Rapid Tranquillisation
JAS SACHDEVA
Definition (NICE)
The use of medication to
 1) calm/lightly sedate the service user,
 2) reduce the risk to self and/or others
 3) achieve an optimal reduction in agitation and
aggression,
thereby allowing a thorough psychiatric evaluation
to take place and allowing comprehension and
response to spoken messages throughout the
intervention.
Typical Assault Cycle
(Based on Kaplan and Wheeler 1983)
Aggressive / Challenging / Violent Behaviour
Escalation
Trigger
Phase
Phase
(B)
(A)
(Potential
Additional
Assaults)
Crisis
Post-Crisis
Depression
Phase
Phase
(C)
(E)
Recovery
Phase
(D)
Approximately 90
mins to fully
recover.
Baseline Behaviour
Aim
 Reduce suffering
 Reduce risk of harm
 To do no harm
Purpose





Risk assessment & management.
Exhaust other strategies
Safety of service users and others
Advance directives
Reasonable & proportionate
Principles
 Rapid response and less accumulation
 Past use , efficacy and tolerance
 Interactions with drugs and exhaustion
 Flumazenil &procyclidine-when & where
 Routes
 Prescription
 Timing
NICE Recs
 Non-psychotic context: lorazepam alone
 Psychotic context: combination
Indications for Parental Routes
If oral
 Refused
 not indicated by previous clinical response
 not proportionate response
 Intramuscular lorazepam should not be
given within 1 hour of i/m olanzapine. Oral
lorazepam should be used with caution.
 Discuss with senior colleagues if prescribing above
BNF limits.
“Vitals are vital”
 Monitor and record BP, pulse, RR, Temp, Hydration
and level of consciousness (every 10min for 1 hr,
then 1/2hrly until pt mobile). If comatose , monitor.
O2 sats.
 Post incident reporting and review
 Discussing events with patient at a suitable time and
consider possibility of advance directives
Product Characteristics
Medication
Time to Cmax
Plasma half-life
Haloperidol injection
15-60 mins
10-36hrs
Haloperidol tab
2-6hrs
1-36hrs
Lorazepam injection
60-90mins
12-16hrs
Lorazepam tab
2hrs
12hrs
Remedial Measures
Problem
Remedial measure
Acute dystonia
Procyclidine/benzatropine
Reduced resps <10/min O2<90%
O2, raise legs, Flumezenil if benzo
induced or transfer and ventilate
Irregular or slow pulse <50/min
Immediate medical care
BP drop >30mm or <50mm diastolic
Lay flat , head tilt, monitor
Temperature raised
Check CK
?NMS/Arrythmia
Acuphase
 NOT RT
 Acts in 2 Hrs, lasts 72 hrs , peaks at 12hrs
 For :Acutely psychotic patient needing repeated RT
 After 15mins of IV and 60mins of IM
 Spaced at 24hrs
Further reading
 Maudsley ,Trust Policy, NICE guidelines
 http://www.nice.org.uk/Guidance/CG25
 http://www.nice.org.uk/nicemedia/live/10964/2971
9/29719.pdf
Questions