of drug error; be sure to check the concentration
that you have on hand.
Mode of action
Midazolam causes hypnosis, sedation and anxiolysis. It is also an anticonvulsant.
It is water soluble
Indications
Management of agitation
Contraindications
Known severe allergic reaction
Cautions
It leads to a fall in SVR of 15-33% drop in cardiac output and BP. Hypotension
is more noticeable in a shocked patient.
It can cause loss of airway reflexes (if not intubated) and respiratory depression.
t has very unpredictable dose requirements and incidence of side effects
Preparation
Midazolam should be prepared for IV use as a 1mg/ml solution
For IM use, the 5mg/ml solution should be used, un-diluted
Syringes must be labelled with an appropriate colour-coded label
Dose (adult)
1 – 2.5 mg boluses IV followed by a 10-20ml flush. Further doses can be given at
intervals not less than 2 minutes apart to a maximum of 10mg. Response to
midazolam cannot always be predicted by age, size or level of agitation. Use
smaller doses and longer intervals if there is any possibility of cardiovascular
instability.
If IV access cannot be achieved (or is not expected to be successful),
consideration should be given to administering boluses of 1 – 2.5mg IM (use the
5mg/ml concentration) with a five minute interval between doses
Dose (children)
Up to 0.1 mg / kg, titrated to effect, IV after discussion with an on-call clinician.
Notes
Intraosseous Access
This should be avoided in the acutely agitated (acute behavioural disturbance)
patient
•
Injection of drugs into the IO space is painful and may worsen agitation
•
Potential for injury if the patient tries to remove the needle themselves,
or if the needle is inadvertently caught on furniture etc.
Haloperidol
Presentation
1 ml ampoules containing 5mg of a clear colourless solution
Mode of action
Halopridol is a neuroleptic – it induces a state of diminshed motor activity
anxiolysis an indifference to the external environment
Indications
Acute Behavioural Disturbance including drug-related behavioural disturbance in
adults aged 18 and over
Contraindications
Children aged under 18
Suspected head injury, sub-arachnid bleed or any other intracranial
pathology
Known prolonged QT syndrome
Cautions
Metabolic disturbances: Hypokalaemia, hypocalcaemia or hypomagnesaemia
Thyrotoxicosis
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Dose (adult)
2.5 mg by IV injection or
5mg by IM injection
Repeat Dose after at least 10 minutes
2.5 mg by IV injection or
5mg by IM injection
Maximum total dose regardless of route is 15mg
Dose (children)
Not Indicated
Notes
Can cause extrapyramidal side effects including tremor and dystonia
HANDOVER
1. The patient must be conveyed to an appropriate Emergency Department
2. The Practitioner must accompany the patient,
3. The practitioner should lead the handover, which should be to a senior clinician and must include a
clear description of the patient’s condition prior to sedation, the reason for sedation, the course
(including maximal depth of sedation and any complications), and the total doses of medicines
administered.
4. This information must also be captured on the Patient Report Form
NOTES
The end point of sedation is compliance – getting the patient into a state where they can safely be
extricated and moved to the ambulance. Do not aim to make the patient comatose.
In severely agitated patients it is easy to assume that large doses of midazolam will be needed. This is often
not the case; relatively small doses may achieve compliance. In the absence of significant injury it is
perfectly acceptable to administer enough midazolam to get the patient into a state where they are able to
walk to the ambulance with assistance.
Flumazenil (which can be used to reverse the effects of iatrogenic pure benzodiazepine overdose) is
contraindicated in this group of patients, as it is very possible that the patient may have taken unknown
amounts of either illicit or prescribed medication.
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