Rapid Tranquillisation Guideline - WhatDoTheyKnow · 2020-05-04 · Rapid Tranquillisation...

Rapid Tranquillisation Guideline

Behavioural disturbance, including agitation and aggression, can occur during the acute phase of psychosis, schizophrenia and in individuals with a learning disability. This can, in a minority of cases, require management by means of rapid tranquillisation.

Policy Number RTG-0408

Implementation Date 1st May 2008

First Review Date May 2010

Review Frequency Every 2 years

Date Approved

The Principal Pharmacist, Medicines Resource Management is responsible for monitoring the policy

Mental Health Partnerships, NHSGGC. Rapid Tranquillisation Guideline. Scope Application – all mental health and learning disability settings across NHSGGC. This guideline is not applicable for use in the management of alcohol withdrawal or in acute confusional states. Guideline Process This guideline was produced by consolidating the best-practice from the existing set of guidelines in use within the NHSGGC area. The guideline has been updated to take into account NICE guideline No 25 (2005). This guideline therefore supersedes all pre-existing rapid tranquillisation guidelines. The guideline was written by and reviewed by the Mental Health Guideline Harmonisation Group consisting of … Mr Tom Boyle Senior Nurse, Nursing Professional Development Dr Derek Brown Consultant Psychiatrist Dr Fiona Coulter Consultant Psychiatrist Ms Lorna Cuthbertson Senior Mental Health Pharmacist Mr Paul Davies Principal Pharm, Medicines Resource Management Ms Linda Hall Senior Nurse, MHP Dr P Jauhar Clinical Director, Medicines Resource Management Mr Barrat Luft Medicines Information Pharmacist, MHP Dr Ian Matson Consultant Psychiatrist Ms Marion McLoone Governance Support Unit, NHSGGC Ms Pat Spencer Medical Emergency Coordination & Training Officer Mr Andrew Walker Senior Mental Health Pharmacist

Page 1 of 12 RTG-0408

Rapid Tranquillisation Guideline 2007

Introduction Behavioural disturbance, including agitation and aggression, can occur during the acute phase of psychosis, schizophrenia and in individuals with a learning disability. This can, in a minority of cases, require management by means of rapid tranquilisation.

An appropriate environment adapted to suit the needs of acutely unwell patients is important, in addition to ensuring that staff are trained in how to assess and manage potential and actual violence. Techniques include de-escalation, restraint, and if necessary rapid tranquillisation. Staff must also be trained in how to physically monitor patients during such emergency treatment, and be able to undertake cardiopulmonary resuscitation.

From NICE Guideline No25: Violence. The short-term management of disturbed/violent behaviour in in-patient psychiatric settings and emergency departments …

“Rapid tranquillisation (also called urgent sedation): the use of medication to calm/lightly sedate the service user and reduce the risk to self and/or others. The aim is to achieve an optimal reduction in agitation and aggression, thereby allowing a thorough psychiatric evaluation to take place, whilst allowing comprehension and response to spoken messages throughout.

For the purposes of this guideline, rapid tranquillisation describes the use of medication to control severe mental and behavioural disturbance, including aggression associated with … schizophrenia, mania and other psychiatric conditions. It is used when other less coercive techniques of calming a service user, such as verbal de-escalation or intensive nursing techniques, have failed. It usually involves the administration of medication over a time-limited period of 30-60 minutes, in order to produce a state of calm/light sedation. Other medication regimes would be administered over longer periods of time and not time limited.”

This guideline is also applicable to individuals with a learning disability presenting to in-patient units with severe aggression and/or behavioural disturbance who have not responded to verbal de-escalation or intensive nursing techniques, and are a risk to themselves or others.

Contents Page Introduction and contents 2


General Principles 3 Risks associated with rapid tranquillisation 5

Management of problems occurring during rapid tranquillisation 6

Algorithm for Rapid Tranquillisation in ADULTS 7

Algorithm for Rapid Tranquillisation in ELDERLY 8

Algorithm for Rapid Tranquillisation in ADOLESCENTS 9

Prescription Sheet for an episode of rapid tranquillisation (Pending) 10

Clinical Recording Sheet 11

Rapid Tranquillisation Clinical Audit Criteria 12



The following medications are not recommended for rapid tranquillisation. Intramuscular or oral chlorpromazine (a local irritant if given intramuscularly; risk of cardiovascular complications; causes hypotension due to adrenergic receptor blocking effects, especially in the doses required for rapid tranquillisation; is erratically absorbed; its effect on QTc intervals suggests that it is unsuitable for use in rapid tranquillisation). IM diazepam is erratically absorbed and should not be used. Thioridazine. Intramuscular depot antipsychotics. Zuclopenthixol Acetate Injection (Acuphase). Adolescents have developing brains and are vulnerable to side effects. It is NEVER appropriate to use haloperidol in adolescents.

General Principles (a) Assessment

Be aware of procedures before an incident arises. A risk assessment should be undertaken and potential need for rapid tranquillisation documented. Anticipate disturbed behaviour and prevent if possible e.g. alcohol withdrawal. Take a history: where possible from the patient and those who know the patient. Review recent information e.g. U&Es; hypoglycaemia, drug history - rationalise if necessary. If the patient has a history of cardiac illness e.g. previous MI, unstable angina, conduction abnormalities or congestive cardiac failure, lorazepam is the drug of choice. Consideration should be given to the contents of any advance statement. Conduct brief physical examination if possible. Look for any obvious signs of conditions that may require specific treatment: Is the patients cyanotic or having difficulty breathing – hypoxia Does the patient appear to be hallucinating - drug intoxication or withdrawal? Is the patient in pain? Increased bladder dullness – urinary retention?

(b) Use of talking and behavioural interventions Place patient in safe environment, with no potential for weapons or self harm. Ensure environment is low stimulus Employ principles of ‘talking down’ – see below Give clear consistent instructions

Principles of talking down Access Try to obtain unobstructed access to the patient. Clear away moveable furniture and potential weapons and ask onlookers to leave quietly. Maintain a clear exit route. Time Do not rush, allow time for the patient to calm down. Most patients can be “talked down” in time. Engaging patients in conversation and allowing them to air their grievances may be all that is required. Avoid distraction (e.g. pagers), make it clear to the patient you have plenty of time (even if you don’t). Manner / Posture Remain calm and reassuring. Listen. Allow the patient to talk, and avoid interruption. Maintain relaxed posture, with the hands visible and body sideways to the patient. Speak quietly and clearly. Explain any actions you intend to take. Be clear, direct, non-threatening and honest, as this will help confused and aroused patients to calm themselves. Address the patient by name, maintain eye contact. Support Trying to cope alone can lead to disaster. Adequate numbers of staff, preferably trained in dealing with such situations, should be available to contain the incident and if necessary, restrain the patient. This may mean summoning help before attempting to deal with a situation. Avoid crowding the patient. Ensure resuscitation facilities are available.


(c) Is rapid tranquillisation of the patient required? For patients who are so completely out of control that calm reasoning is futile, temporary (i.e. minutes) physical restraint may be necessary while medication is being given. Remember to communicate with family if this would be helpful or appropriate. If the patient is detained under the Mental Health (Care and Treatment) (Scotland) Act (2003), completion of a form T4 will be required.

(d) Assessment and review Senior medical staff will be responsible for the assessment and review of episodes of rapid tranquillisation.

Principles of drug treatment Use oral, then IM as necessary. The intramuscular route is preferred over the intravenous one from a safety point of view.

Vital signs must be monitored after parenteral treatment is administered. Give small amounts. It is far easier to deal with not giving enough than giving too much. Always give time for the drug to work.

Mixing drugs in the same syringe is hazardous and must NEVER be done. Consider concurrent antipsychotics and the potential risk of inadvertent high dose therapy. Whenever practice deviates from the advice contained within this guideline and algorithm, a rationale must be noted in the case record.

Consider any on-going physical risks in relation to other medical disorders, other drug treatment and any potential for substance misuse.

Treatment choices in rapid tranquillisation – see accompanying algorithm If a patient has previously responded to a particular drug for rapid tranquillisation, use again, with the exception of the drugs not recommended for use (above).

If the patient is antipsychotic naïve, use low doses and monitor for response and side effects closely.

Oral medication should be considered initially. It should be noted that the doses for lorazepam within this guideline exceed the recommended doses for the treatment of anxiety.

The IM preparations currently recommended for use in rapid tranquillisation are lorazepam, haloperidol and IM olanzapine. In general, IM lorazepam is preferred.

When using an IM typical antipsychotic agent, such as haloperidol, an anticholinergic agent should be routinely available to manage dystonia and other extrapyramidal side effects, e.g. IM procyclidine or benzatropine (benztropine).

IM olanzapine is for short-term use only, for up to a maximum of three consecutive days. Simultaneous injection of intramuscular olanzapine and parenteral benzodiazepine is not recommended. If the patient is considered to need parenteral benzodiazepine treatment, this should not be given until at least one hour after IM olanzapine administration. If the patient has received parenteral benzodiazepine, IM olanzapine administration should only be considered after careful evaluation of clinical status, and the patient should be closely monitored for excessive sedation and cardiorespiratory depression.

(e) After Treatment Each episode of acute crisis should be thoroughly reviewed and documented, including wherever possible, the patient’s experience.

• Monitoring of vital signs should be conducted whenever an IM drug is used including: respiration rate, temperature, BP, and pulse every 5 -10min for 1 hour then ½ hourly until the patient is ambulatory. Write result in notes and recording sheet.

• Increased temperature, sweating, restlessness or marked muscular rigidity should alert staff to the possibility of neuroleptic malignant syndrome (NMS). Such signs require urgent medical assessment. If NMS suspected after medical assessment, stop all antipsychotic drugs, attempt to cool patient and consider transfer to ITU.

• Ensure adequate hydration. • Monitor urea, electrolytes and glucose.


Risks associated with benzodiazepines • Respiratory depression or arrest. • Loss of consciousness. Risks associated with antipsychotic drugs • Cardiovascular complications and collapse. • Seizures. • Care must be taken in struggling patients to avoid inadvertent i/v

administration • Adverse side effects: subjective experience of restlessness (akathisia), acute

rigidity (dystonia) and involuntary movements (dyskinesias). • Neuroleptic malignant syndrome: hyperthermia, sweating, agitation, altered

consciousness and marked muscle rigidity. • Altered consciousness. Precautions with rapid tranquillisation, including special situations: • Use lower doses in: elderly, patients who are antipsychotic naïve, patients

with organic disorder (delirium). • Use extreme caution in patients intoxicated with drugs or alcohol. • In patients with cardiac disease avoid antipsychotics – use benzodiazepines

alone. • In individuals with a learning disability especially where they have reduced

ability to communicate a thorough physical exam should be undertaken to exclude a physical cause for behavioural disturbance if possible.

• In individuals with a learning disability and behavioural disturbance oral lorazepam is the preferred option.

• The issue of consent must be considered. • In individuals with a learning disability consider using lower doses and

reduced administration as per elderly algorithm.


Management of problems occurring during rapid tranquillisation: Problem Remedial Measures: Acute dystonias (including oculogyric crises)

Give procyclidine 5-10mg IM OR benzatropine (benztropine) 1-2mg IM

Reduced respiratory rate <10 / minute or oxygen saturation <90% In Hospital Dial 2222 Dial 999/appropriate local emergency number for learning disability in-patient units and Forensic Units

Give Oxygen. Give flumazenil if benzodiazepine-induced Initially 200mcg IV over 15 seconds – if required level of consciousness not achieved after 60 seconds then: Subsequent dose: 100mcg over 10 seconds, repeated after 60 seconds if necessary. Maximum dose: 1mg in 24 hours (one initial dose and eight subsequent doses) Monitor respiration until rate returns to baseline level. If induced by other agent patient may require mechanical ventilation – arrange transfer to ITU immediately.

Reduced respiratory rate <5 / minute

Medical Emergency – institute emergency treatment and immediate transfer.

Tachycardia (>140min) Refer to specialist medical care immediately Irregular pulse or bradycardia (<50 / min)

Refer to specialist medical care immediately

Orthostatic hypotension Lie patient flat, raise legs if possible, monitor closely including blood pressure

Fall in blood pressure (systolic <90mmHg or diastolic <50mmHg)

Urgent medical assessment Lie patient flat, raise legs if possible

Increased temperature (>37.50C) Urgent medical assessment Withhold antipsychotics Assess risk of NMS and perhaps arrhythmias

Bibliography

1. National Institute for Clinical Excellence. Schizophrenia – core interventions in the treatment and management of schizophrenia in primary and secondary care. December 2002.

2. McAllister-Williams RH and Ferrier IN. Rapid tranquillisation: time for reappraisal of options for parenteral therapy. British Journal of Psychiatry 2002 180: 485-489

3. Kerr IB and Taylor D. Acute disturbed or violent behaviour: principles of treatment. Journal of Psychopharmacology 1997; 11:271-277

4. Dubin WR. Rapid tranquillisation: antipsychotics or benzodiazepines. Journal of Clinical Psychiatry 1988; 49(suppl. 12): 5-11

5. Guidelines for rapid tranquillisation. South West London & St Georges Mental Heath NHS Trust. 2001. 6. Managing acutely disturbed or violent patients – monitoring. From: Dumfries Prescribing Guidelines 2001. 7. Karagianis JL, Dawe IC, Thakur A et al. Rapid tranquilization with olanzapine in acute psychosis: A case

series. 8. Currier GW and Simpson GM. Risperidone liquid concentrate and oral lorazepam versus intramuscular

haloperidol and intramuscular lorazepam for treatment of psychotic agitation. Journal of Clinical Psychiatry 2001; 62:153-157

9. Summary of Product Characteristics: Zyprexa Powder for Solution for Injection. Eli Lilly and Company Ltd. March 2004.

10. NICE Guideline No25: Violence. The short-term management of disturbed/violent behaviour in in-patient psychiatric settings and emergency departments


Algorithm for Rapid Tranquillisation in ADULTS

Consider non-drug strategies, If behaviour continues to pose risk to self or others …

Antipsychotic naïve or severe cardiac disease

Confirmed history of significant antipsychotic exposure

Consider oral therapy

lorazepam 1-2mg (max 8mg/24hrs) or olanzapine 5-10mg (max 20mg/24hrs) or

quetiapine 50-150mg (max 750mg/24hrs) or risperidone 2mg (max 16mg/24hrs)

Beware of contraindication to some antipsychotics with

co-existing dementia

Consider a combination of lorazepam and olanzapine OR quetiapine OR risperidone if single agent ineffective


lorazepam 1-2mg (max 8mg/24hrs) or haloperidol 5-10mg (max 30mg oral/24hrs) or

olanzapine 5-10mg (max 20mg oral or IM/24hrs) or quetiapine 50-150mg (max 750mg/24hrs) or

risperidone 2mg (max 16mg/24hrs)

Beware of contraindication to some antipsychotics with co-existing dementia

Consider a combination of lorazepam and olanzapine OR quetiapine OR risperidone if single agent ineffective

Patient refuses oral therapy, or … If no response observed after 2 (two) repeated oral doses (60 minutes apart) ..

Consider injection

*lorazepam 1-2mg IM (max 8mg by oral or IM/24hrs)

Give over 2-3 minutes Dilute 1:1 with water for injection or 0.9%NaCl before use. *NB When administering IM lorazepam, equipment necessary to maintain a patent airway and to support respiration/ should be available and used when necessary

Following injection, reconsider feasibility of administration of oral atypical antipsychotic

as detailed above

Consider injection

*lorazepam 1-2mg IM (max 8mg by oral or IM/24hrs)

Dilute 1:1 with water for injection or 0.9%NaCl before use.

AND/OR ♦haloperidol 5-10mg IM

(max 30mg oral or 18mg IM/24hrs)

Alternatively, IM Olanzapine 5-10mg (max 20mg oral or IM/24hrs)

*♦Give over 2-3 minutes *NB When administering IM lorazepam, equipment necessary to maintain a patent airway and to support respiration/ should be available and used when necessary

Administer according to the NHSGGC Mental Health Partnerships Use of Olanzapine IM advice.

Following lorazepam injection only, reconsider feasibility of administration of oral atypical

antipsychotic as detailed above Continue talking and using non-drug approaches

Wait 30 minutes then if no benefit …

Repeat lorazepam injection if necessary.

(max 8mg by oral or IM/24hrs)

Revert to vital sign monitoring

Repeat injection(s) if necessary. NB: if IM olanzapine to be repeated – wait 2 hours.

Not more than three olanzapine injections to be administered in any 24-hour period. If olanzapine IM administered, wait one hour before administering an IM benzodiazepine If an IM benzodiazepine administered, the clinical status of the patient should be assessed and consultant advice obtained prior to IM olanzapine being administered.

Revert to vital sign monitoring Continue talking and using non-drug approaches

If no response to second injection, seek advice from senior experienced doctor / consultant on call


Algorithm for Rapid Tranquillisation in psychosis of the ELDERLY (excluding behavioural disturbance due to dementia)





lorazepam 0.5-1mg (max 4mg/24hrs) or olanzapine 2.5-5mg (max 20mg/24hrs) or quetiapine 25-75mg (max 750mg/24hrs) risperidone 0.5-1mg (max 4mg/24hrs) or

Beware of contraindication to some antipsychotics with

co-existing dementia

Consider combination of lorazepam and olanzapine OR quetiapine OR risperidone if single agent ineffective


lorazepam 0.5-1mg (max 4mg/24hrs) or haloperidol 0.5-5mg (max 10mg oral/24hrs)

olanzapine 2.5-5mg (max 20mg oral or IM/24hrs) or quetiapine 25-75mg (max 750mg/24hrs) or risperidone 0.5-1mg (max 4mg/24hrs) or

Beware of contraindication to some antipsychotics with co-existing dementia

not to be given if suspected dementia with Lewy bodies Consider combination of lorazepam and olanzapine OR quetiapine OR risperidone if single agent ineffective


Consider injection

*lorazepam 0.5-1mg IM (max 4mg by oral or IM/24hrs)



as detailed above

Consider injection


Dilute 1:1 with water for injection or 0.9%NaCl before use.

AND/OR ♦haloperidol 0.5-2mg IM

(max 10mg oral or 5mg IM/24hrs) *♦Give over 2-3 minutes ♦Not to be given if suspected dementia with Lewy bodies *NB When administering IM lorazepam, equipment necessary to maintain a patent airway and to support respiration/ should be available and used when necessary

Following lorazepam injection only, reconsider feasibility of administration of oral atypical

antipsychotic as detailed above Occasionally:

IM olanzapine 2.5-5mg as a single agent. Reconstitute only with water for injection as per the NHSGGC Mental Health Partnerships Use of Olanzapine IM advice. Not to be used in dementia.

Continue talking and using non-drug approaches Wait 30 minutes then if no benefit …




Repeat injection(s) if necessary. NB: if IM olanzapine to be repeated – wait 2 hours.

2.5-5mg, may be administered 2 hours after the first injection. The maximum daily dose of olanzapine (including oral olanzapine) is 20mg, with not more than 3 injections in any 24-hour period.) If olanzapine IM administered, wait one hour before administering an IM benzodiazepine If an IM benzodiazepine administered, the clinical status of the patient should be assessed and consultant advice obtained prior to IM olanzapine being administered.




Algorithm for Rapid Tranquillisation in psychosis of ADOLESCENTS





lorazepam 0.5-2mg (max 4-8mg/24hrs) or olanzapine 2.5-5mg (max 20mg/24hrs) or

quetiapine 25-50mg (max 750mg/24hrs) or risperidone 0.5-2mg (max 16mg/24hrs)

Consider combination of lorazepam and olanzapine OR quetiapine OR risperidone if single agent ineffective


lorazepam 1-2mg (max 4-8mg/24hrs) or olanzapine 2.5-5mg (max 20mg oral or IM/24hrs) or

quetiapine 25-50mg (max 750mg/24hrs) or risperidone 0.5-2mg (max 16mg/24hrs)

Consider combination of lorazepam and olanzapine OR quetiapine OR

risperidone if single agent ineffective


Consider injection




as detailed above

Consider injection




as detailed above Occasionally:

IM olanzapine 2.5-10mg as a single agent. Reconstitute only with water for injection as per the NHSGGC Mental Health Partnerships Use of Olanzapine IM advice.

Continue talking and using non-drug approaches Wait 30 minutes then if no benefit …




Repeat injection(s) if necessary. Lorazepam: max 4mg by oral or IM/24hrs

NB: if IM olanzapine to be repeated – wait 2 hours. 2.5-10mg, may be administered 2 hours after the first injection. The

maximum daily dose of olanzapine (including oral olanzapine) is 20mg, with not more than 3 injections in any 24-hour period.) If olanzapine IM administered, wait one hour before administering an IM benzodiazepine If an IM benzodiazepine administered, the clinical status of the patient should be assessed and consultant advice obtained prior to IM olanzapine being administered.



Adolescents have developing brains and are vulnerable to side effects e.g. disinhibition due to the use of benzodiazepine medication. It is NEVER appropriate to use haloperidol in adolescents.


Prescription/Monitoring Sheet for an episode of rapid tranquillisation: To be Piloted prior to inclusion.


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IM Injection Vital Sign Monitoring Clinical Recording Sheet 10min 20min 30min 40min 50min 1hr 1hr30 2hr 2hr30 3hr 3hr30 4hr 4hr30 5hr 5hr30 6hr Temp Pulse BP / / / / / / / / / / / / / / / / Resp O2 Sat.

Rapid Tranquillisation Guideline: Audit Criteria Criterion Statement Standard Exceptions There is a risk assessment and risk management plan in the case notes of each service user.

100% None

Services have a policy for training employees and staff- in-training in the short-term management of disturbed/violent behaviour.

100% None

Drugs used for rapid tranquillisation are used within the dose ranges specified.

100% Clinically appropriate to use lower/higher doses

There is a record of medication administered for rapid tranquillisation.

100% None

Doses or total daily dose outwith those advised in the guideline are recorded in the care record.

100% None

All relevant physical monitoring during a period of rapid tranquillisation is undertaken and documented.

100% No IM medication administered Patient refuses to contribute

The patient’s experience of rapid tranquillisation is recorded.

100% Patient refuses to contribute

If no response to second injection during a period of rapid tranquillisation, advice is sought from a senior experienced doctor / consultant on call and recorded

100% None


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