Chemical Restraint and Acute Behavioural Disturbance

Quick Answer

One-liner: Chemical restraint is the use of sedative medications to control acute behavioural disturbance when de-escalation has failed and the patient poses an immediate risk to themselves or others.

Acute behavioural disturbance (ABD) affects 5-10% of ED presentations and represents a medical emergency requiring rapid assessment to exclude organic causes (hypoglycaemia, hypoxia, intoxication, head injury). De-escalation is always first-line. When this fails and safety is at risk, chemical restraint with droperidol 10 mg IM (first-line in Australia) or midazolam 5-10 mg IM provides rapid sedation within 10-30 minutes. Continuous monitoring for respiratory depression, QTc prolongation, and positional asphyxia is mandatory. Indigenous patients experience disproportionate rates of restraint, requiring trauma-informed, culturally safe approaches.

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ACEM Exam Focus

Primary Exam Relevance

• Pharmacology:
  • Droperidol (butyrophenone, D2 antagonist, α-blockade, QTc prolongation)
  • Midazolam (GABA-A agonist, respiratory depression, paradoxical agitation)
  • Haloperidol (typical antipsychotic, EPS, QTc prolongation)
  • Olanzapine (atypical antipsychotic, contraindicated with concurrent IM benzodiazepines)
• Physiology:
  • GABA-A receptor pharmacology
  • Dopamine D2 receptor antagonism
  • Respiratory drive and CO2 response curves
  • QTc interval and Torsades de Pointes risk

Fellowship Exam Relevance

• Written:
  • Differential diagnosis of acute agitation (organic vs psychiatric)
  • Medication choice, dosing, contraindications
  • Legal frameworks (Mental Health Acts, duty of care)
  • Post-restraint monitoring and documentation
  • Complications (NMS, acute dystonia, respiratory depression)
• OSCE:
  • Communication with agitated patient (de-escalation)
  • Leading resuscitation team during "Code White"
  • Breaking bad news post-restraint (family debrief)
  • Discussing restraint with psychiatry team
• Key domains tested: Medical Expert, Professional (ethics, legal), Communicator (de-escalation, family), Collaborator (security, mental health team)

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Key Points

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Epidemiology

Australian/NZ Specific

• Methamphetamine ("ice") epidemic: 25-40% of acute behavioural disturbance presentations in Australian metropolitan EDs involve stimulant intoxication, requiring higher sedation doses and prolonged monitoring [8,9].
• Indigenous health disparities: Aboriginal, Torres Strait Islander, and Māori peoples experience significantly higher rates of restraint due to systemic barriers (lack of early intervention, cultural trauma, police involvement). Restraint re-traumatizes communities affected by Stolen Generations and colonization [10,11].
• Rural/remote challenges: Limited mental health crisis teams, reliance on police and general practitioners, long retrieval times via RFDS, and language barriers (English as third/fourth language in remote communities) increase restraint use [12].
• Legal frameworks: Mental Health Acts differ across Australian states (NSW 2007, VIC 2022, QLD 2016, WA 2014)—all require restraint to be "last resort," proportionate, and regularly reviewed under National Safety and Quality Health Service (NSQHS) Standards [13].

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Pathophysiology

Mechanism of Acute Behavioural Disturbance

Acute agitation results from imbalance in neurotransmitter systems:

1. Dopaminergic hyperactivity: Schizophrenia, psychostimulants (amphetamines, cocaine), dopamine agonists (levodopa)
2. GABAergic hypofunction: Alcohol withdrawal, benzodiazepine withdrawal, anxiety disorders
3. Cholinergic deficit/excess: Anticholinergic toxicity (delirium, confusion), cholinergic crisis (organophosphates)
4. Serotonergic excess: Serotonin syndrome (SSRIs + MAOIs)

Pharmacological Targets

Why It Matters Clinically

• Droperidol: Rapid sedation with preserved respiratory drive—ideal for undifferentiated agitation when respiratory depression risk is high (alcohol, opioids).
• Midazolam: Fast onset but significant respiratory depression—requires airway equipment immediately available. Risk of paradoxical agitation in below 1-2% (treat with flumazenil 0.2 mg IV).
• Haloperidol: Slower onset, higher EPS risk (10-25%)—reserved for psychotic agitation when antipsychotic effect is desired.
• Olanzapine: Cannot combine with IM benzodiazepines due to additive CNS/respiratory depression—use only when benzodiazepines are NOT planned.

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Clinical Approach

Recognition

Key triggers for chemical restraint consideration:

• Verbal/physical aggression toward staff, patients, or self
• Failure of verbal de-escalation after 10-15 minutes
• Immediate threat to safety (weapon, self-harm attempt)
• Medical assessment required but patient non-cooperative (e.g., head injury, overdose)

Initial Assessment

Primary Survey (ABCDE in Agitated Patient)

• A (Airway): Patent? Can patient speak? Risk of aspiration (vomiting, decreased GCS)?
• B (Breathing): Respiratory rate, SpO2, work of breathing—stimulants cause tachypnoea, CNS depressants cause bradypnoea
• C (Circulation): Heart rate, BP, capillary refill—tachycardia (sympathomimetics, alcohol withdrawal), hypotension (sepsis, intoxication)
• D (Disability): GCS, pupils (dilated = sympathomimetics/anticholinergics, pinpoint = opioids), blood sugar (ALWAYS check)
• E (Exposure): Temperature (hyperthermia = serotonin syndrome, NMS, stimulants; hypothermia = sepsis, alcohol), trauma (bruising, lacerations)

Organic vs Psychiatric: Key Differentiators

History

Key Questions (if patient cooperative or from collateral sources)

Red Flag Symptoms

Examination

General Inspection

• Appearance: Disheveled, poor hygiene (chronic psychiatric illness), sweating (sympathomimetic toxicity, alcohol withdrawal), trauma (bruises, lacerations)
• Behaviour: Pacing, responding to internal stimuli (hallucinations), eye contact (paranoid patients avoid eye contact)
• Speech: Pressured (mania, stimulants), slurred (intoxication), incoherent (psychosis, delirium)

Specific Findings

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Investigations

Immediate (Resus Bay)

Standard ED Workup (Post-Restraint if Initial Organic Screen Negative)

Advanced/Specialist

Point-of-Care Ultrasound (POCUS)

• Cardiac POCUS: Severe sepsis (hyperdynamic vs cardiogenic shock), tamponade (trauma)
• Lung POCUS: Pneumonia (consolidation), pulmonary oedema (B-lines)
• Renal POCUS: Hydronephrosis (urinary retention in anticholinergic toxicity)

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Management

Step 1: Verbal De-Escalation (ALWAYS FIRST-LINE)

Environmental modifications:

• Move to quiet room (low stimulation, remove potential weapons)
• Reduce noise, dim lights
• Show of concern, not show of force: Adequate staff for safety, but avoid crowding/intimidating patient
• Offer food, water, blanket—address basic needs

Success rate: Verbal de-escalation reduces need for restraint by 50-60% [14,15].

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Step 2: Chemical Restraint (When De-Escalation Fails)

Indications for Chemical Restraint

1. Imminent risk of harm to self, others, or staff
2. Failure of verbal de-escalation (10-15 minutes attempted)
3. Medical assessment required but patient unable to cooperate (e.g., head injury assessment, overdose management)
4. Prevent exhaustion/injury (patient or staff)

Contraindications (Relative)

• Respiratory compromise (SpO2 below 90%, respiratory rate below 10)—intubate first, then sedate
• Haemodynamic instability (SBP below 90 mmHg)—resuscitate first
• Known prolonged QTc (greater than 500 ms)—avoid droperidol/haloperidol, use benzodiazepines
• Allergy to proposed agent

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Medication Options

First-Line: Droperidol 10 mg IM (Australia/RCEM Guidelines)

Evidence: DORM I and DORM II trials (1,009 patients) showed:

• Superior efficacy vs midazolam: Less repeat sedation required (27% vs 40%), shorter sedation time
• Respiratory safety: Significantly less respiratory depression than benzodiazepines (2% vs 12%)
• QTc safety: No cases of Torsades de Pointes at 10 mg dose; 13/1,009 had QTc prolongation (all had confounders) [16,17]
• Onset: 10-20 minutes

Dosing:

• Adult: 10 mg IM (or 5 mg IV if IV access available)
• Elderly (greater than 65 years): 5 mg IM
• Repeat dose: 5 mg IM at 20-30 minutes if inadequate sedation

Advantages:

• Minimal respiratory depression
• Faster onset than haloperidol
• Lower EPS risk than haloperidol
• Can combine with midazolam if severe agitation (droperidol 5-10 mg + midazolam 5 mg IM)

Disadvantages:

• QTc prolongation (dose-dependent, rarely clinically significant at ED doses)
• Hypotension (α1-blockade, usually mild)
• EPS (5-10% incidence—akathisia, dystonia)

Monitoring:

• Vital signs every 15 minutes for 2 hours
• ECG if pre-existing cardiac disease or QTc risk factors
• Sedation score (RASS: target -1 to -2)

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Alternative 1: Midazolam 5-10 mg IM

Indications:

• Droperidol unavailable
• Alcohol withdrawal (GABA agonist is mechanism-specific)
• Benzodiazepine withdrawal
• QTc prolongation greater than 500 ms (cannot use antipsychotics)

Dosing:

• Adult: 5-10 mg IM (or 2-5 mg IV slow push)
• Elderly (greater than 65 years): 2.5-5 mg IM
• Repeat dose: 5 mg IM at 15-20 minutes if inadequate sedation

Advantages:

• Fastest onset (5-15 minutes)
• Anterograde amnesia (patient unlikely to recall restraint—may reduce trauma)
• No QTc prolongation
• Reversible with flumazenil

Disadvantages:

• Respiratory depression (12-20% risk)—requires airway equipment, SpO2 monitoring
• Paradoxical agitation (1-2% incidence, especially children/elderly)—treat with flumazenil 0.2 mg IV
• Shorter duration (1-2 hours)—may require repeat doses

Monitoring:

• Continuous SpO2 for 1 hour
• Airway equipment at bedside (bag-valve-mask, suction, intubation kit)
• Sedation score (RASS)

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Alternative 2: Haloperidol 5 mg IM + Promethazine 25-50 mg IM

Evidence: TREC trials showed haloperidol + promethazine superior to haloperidol alone:

• Faster sedation (30 minutes vs 60 minutes)
• Lower EPS rate (promethazine's anticholinergic effect prevents dystonia)
• Better tolerability [18,19]

Dosing:

• Haloperidol: 5 mg IM
• Promethazine: 25-50 mg IM (or benztropine 1-2 mg IM, or diphenhydramine 50 mg IM)
• Repeat: Haloperidol 2.5-5 mg IM at 30-60 minutes if inadequate

Advantages:

• Longer duration (4-8 hours)—fewer repeat doses
• Antipsychotic effect (beneficial if psychosis is primary driver)
• Minimal respiratory depression

Disadvantages:

• Slower onset (30-60 minutes)
• EPS (10-25% risk even with anticholinergic)—acute dystonia (laryngospasm risk), akathisia
• QTc prolongation (higher risk than droperidol)
• Hypotension (α1-blockade)

Monitoring:

• Vital signs every 15 minutes
• ECG if cardiac risk factors
• Watch for dystonic reactions (treat with benztropine 1-2 mg IV/IM)

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Alternative 3: Olanzapine 10 mg IM

Indications:

• Psychotic agitation (schizophrenia, bipolar mania)
• Droperidol/haloperidol unavailable
• Preference for atypical antipsychotic (lower EPS risk)

Dosing:

• Adult: 5-10 mg IM
• Elderly (greater than 65 years): 2.5-5 mg IM
• Maximum: 30 mg/24 hours

Advantages:

• Lower EPS risk than haloperidol (5% vs 10-25%)
• Longer duration (6-12 hours)
• Less QTc prolongation than haloperidol

Disadvantages:

• Cannot combine with benzodiazepines (see black box warning)
• Slower onset than droperidol (15-30 minutes)
• Hypotension, somnolence

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Rescue/Severe Agitation: Combination Therapy

Droperidol 5-10 mg IM + Midazolam 5 mg IM:

• For severe, uncontrolled agitation (e.g., methamphetamine toxicity)
• Synergistic sedation (different mechanisms: D2 antagonist + GABA agonist)
• Risk: Additive respiratory depression—requires continuous SpO2, airway equipment

"B52" Cocktail (less common in Australia, more common in USA):

• B: Benztropine 1-2 mg IM (or diphenhydramine 50 mg IM)
• 5: Haloperidol 5 mg IM
• 2: Lorazepam 2 mg IM (or midazolam 5 mg IM)
• Provides rapid sedation with EPS prophylaxis

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Paediatric Dosing (Chemical Restraint Rarely Used—Prioritise De-Escalation)

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Step 3: Post-Restraint Monitoring

Monitoring Protocol (First 2 Hours)

Sedation Scales

Richmond Agitation-Sedation Scale (RASS):

• +4: Combative, violent
• +3: Very agitated, pulls tubes
• +2: Agitated, frequent non-purposeful movement
• +1: Restless, anxious
• 0: Alert and calm ✓ (GOAL after initial sedation)
• -1: Drowsy, arousable (greater than 10 sec eye opening to voice) ✓ (ACCEPTABLE)
• -2: Light sedation (eye opening below 10 sec to voice) ✓ (ACCEPTABLE)
• -3: Moderate sedation (movement to voice, no eye opening)
• -4: Deep sedation (movement to physical stimulation only)
• -5: Unarousable (no response to stimulation) ⚠️ OVER-SEDATED

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Step 4: Documentation (Legal Requirement)

Every restraint episode must be documented under state Mental Health Acts and NSQHS Standards:

1. Time and date of restraint
2. Indication: Specific behaviour prompting restraint (e.g., "Patient punched nurse, attempted to leave ED despite altered mental state")
3. De-escalation attempts: Verbal techniques used, duration (e.g., "Verbal de-escalation attempted for 15 minutes, patient escalated to throwing chairs")
4. Type of restraint: Chemical (drug, dose, route, time) and/or physical (limb restraints, duration)
5. Monitoring: Vital signs, sedation score, adverse events
6. Review: Senior doctor review within 1 hour, ongoing review every 4 hours
7. Cessation: Time restraint ceased, patient condition at cessation
8. Debrief: Patient and family informed, concerns addressed

Failure to document = medico-legal risk (assault, battery, false imprisonment claims) [24].

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Complications of Chemical Restraint

Immediate (Minutes to Hours)

Delayed (Hours to Days)

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Special Populations

Stimulant Toxicity (Amphetamines, Cocaine, Synthetic Cathinones)

Clinical features: Severe agitation, hyperthermia (greater than 40°C), tachycardia (HR greater than 140), hypertension, diaphoresis, mydriasis

Chemical restraint:

• First-line: Benzodiazepines (midazolam 5-10 mg IM) + cooling—avoid antipsychotics if possible (lower seizure threshold, worsen hyperthermia)
• Refractory agitation: Droperidol 10 mg IM + midazolam 5 mg IM (combination therapy)
• Severe hyperthermia (greater than 40°C): Intubation, paralysis (rocuronium), active cooling (ice packs, evaporative cooling), dantrolene 1-2.5 mg/kg IV if refractory [27,28]

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Alcohol Withdrawal (Delirium Tremens)

Clinical features: Tremor, tachycardia, hypertension, hallucinations (tactile, visual), seizures

Chemical restraint:

• First-line: Benzodiazepines (diazepam 10-20 mg IV or lorazepam 2-4 mg IV)—titrate to CIWA-Ar score
• Refractory agitation: Phenobarbital 130-260 mg IV, propofol sedation (ICU), intubation if severe
• Avoid antipsychotics: Lower seizure threshold (haloperidol, droperidol) [29]

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Elderly (greater than 65 Years)

Considerations:

• Increased sensitivity to sedatives (reduced hepatic metabolism, lower lean body mass)
• Higher fall risk post-sedation
• Polypharmacy: Drug interactions (QTc prolongation with macrolides, antifungals)

Modified dosing:

• Droperidol 5 mg IM (half standard dose)
• Midazolam 2.5-5 mg IM
• Haloperidol 2.5 mg IM

Delirium workup mandatory: UTI (most common cause in elderly), pneumonia, stroke, medication toxicity (anticholinergics)

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Pregnancy

Considerations:

• Agitation in pregnancy: Eclampsia (hypertension, seizures), psychosis (postpartum psychosis risk), substance use
• Avoid benzodiazepines in 1st trimester (cleft palate risk—though minimal at single dose)
• Antipsychotics: Haloperidol Category C (human data reassuring), droperidol Category C (limited data)

Preferred agents:

• Haloperidol 5 mg IM (most data in pregnancy)
• Midazolam 5 mg IM (if benzodiazepines required—single dose unlikely harmful)
• Consult obstetrics for eclampsia workup (magnesium sulfate if severe pre-eclampsia)

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Indigenous Health: Aboriginal, Torres Strait Islander, and Māori Considerations

Important Note: Restraint as Re-Traumatization:

Aboriginal, Torres Strait Islander, and Māori peoples experience restraint 3-4 times more frequently than non-Indigenous patients in Australian and NZ EDs [30,31]. Historical trauma (Stolen Generations, forced institutionalization, police brutality) means restraint is often perceived as:

• Loss of autonomy and dignity
• Repetition of colonial violence
• "Spirit-breaking" and disconnection from Country/Whakapapa

Culturally Safe Approaches:

1. Involve Aboriginal Health Workers (AHWs) or Māori Health Workers early:

   • AHWs can navigate cultural nuances, family dynamics, language barriers
   • Presence of AHWs reduces restraint use by 40-50% [32]

2. Whānau (family) involvement:

   • Māori: Engage whānau in de-escalation—family presence often calms patient more effectively than clinical staff
   • Aboriginal: Involve family/community elders if patient consents

3. Dadirri (Deep Listening):

   • Aboriginal concept of "inner, deep listening and quiet, still awareness"—patience, silence, allowing patient to speak without interruption
   • Reduces need for rapid intervention [33]

4. Language and communication:

   • English may be 3rd or 4th language in remote communities—use interpreters (Aboriginal Interpreter Service, Māori Language Commission)
   • "Non-compliance" is often communication breakdown, not refusal

5. Avoid police involvement unless absolutely necessary:

   • Police presence re-traumatizes many Indigenous patients
   • Use mental health crisis teams, peer support workers, AHWs instead

6. Post-restraint debrief:

   • Mandatory for Indigenous patients—explain actions, apologize for distress, involve family
   • Offer cultural liaison services, Aboriginal Hospital Liaison Officers (AHLOs)

7. Address systemic barriers:

   • Early intervention: Lack of community mental health services in remote areas leads to crisis presentations
   • Substance use: Higher rates of alcohol/cannabis use (coping with intergenerational trauma)—screen for social determinants (housing, family violence, unemployment)

Resources:

• Gayaa Dhuwi (Proud Spirit) Australia: National Aboriginal and Torres Strait Islander leadership in mental health
• Te Pou (NZ): Māori mental health workforce development, seclusion/restraint reduction initiatives

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Remote/Rural Considerations

Challenges

1. Limited mental health resources: No 24/7 crisis teams—reliance on general practitioners, rural generalist doctors, police
2. Long retrieval times: RFDS transfers can take 4-12 hours—patient may require prolonged restraint during flight (high-risk for positional asphyxia, aspiration)
3. Language barriers: Remote Aboriginal communities—interpreter access limited
4. Equipment limitations: Some rural EDs lack advanced airway equipment, ICU—intubation risk if over-sedation occurs

Modified Approach

De-escalation prioritized:

• More time spent on verbal de-escalation (retrieval delays mean patient will be in ED longer)
• Environmental modifications (quiet room, family presence)

Medication choices:

• Droperidol 10 mg IM preferred: Less respiratory depression than midazolam (safer if airway equipment limited)
• Avoid combination therapy unless absolutely necessary (higher respiratory depression risk)

Retrieval considerations:

• Contact RFDS early if psychiatric admission likely (retrieval to tertiary centre)
• Minimal sedation for transfer: Risk of positional asphyxia during flight—target RASS 0 to -1 (calm, arousable), NOT deep sedation
• Lateral positioning during flight (never prone)
• Continuous SpO2 monitoring during retrieval

Telemedicine:

• Virtual psychiatric consultation (Emergency Telehealth Service in NSW, Victorian Virtual Emergency Department)
• Psychiatrist can guide medication choices, disposition, de-escalation strategies remotely

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Pitfalls & Pearls

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Viva Practice

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OSCE Scenarios

Station 1: De-escalation and Chemical Restraint Decision

Format: Communication and Clinical Management Time: 11 minutes Setting: ED resuscitation bay

Candidate Instructions:

You are the ED registrar on a Saturday night. A 32-year-old male has been brought to the ED by police after a disturbance at a pub. He is pacing in the resus bay, shouting that "they are trying to poison him," and has pushed a nurse when she attempted to take vital signs. Security is present. Your task is to assess the patient and manage the situation, including de-escalation and, if necessary, chemical restraint. The examiner will play the role of the patient.

Examiner Instructions: You are playing a 32-year-old male with paranoid delusions (undiagnosed schizophrenia). You are terrified—you believe the hospital staff are trying to harm you. You will initially be agitated, pacing, making poor eye contact, and responding to internal stimuli (hearing voices telling you to leave).

Progression:

• If the candidate approaches you aggressively, crowds you, or is dismissive, escalate your agitation (raise voice, threaten to leave).
• If the candidate maintains distance, speaks calmly, introduces themselves, and asks what would help you feel safe, gradually de-escalate (sit down, make brief eye contact, answer questions).
• If de-escalation is effective (candidate offers choices, validates your fear), you become cooperative enough for basic assessment (BSL, vital signs).
• If de-escalation fails (candidate is impatient, threatens restraint early), you remain agitated and refuse assessment.

Actor/Patient Brief:

• You are scared, not violent—you only pushed the nurse because she grabbed your arm without explaining what she was doing.
• You will respond positively to: Calm tone, introduction, explanation ("I'm Dr X, I'm here to help you feel safe"), choices ("Would you like to sit or stand?"), validation ("I can see you're frightened").
• You will respond negatively to: Raised voices, crowding, threats ("We'll have to sedate you"), dismissing your fears ("There's nothing to worry about").

Marking Criteria:

Expected Standard:

• Pass (≥6/11): Maintains safe distance, attempts verbal de-escalation with some Project BETA principles, assesses for organic causes, makes reasonable restraint decision.
• Fail (below 6/11): Crowds patient, uses threatening language, skips de-escalation, immediate restraint without attempting communication.
• Key discriminators:
  • Maintains personal space (candidates who crowd patient fail safety domain)
  • Genuine attempt at de-escalation (candidates who go straight to "I'm going to sedate you" fail communication domain)
  • Assesses for organic causes (BSL, drugs/alcohol history)—candidates who assume "just psychiatric" fail assessment domain

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Station 2: Post-Restraint Monitoring and Complication Management

Format: Acute Management Time: 11 minutes Setting: ED resuscitation bay with simulated patient

Candidate Instructions:

You are the ED registrar. A 28-year-old male with acute agitation was given droperidol 10 mg IM 15 minutes ago. The nurse calls you because the patient's oxygen saturation has dropped to 88% and his respiratory rate is 8 breaths per minute. Assess and manage the patient.

Examiner Instructions: The simulated patient (mannequin) has the following parameters:

• Vitals: BP 110/70, HR 95, RR 8, SpO2 88% on room air, Temp 36.8°C
• GCS: Eyes 2 (opens to pain), Verbal 2 (incomprehensible sounds), Motor 4 (withdraws to pain) = GCS 8
• Pupils: Equal, 3 mm, sluggish reaction to light
• Airway: Partially obstructed (gurgling, drooling)
• Breathing: Shallow, irregular

Progression:

• If candidate opens airway (head tilt-chin lift, jaw thrust), SpO2 improves to 92%.
• If candidate applies supplemental O2 (Hudson mask 10 L/min), SpO2 improves to 94-95%.
• If candidate provides bag-valve-mask ventilation, SpO2 improves to 98-100%.
• If candidate gives flumazenil (benzodiazepine reversal agent), no improvement (droperidol is NOT reversed by flumazenil—this is a mistake).
• If candidate calls for intubation, ICU team arrives and intubates.

Expected actions:

1. ABCDE assessment (Airway: gurgling, partially obstructed; Breathing: RR 8, SpO2 88%; Circulation: stable; Disability: GCS 8; Exposure: no trauma)
2. Airway maneuvers: Head tilt-chin lift, jaw thrust, suction (clear secretions)
3. Supplemental oxygen: Hudson mask 10-15 L/min or non-rebreather mask
4. Airway adjuncts: Oropharyngeal airway (OPA) or nasopharyngeal airway (NPA)
5. Bag-valve-mask ventilation: If RR remains below 10 or SpO2 below 90% despite oxygen
6. Call for help: ICU/anaesthetics for intubation if no improvement
7. Recognise complication: Droperidol does NOT usually cause respiratory depression (this is atypical—consider co-ingestion of alcohol, opioids, benzodiazepines, or individual susceptibility)
8. Investigations: Venous blood gas (hypercapnia? pH?), UEC, toxicology screen

Marking Criteria:

Expected Standard:

• Pass (≥6/11): Recognizes respiratory emergency, manages airway (O2, airway adjuncts, BVM), calls for help.
• Fail (below 6/11): Delays airway management, gives incorrect reversal agent, does not call for help.
• Key discriminators:
  • Airway management (candidates who do not open airway, give O2, or use BVM fail)
  • Calls for help early (candidates who try to manage alone without ICU backup fail)
  • Avoids flumazenil (droperidol is a butyrophenone, not a benzodiazepine—flumazenil is incorrect)

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Station 3: Breaking Bad News Post-Restraint (Family Communication)

Format: Communication Time: 11 minutes Setting: ED relatives' room

Candidate Instructions:

You are the ED registrar. A 45-year-old woman was brought to the ED by police for acute agitation. She was given droperidol 10 mg IM and is now resting comfortably in the resus bay. Her husband has arrived and is asking to speak with you. He is upset because he was told his wife was "restrained." Your task is to speak with the husband, explain what happened, address his concerns, and discuss the plan.

Examiner Instructions: You are playing the husband of a 45-year-old woman with bipolar disorder. Your wife stopped taking her lithium 2 weeks ago and became increasingly manic (not sleeping, spending money, agitated). You called the police this morning because she was threatening to drive the car off a bridge. You are now upset and angry because:

1. You feel guilty for calling the police.
2. You are worried that "restraint" means your wife was hurt or mistreated.
3. You are concerned about her safety in the ED (she has a history of being traumatized by previous psychiatric admissions).

Progression:

• If the candidate is defensive, dismissive, or uses jargon ("She was chemically restrained for acute behavioural disturbance"), you become angry and threaten to make a complaint.
• If the candidate is empathetic, explains clearly, apologizes for distress, and involves you in planning, you calm down and engage cooperatively.

Actor Brief:

• You are scared and feeling guilty—you want reassurance that you did the right thing by calling the police.
• You will respond positively to: Empathy ("I can see this is very distressing for you"), clear explanations ("We gave her a medication to help her feel calm so we could assess her safely"), apologies ("I'm sorry this was frightening for you"), involvement ("What do you think would help her feel safe?").
• You will respond negatively to: Defensiveness ("We had no choice but to restrain her"), jargon ("She required chemical sedation for ABD"), dismissing your concerns ("She's fine now, don't worry").

Marking Criteria:

Expected Standard:

• Pass (≥6/11): Empathetic, clear explanation without jargon, apologizes for distress, involves husband in planning.
• Fail (below 6/11): Defensive, uses jargon, dismisses husband's concerns, does not apologize or involve husband.
• Key discriminators:
  • Empathy and apology (candidates who do not acknowledge husband's distress or apologize fail communication domain)
  • Clear explanation without jargon (candidates who say "chemical restraint for ABD" without explaining fail)
  • Involvement of husband in planning (candidates who dictate plan without asking for input fail shared decision-making)

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SAQ Practice

Question 1 (8 marks)

Stem: A 35-year-old man presents to the ED with acute agitation. He is pacing, shouting, and has threatened to punch staff. Vital signs: BP 160/95, HR 125, RR 24, Temp 37.2°C, SpO2 97% on room air. BSL 5.8 mmol/L.

Question: a) List four (4) organic causes of acute agitation that must be excluded in the ED. (4 marks) b) Describe four (4) key principles of verbal de-escalation from the Project BETA framework. (4 marks)

Model Answer:

a) Four organic causes of acute agitation (4 marks):

1. Hypoglycaemia (BSL below 4 mmol/L)—causes confusion, aggression, diaphoresis; treat with 50 mL 50% dextrose IV or 100 mL 10% dextrose (1 mark)
2. Hypoxia (SpO2 below 90%)—causes altered mental state, combativeness; treat with supplemental oxygen, investigate cause (pneumonia, PE, pulmonary oedema) (1 mark)
3. Head injury/intracranial pathology—traumatic brain injury, subdural haematoma, intracranial haemorrhage; check for history of fall/assault, focal neurology, GCS below 15; CT brain if suspected (1 mark)
4. Toxidromes—sympathomimetic (amphetamines, cocaine: tachycardia, hypertension, mydriasis), anticholinergic (antihistamines, TCAs: dry, flushed, urinary retention, fever), alcohol withdrawal (tremor, tachycardia, hallucinations) (1 mark)

Accept: Sepsis/meningitis (fever, neck stiffness), thyrotoxicosis (tachycardia, tremor, heat intolerance), hyponatraemia (below 125 mmol/L, confusion, seizures), hepatic encephalopathy (chronic liver disease, asterixis, elevated ammonia)

Do not accept: "Psychiatric illness" (question asks for organic causes), "drugs" (too vague—must specify toxidrome)

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b) Four key principles of verbal de-escalation (Project BETA) (4 marks):

1. Respect personal space—maintain ≥2 arm-lengths distance, do NOT tower over patient (crouch or sit to eye level), avoid blocking exit (1 mark)
2. Establish verbal contact—one person speaks (avoid multiple staff talking at once), introduce yourself, explain role ("I'm Dr X, I'm here to help you feel safe") (1 mark)
3. Be concise—use short, simple sentences (agitated patients cannot process complex information); avoid medical jargon (1 mark)
4. Offer choices and optimism—provide options ("Would you like to sit here or in the quiet room?"), instill hope ("We can help you feel calmer") (1 mark)

Accept: "Identify wants and feelings" (ask open-ended questions: "What would help you feel safe?"), "Listen closely" (reflective listening: "I hear that you're frustrated about the wait"), "Agree or agree to disagree" (find common ground: "I agree it's loud in here"), "Set clear limits calmly" ("I need you to put down the chair so we can talk safely")

Do not accept: "Use physical restraint" (this is not verbal de-escalation), "Give medication" (this is chemical restraint, not verbal de-escalation)

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Question 2 (8 marks)

Stem: You decide to give chemical restraint to a 28-year-old agitated male. You administer droperidol 10 mg IM.

Question: a) List four (4) advantages of droperidol compared to benzodiazepines (e.g., midazolam) for chemical restraint. (4 marks) b) List four (4) adverse effects of droperidol and their management. (4 marks)

Model Answer:

a) Four advantages of droperidol vs benzodiazepines (4 marks):

1. Less respiratory depression—DORM trials: 2% respiratory depression with droperidol vs 12% with midazolam; preserves respiratory drive (safer when airway equipment limited) (1 mark)
2. Less repeat sedation required—DORM trials: 27% required repeat sedation with droperidol vs 40% with midazolam; longer duration of action (2-4 hours) (1 mark)
3. Faster onset in some patients—10-20 minutes IM (midazolam 5-15 minutes, but droperidol more predictable sedation without overshoot) (1 mark)
4. No paradoxical agitation—midazolam causes paradoxical agitation in 1-2% (especially children, elderly); droperidol does not have this risk (1 mark)

Accept: "Can combine with midazolam for severe agitation" (synergistic effect), "RCEM/Australian guidelines recommend droperidol first-line" (evidence-based), "Lower risk of over-sedation" (less likely to cause RASS -4/-5 unarousable state)

Do not accept: "Droperidol has no side effects" (incorrect—has QTc prolongation, EPS, hypotension), "Droperidol is cheaper" (not consistently true across jurisdictions)

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b) Four adverse effects of droperidol and management (4 marks):

1. QTc prolongation—dose-dependent, risk of Torsades de Pointes (rare at 10 mg dose); monitor ECG if pre-existing cardiac disease, electrolyte abnormalities, or QTc-prolonging drugs; avoid if QTc greater than 500 ms (1 mark)
2. Acute dystonic reaction (5-10% incidence)—torticollis, oculogyric crisis, trismus, laryngospasm; treat with benztropine 1-2 mg IV/IM or diphenhydramine 50 mg IV (resolves in 5-10 minutes) (1 mark)
3. Hypotension—α1-adrenergic blockade causes vasodilation (usually mild, SBP 90-100 mmHg); treat with IV fluids 500 mL bolus, phenylephrine 50-100 mcg IV if refractory (1 mark)
4. Akathisia (5-10% incidence)—inner restlessness, inability to sit still (can be mistaken for worsening agitation); treat with benztropine 1-2 mg PO/IM or propranolol 10-20 mg PO (1 mark)

Accept: "Neuroleptic malignant syndrome (NMS)" (0.01-0.1% incidence: fever greater than 38.5°C, muscle rigidity, altered mental state, autonomic instability; stop droperidol immediately, dantrolene 1-2.5 mg/kg IV, ICU admission), "Over-sedation" (RASS -4/-5: stimulate patient, reduce dose, airway support if needed)

Do not accept: "Respiratory depression" (droperidol has MINIMAL respiratory depression—this is incorrect)

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Question 3 (6 marks)

Stem: A 72-year-old woman with dementia is agitated in the ED. She is trying to climb out of bed and has pulled out her IV cannula. Vital signs: BP 145/85, HR 100, RR 20, Temp 38.0°C, SpO2 94% on room air.

Question: List six (6) steps in the assessment and management of this patient, prioritizing de-escalation and treatment of organic causes.

Model Answer:

1. Verbal de-escalation and environmental modifications—speak calmly, introduce self, explain actions; move to quiet room, dim lights, involve nursing home staff or family (familiar faces), offer comfort (blanket, water) (1 mark)
2. Assess for pain—elderly often cannot articulate pain; look for grimacing, guarding; give paracetamol 1 g PO/IV empirically; check for fractures (hip, vertebral compression), constipation (abdominal discomfort) (1 mark)
3. Check blood glucose (BSL)—exclude hypoglycaemia (BSL below 4 mmol/L); treat with 50 mL 50% dextrose IV or 100 mL 10% dextrose if low (1 mark)
4. Investigate cause of fever (38.0°C)—most common cause of delirium in elderly is infection: urinalysis (UTI most common in elderly women), CXR (pneumonia), blood cultures; start antibiotics if sepsis suspected (e.g., ceftriaxone 1 g IV) (1 mark)
5. Supplemental oxygen—SpO2 94% is borderline; give 2-4 L/min via nasal prongs to target SpO2 greater than 94% (hypoxia worsens delirium) (1 mark)
6. Avoid benzodiazepines; use low-dose antipsychotic only if immediate danger—benzodiazepines worsen delirium and increase falls risk in elderly; if chemical restraint required (patient at risk of injury), use haloperidol 0.5-1 mg PO/IM (elderly are extremely sensitive—half doses) (1 mark)

Accept: "Medication review" (check for anticholinergic burden—antihistamines, TCAs, oxybutynin worsen delirium), "CT brain if focal neurology or fall history" (stroke, subdural haematoma), "Bladder scan" (urinary retention causing discomfort), "Full septic screen" (FBC, UEC, CRP, VBG, blood cultures)

Do not accept: "Give midazolam" (benzodiazepines are contraindicated in elderly delirium—worsen confusion, increase falls), "Physical restraint" (increases agitation, trauma, and injury risk—last resort only)

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Question 4 (6 marks)

Stem: You are managing an agitated patient in a remote ED. You have given droperidol 10 mg IM. The patient is now calm (RASS -1). You are preparing for RFDS retrieval to a tertiary psychiatric service (estimated 6-hour flight).

Question: List six (6) key considerations for monitoring and managing this patient during retrieval.

Model Answer:

1. Minimal sedation for transfer—target RASS 0 to -1 (calm, arousable), NOT deep sedation (RASS -3/-4); deep sedation increases risk of positional asphyxia, aspiration during flight (1 mark)
2. Lateral positioning (recovery position)—NEVER prone during retrieval (positional asphyxia risk); lateral or supine with head elevated 30° is safest (1 mark)
3. Continuous SpO2 monitoring—monitor oxygen saturation throughout flight; supplemental oxygen (2-4 L/min nasal prongs) if SpO2 below 90% (1 mark)
4. Vital signs monitoring—respiratory rate, heart rate, blood pressure every 15-30 minutes during flight; watch for respiratory depression (RR below 10), hypotension (SBP below 90), or over-sedation (RASS -4/-5 unarousable) (1 mark)
5. Airway equipment available—bag-valve-mask, oropharyngeal airway, suction on RFDS aircraft; if respiratory depression occurs, provide airway support (jaw thrust, bag-valve-mask ventilation) (1 mark)
6. Avoid repeat sedation unless absolutely necessary—if patient becomes agitated during flight, first attempt verbal de-escalation, reposition, offer water/food; only give additional droperidol 5 mg IM if immediate danger and de-escalation fails (minimize over-sedation risk) (1 mark)

Accept: "Handover to RFDS team" (clear communication: drug given, dose, time, patient's response, monitoring plan), "Document restraint episode" (time, date, indication, monitoring, vital signs), "Family communication" (inform family of retrieval plan, expected arrival time, psychiatric service contact details), "Legal documentation" (Mental Health Act involuntary detention paperwork if required for psychiatric admission)

Do not accept: "Give benzodiazepines for flight" (increases respiratory depression risk—not recommended unless patient extremely agitated and droperidol ineffective), "Prone positioning" (NEVER—positional asphyxia risk)

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Australian Guidelines

RCEM (Royal College of Emergency Medicine) Toolkit

Acute Behavioural Disturbance in the Emergency Department (2021):

• De-escalation first: Verbal de-escalation is first-line—Project BETA framework recommended (10 domains)
• First-line chemical restraint: Droperidol 10 mg IM (Australia) or haloperidol 5 mg IM + promethazine 50 mg IM (UK TREC trials)
• Exclude organic causes: BSL, SpO2, vital signs mandatory before assuming psychiatric cause
• Monitoring post-restraint: Vital signs every 15 minutes for 2 hours, sedation score (RASS), continuous SpO2 if benzodiazepines used
• Documentation: Time, indication, de-escalation attempts, drug/dose, monitoring, senior review within 1 hour

Therapeutic Guidelines Australia

Psychotropic: Acute Agitation and Aggression (2023):

• Antipsychotics: Droperidol 5-10 mg IM, haloperidol 5 mg IM, olanzapine 5-10 mg IM
• Benzodiazepines: Midazolam 5-10 mg IM, diazepam 5-10 mg IV
• Combination: Droperidol 5-10 mg + midazolam 5 mg IM for severe agitation
• Avoid olanzapine + benzodiazepines: Wait ≥60 minutes between IM olanzapine and IM/IV benzodiazepines (respiratory depression risk)
• Elderly: Half doses (droperidol 5 mg, haloperidol 2.5 mg, midazolam 2.5 mg)
• Pregnancy: Haloperidol 5 mg IM (Category C, most data in pregnancy)

State-Specific Mental Health Legislation

Common requirements across all states:

1. Restraint is last resort (de-escalation first)
2. Proportionate to risk (minimum force, shortest duration)
3. Documented (time, date, indication, drug/dose, monitoring, review)
4. Senior review (within 1-4 hours depending on state)
5. Cessation as soon as safe (patient no longer immediate danger)

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Remote/Rural Considerations

Pre-Hospital

Ambulance/Police Transport:

• In rural areas, police are often first responders (no 24/7 crisis teams)—patient may arrive in handcuffs, already traumatized
• Paramedics carry midazolam 5-10 mg IM (droperidol not always available on ambulances)
• Long transport times (30 minutes to 2 hours from remote communities)—patient may require pre-hospital sedation

Resource-Limited Setting

Modified approach when droperidol unavailable:

• Midazolam 5-10 mg IM (most rural EDs stock midazolam for procedural sedation)
• Haloperidol 5 mg IM (if available)—slower onset but less respiratory depression than midazolam
• Avoid combination therapy (droperidol + midazolam) unless absolutely necessary—higher respiratory depression risk, and rural EDs may lack advanced airway equipment (no ICU, no anaesthetist on site)

Equipment limitations:

• Some rural EDs have no ICU, no mechanical ventilation—if over-sedation causes respiratory failure, patient may require manual bag-valve-mask ventilation for hours until RFDS arrives
• Use lowest effective dose—droperidol 5 mg IM (not 10 mg), midazolam 5 mg IM (not 10 mg)—titrate to effect

Retrieval

RFDS (Royal Flying Doctor Service) Considerations:

• Contact RFDS early if psychiatric admission likely (retrieval to tertiary centre can take 4-12 hours)
• RFDS brings additional medications (droperidol, midazolam, haloperidol, benztropine) and equipment (airway kit, monitoring)
• Sedation during flight:
  • Target RASS 0 to -1 (calm, arousable), NOT deep sedation (RASS -3/-4)
  • Lateral positioning (recovery position) during flight—NEVER prone (positional asphyxia risk)
  • Continuous SpO2 monitoring, vital signs every 15-30 minutes
  • Minimize repeat sedation (increases respiratory depression, aspiration risk)
• Handover to RFDS: Clear documentation—drug given, dose, time, patient's response, ongoing monitoring plan

Telemedicine

Virtual Psychiatric Consultation:

• NSW Emergency Telehealth Service (24/7 psychiatry consult via video link)
• Victorian Virtual Emergency Department (remote specialist advice)
• Queensland Mental Health Line (1300 642 255)
• Psychiatrist can guide:
  • Medication choice (droperidol vs midazolam vs haloperidol)
  • De-escalation strategies
  • Disposition (psychiatric admission vs discharge with community follow-up)
  • Legal framework (Mental Health Act assessment, involuntary detention criteria)

Reduces restraint use by 30-40% in rural EDs (specialist advice prevents unnecessary sedation, improves de-escalation) [35].

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References

Guidelines

1. Royal College of Emergency Medicine (RCEM). Acute Behavioural Disturbance in the Emergency Department: Toolkit. 2021. Available from: https://rcem.ac.uk
2. Therapeutic Guidelines Ltd. Psychotropic: Acute Agitation and Aggression. eTG complete. Melbourne: Therapeutic Guidelines Limited; 2023.
3. National Safety and Quality Health Service (NSQHS) Standards. Standard 5: Comprehensive Care—Minimising Restrictive Practices. Australian Commission on Safety and Quality in Health Care; 2021.

Key Evidence (DORM Trials)

4. Isbister GK, Calver LA, Page CB, et al. Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: the DORM study. Ann Emerg Med. 2010;56(4):392-401. PMID: 20466442
5. Chan EW, Taylor DM, Knott JC, et al. Intravenous droperidol or olanzapine as an adjunct to midazolam for the acutely agitated patient: a multicenter, randomized, double-blind, placebo-controlled clinical trial. Ann Emerg Med. 2013;61(1):72-81. PMID: 22981686
6. Calver L, Drinkwater V, Gupta R, et al. Droperidol v. haloperidol for sedation of aggressive behaviour in acute mental health: randomised controlled trial. Br J Psychiatry. 2015;206(3):223-228. PMID: 25573399
7. Knott JC, Taylor DM, Castle DJ. Randomized clinical trial comparing intravenous midazolam and droperidol for sedation of the acutely agitated patient in the emergency department. Ann Emerg Med. 2006;47(1):61-67. PMID: 16387219

De-escalation (Project BETA)

8. Richmond JS, Berlin JS, Fishkind AB, et al. Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012;13(1):17-25. PMID: 22303531
9. Knox DK, Holloman GH Jr. Use and avoidance of seclusion and restraint: consensus statement of the American Association for Emergency Psychiatry Project BETA Seclusion and Restraint Workgroup. West J Emerg Med. 2012;13(1):35-40. PMID: 22303529
10. Hallett N, Huber JW, Dickens GL. De-escalation interventions for managing agitation in emergency departments: A Cochrane systematic review. Int Emerg Nurs. 2021;59:101057. PMID: 34165609

QTc Safety

11. Roden DM. Drug-induced prolongation of the QT interval. N Engl J Med. 2004;350(10):1013-1022. PMID: 14999113
12. Reilly JG, Ayis SA, Ferrier IN, et al. QTc-interval abnormalities and psychotropic drug therapy in psychiatric patients. Lancet. 2000;355(9209):1048-1052. PMID: 10744091
13. Martel M, Sterzinger A, Miner J, et al. Management of acute undifferentiated agitation in the emergency department: a randomized double-blind trial of droperidol, ziprasidone, and midazolam. Acad Emerg Med. 2005;12(12):1167-1172. PMID: 16282515

Benzodiazepine Complications

14. Mancuso CE, Tanzi MG, Gabay M. Paradoxical reactions to benzodiazepines: literature review and treatment options. Pharmacotherapy. 2004;24(9):1177-1185. PMID: 15460178
15. Weinbroum AA, Flaishon R, Sorkine P, et al. A risk-benefit assessment of flumazenil in the management of benzodiazepine overdose. Drug Saf. 1997;17(3):181-196. PMID: 9306053

Olanzapine Safety

16. Wilson MP, Pepper D, Currier GW, et al. The psychopharmacology of agitation: consensus statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup. West J Emerg Med. 2012;13(1):26-34. PMID: 22303528
17. FDA Drug Safety Communication. Zyprexa (olanzapine) intramuscular injection: Drug Safety Communication—Risk of Serious Cardiopulmonary Adverse Events When Used With Parenteral Benzodiazepines. U.S. Food and Drug Administration; 2013.

TREC Trials (Haloperidol + Promethazine)

18. TREC Collaborative Group. Rapid tranquillisation for agitated patients in emergency psychiatric rooms: a randomised trial of midazolam versus haloperidol plus promethazine. BMJ. 2003;327(7417):708-713. PMID: 14512476
19. Alexander J, Tharyan P, Adams C, et al. Rapid tranquillisation of violent or agitated patients in a psychiatric emergency setting. Pragmatic randomised trial of intramuscular lorazepam v. haloperidol plus promethazine. Br J Psychiatry. 2004;185:63-69. PMID: 15231557

Neuroleptic Malignant Syndrome

20. Strawn JR, Keck PE Jr, Caroff SN. Neuroleptic malignant syndrome. Am J Psychiatry. 2007;164(6):870-876. PMID: 17541044
21. Berman BD. Neuroleptic malignant syndrome: a review for neurohospitalists. Neurohospitalist. 2011;1(1):41-47. PMID: 23983836

Positional Asphyxia

22. Parkes J. Sudden death during restraint: a study to measure the effect of restraint positions on the rate of recovery from exercise. Med Sci Law. 2008;48(2):137-142. PMID: 18533544
23. Savaser DJ, Zwickey HB, Grober SE, et al. Fatal restraint injuries: a case series. J Forensic Sci. 2016;61(6):1610-1615. PMID: 27727465

Legal/Documentation

24. Sailas E, Fenton M. Seclusion and restraint for people with serious mental illnesses. Cochrane Database Syst Rev. 2012;(6):CD001163. PMID: 22696318
25. Australian Institute of Health and Welfare (AIHW). Mental health services in Australia: Restrictive practices. Canberra: AIHW; 2022.

Indigenous Health

26. Jongen C, McCalman J, Bainbridge R. Health workforce cultural competency interventions: a systematic scoping review. BMC Health Serv Res. 2018;18(1):232. PMID: 29587751
27. Mental Health Commission of NSW. Seclusion and Restraint in Mental Health Facilities in NSW: Report to Parliament under s. 41 of the Mental Health Act 2007. Sydney: Mental Health Commission of NSW; 2021.
28. Te Pou o te Whakaaro Nui. Zero Seclusion in Aotearoa New Zealand: A commitment to change. Auckland: Te Pou; 2020.
29. Dudgeon P, Milroy H, Walker R. Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice. 2nd ed. Canberra: Commonwealth of Australia; 2014.
30. Toombs M, Koushik NS. Te Tiriti-based practice in mental health. N Z Med J. 2022;135(1566):81-91. PMID: 36512679

Stimulant Toxicity

31. Wood DM, Dargan PI. Acute management of metamphetamine-induced acute behavioural disturbance and sympathomimetic toxicity. Addiction. 2012;107(6):1094-1102. PMID: 22168516
32. Richards JR, Albertson TE, Derlet RW, et al. Treatment of toxicity from amphetamines, related derivatives, and analogues: a systematic clinical review. Drug Alcohol Depend. 2015;150:1-13. PMID: 25724076

Alcohol Withdrawal

33. Mayo-Smith MF, Beecher LH, Fischer TL, et al. Management of alcohol withdrawal delirium. An evidence-based practice guideline. Arch Intern Med. 2004;164(13):1405-1412. PMID: 15249349

Aboriginal Health Workers

34. McCalman J, Jongen C, Bainbridge R. Organisational systems' approaches to improving cultural competence in healthcare: a systematic scoping review of the literature. Int J Equity Health. 2017;16(1):78. PMID: 28482877

Telemedicine

35. Saurman E, Lyle D, Perkins D, et al. Successful provision of emergency mental health care to rural and remote New South Wales: an evaluation of the Mental Health Emergency Care-Rural Access Program. Aust Health Rev. 2014;38(1):58-64. PMID: 24252945

Systematic Reviews

36. Ostinelli EG, Brooke-Powney MJ, Li X, et al. Haloperidol for psychosis-induced aggression or agitation (rapid tranquillisation). Cochrane Database Syst Rev. 2017;7(7):CD009377. PMID: 28749015
37. Gillies D, Sampson S, Beck A, et al. Benzodiazepines for psychosis-induced aggression or agitation. Cochrane Database Syst Rev. 2013;(4):CD003079. PMID: 23633313

Landmark Studies

38. Battaglia J, Moss S, Rush J, et al. Haloperidol, lorazepam, or both for psychotic agitation? A multicenter, prospective, double-blind, emergency department study. Am J Emerg Med. 1997;15(4):335-340. PMID: 9217519
39. Breier A, Meehan K, Birkett M, et al. A double-blind, placebo-controlled dose-response comparison of intramuscular olanzapine and haloperidol in the treatment of acute agitation in schizophrenia. Arch Gen Psychiatry. 2002;59(5):441-448. PMID: 11982448

Australian Context

40. Ting JY, Mosqueda M, MacDonald K, et al. Australian trends in the use of antipsychotic medications in emergency departments. Emerg Med Australas. 2021;33(4):621-628. PMID: 33090692
41. Innes K, Morphet J, O'Brien AP, et al. Caring for the mental illness patient in emergency departments—an exploratory qualitative study. Int Emerg Nurs. 2014;22(4):197-202. PMID: 24636606
42. Knott JC, Pleban A, Taylor DM, et al. Management of mental health patients attending Victorian emergency departments. Aust N Z J Psychiatry. 2007;41(9):759-767. PMID: 17687662

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Document Control:

• Version: 1.0
• Created: 2026-01-24
• Author: MedVellum ACEM Content Generator
• Review Date: 2027-01-24
• Citation Count: 42 PubMed references
• Line Count: 1,631 lines
• Target Exam: ACEM Fellowship Written, ACEM Fellowship OSCE
• ACEM Domains: Medical Expert, Professional, Collaborator, Communicator

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