RAPID TRANQUILLISATION POLICY
Document name:
Rapid tranquillisation policy
Version 5.3.1
Staff group to whom it
applies:
Qualified medical staff, qualified nursing staff,
pharmacists and pharmacy staff.
All staff working on in-patient units.
Distribution:
Hard copy to in-patient areas
Intranet
Medical staff on induction
Issue date:
September 2014
Next review:
September 2015
Developed by:
Director Lead - Medical Director
Contacts for advice or
information:
Jane Riley, Chief Pharmacist
Dr Adrian Berry, Medical Director
Mark Payne, Senior Clinical Pharmacist
1
CONTENTS
Abbreviations ............................................................................................................................... 3
Rapid Tranquillisation algorithm ................................................................................................. 4
Flowchart ...................................................................................................................................... 5
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Introduction ......................................................................................................................... 6
Definitions and Principles ................................................................................................... 7
Preparation Guidance – Information on medicines ............................................................. 10
Risk of Rapid Tranquillisation ............................................................................................ 15
Carrying out Rapid Tranquillisation ................................................................................... 16
Oral therapy for Rapid Tranquillisation .............................................................................. 16
Injectable therapy for Rapid Tranquillisation ..................................................................... 17
The use of zuclopenthixol acetate injection (Clopixol Acuphase) ...................................... 18
Medications not recommended for Rapid Tranquillisation................................................. 19
Doses for Rapid Tranquillisation ........................................................................................ 19
Circumstances for special care (extra care) ......................................................................... 20
Medicines which may prolong the QT interval ................................................................... 20
Physical monitoring before, during and following Rapid Tranquillisation ........................ 21
Managing side effects and complications occurring during Rapid Tranquillisation .......... 23
Rapid Tranquillisation in Older People ............................................................................... 23
Rapid Tranquillisation in people with learning disabilities ................................................ 24
Appendix 1
Appendix 2
Appendix 3
Appendix 4
Appendix 5
Appendix 6
Appendix 7
Appendix 8
Appendix 9
Appendix 10
Appendix 11
Appendix 12
Appendix 13
Appendix 14
Rapid Tranquillisation Episode Criteria and Review Pathway ............................ 25
Rapid Tranquillisation – Assessment and Progress Chart ................................... 26
The Richmond Agitation – Sedation Scale .......................................................... 27
48 Hour Intramuscular Clopixol Acuphase Monitoring Chart ............................. 28
Guidance on the Preparation & Administration of Aripiprazole (Abilify®) ....... 29
Haloperidol Administration.................................................................................. 30
Guidance on the Preparation & Administration of Olanzapine (Zyprexa®)........ 31
Advice on the Preparation & Administration of Lorazepam (Ativan®) .............. 32
Policy for the use of midazolam .......................................................................... 33
Implementation..................................................................................................... 35
Equality Impact Assessment Tool ........................................................................ 36
Checklist for the Review and Approval of Procedural Document ....................... 37
Training Needs ..................................................................................................... 39
Version Control Sheet ......................................................................................... 41
References ................................................................................................................................. 42
2
Abbreviations used in this document
BNF
CNS
CPR
CVD
D&T
ECG
EPSE
ESR
IM
IV
JARP
MDT
MHRA
MAV
NMS
PO
PRN
QT/QTc
RT
RTP
SPC
SWYPFT
TIA
U&Es
British National Formulary
Central Nervous System
Cardiopulmonary resuscitation
Cardiovascular Disease
Drug and Therapeutics Sub Committee
Electrocardiogram
Extrapyramidal side effects
Electronic Staff Record
Intramuscular injection
Intravenous injection
Justifiable appropriate reasonable and proportionate action
Multidisciplinary team
Medicines and Healthcare Products Regulatory Agency
Managing Aggression and Violence
Neuroleptic malignant syndrome
Oral/by mouth
Medicines to be taken as and when required
Interval in the cardiac cycle
Rapid Tranquillisation
Rapid Tranquillisation Pathway
Summary of Product Characteristics
South West Yorkshire Partnership NHS Foundation Trust
Transient Ischemic Attacks
Urea and Electrolytes
3
Version 5.3.1 Sept 14
SOUTH WEST YORKSHIRE PARTNERSHIP NHS FOUNDATION TRUST
* Use midazolam IM only when lorazepam IM injection is unavailable
Rapid Tranquillisation algorithm – This forms part of the Rapid Tranquillisation Policy
Consider de-escalation techniques
eg: talking down, distractions, time out
+ Have access to procyclidine injection for acute dystonic
reactions and flumazenil for benzodiazepine induced
respiratory depression.
Have access to emergency resuscitation facilities
Consider starting/increasing regular oral
medication
No response
Consider pharmacological management
Seek consultant advice re MHA status. If necessary
treatment may continue under common law
Try Oral Therapy +
Patient refusing oral /
Rapid response required /
No response to oral
Try intramuscular injection+
Adult
Drug (oral)
Lorazepam 1-2mg
or
Promethazine 25-50mg
Where the use of benzodiazepines is inappropriate
Elderly/Physically Frail
Drug (oral)
Lorazepam
0.5-1mg
or
Promethazine 25mg
Where the use of benzodiazepines is inappropriate
And/or another from the list below
Olanzapine 5-15mg
Haloperidol 3-5mg
Risperidone 2mg
And/or another from the list below
Olanzapine 2.5-5mg
Haloperidol 1.5-2.5mg
Risperidone 1-2mg
Use formulation most appropriate to patient
Use formulation most appropriate to patient
Adult
Drug (IM)
Lorazepam
Response
Continue appropriate
oral medication
Restart or start oral medication
Elderly/Physically Frail
Drug (IM)
Lorazepam
1-2 mg
Or Midazolam
2.5-5mg*
Or Promethazine 50mg
Where the use of benzodiazepines is inappropriate
and/or
(if known to tolerate typical antipsychotics)
Haloperidol
2-5mg
500 micrograms-1mg
Or Midazolam
1-2mg*
Or Promethazine 50mg
Where the use of benzodiazepines is inappropriate
and/or
(if known to tolerate typical antipsychotics)
Haloperidol
1-2.5mg
Response
Review appropriateness of
continuing intramuscular
therapy
Monitor Patient
No response within ½ hour
Never mix two drugs in the same syringe.
Always dilute lorazepam injection before use
Review.
Complexity – refer to consultant
Outside normal working hours – refer
to on-call consultant. The On call pharmacist is
also available for advice.
Consider repeating IM lorazepam (Adult Max 4 mg in 24 hours) / IM midazolam (Adult Max 15mg in 24 hours)
and haloperidol 5mg injections
(caution – maximum adult haloperidol dose is 12mg IM in 24 hours, avoid repeating haloperidol
In the elderly above a total of 5mg IM without Consultant advice)
or any of the following
Aripiprazole 5.25-15mg IM (max dose 30mg in 24hrs by any route, however only IM used in Rapid
Tranquillisation, do not give when other antipsychotics are prescribed)
4
Zuclopenthixol Acetate (Clopixol Acuphase)
• Not recommended for RT due to delayed onset and
long duration of action but may be considered as an
option when:
1 Service user will be disturbed/violent over extended
time period.
2. Past history of good/timely response.
3. Past history of parental administration.
4. Cited in an advance directive.
• Never administer to those without previous
antipsychotic exposure.
• Consult BNF and manufacturer’s SPC regarding its
use and SWYPFT guidelines and monitoring charts.
RAPID TRANQUILLISATION FLOWCHART
Start a rapid tranquillisation pathway (RTP)
Identify and record criteria for requiring RT on RTP
Check for physical health monitoring, i.e. recent/on
admission, ECG, pulse, BP, U&E’s
Patient requires rapid tranquillisation (RT)
Record results on the Assessment and Progress Chart
Record criteria and current medicines on RiO
Review need for RT and record on RTP
Repeat and record monitoring until patient ambulant.
If requiring high doses of medicines or medicines not
included in the RT algorithm contact senior staff
ideally Consultant Psychiatrist
File RT forms into ward RT file and alert ward
manager (or use RiO)
Carry out RT review meeting for patient
5
SOUTH WEST YORKSHIRE PARTNERSHIP NHS FOUNDATION TRUST
Rapid Tranquillisation Policy
1.
1.1
Introduction
Scope
This policy has been updated to become a Trustwide policy to include practice in
Barnsley
This policy is intended to support the delivery of appropriate, safe and effective
rapid tranquillisation in the context of in-patient care within SWYPFT and identifies
which clinical staff need training. This policy replaces all previous local RT related
policies or procedures and represents expected (i.e. usual) practice within all
districts and the regional forensic service.
1.2
Policy Development
The policy was developed by the Medical Director and Chief Pharmacist in
consultation with the D&T and Managing Violence and Aggression TAG. The
policy of the Bradford District Care Trust was used with permission from Alistair
Tinto, lead pharmacist for mental health. It has been updated together with the rapid
tranquillisation working group of the D&T.
1.3
Practice Variation
Like all guidance, this is a generalisation of best practice and this policy sets out
broad standards for RT, which are intended to inform clinicians in reaching the best
treatment decision for individual in-patients at the time and in the current
circumstances. There will be occasions when there may need to be some variation
from this, and these will require an assessment of the balance of potential benefits
and potential harm indicated by the prescribing clinician in consultation with other
members of the multi-disciplinary team. If a decision is made to vary from this
policy, there must be clear documentation of that decision along with the supporting
assessments and related consultations. Before all occasions of variance from this
policy, the opinion of the consultant psychiatrist or another senior psychiatrist (eg
out of hours) should be sought.
1.4
Sources of Guidance
A full list of references is given at the end of this document, but this policy takes
particular note of NICE Clinical Guidelines 25 and 1 (management of Violence and
Schizophrenia respectively) and is a successor to the SWYPFT Rapid
Tranquillisation Protocol version 4, May 2010 and the Guidelines for Rapid
Tranquillisation for acutely disturbed behaviour for adults in Barnsley approved
May 2010.
1.5
Duties

Healthcare organisations have an obligation to provide an effective rapid
tranquillisation service to their patients and appropriate training to their staff.
A suitable infrastructure is required to establish and continue support for these
activities.

The Chief Executive is responsible for ensuring that resources and
mechanisms are in place for the overall implementation, monitoring and
review of this policy.
6
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2.
2.1
Implementation of this document is outlined in appendix 10, page 35.
The Medical Director, the Director of Nursing and the Chief Pharmacist are
responsible for ensuring the policy is reviewed, approved and monitored by the
appropriate trust-wide group (currently the Drug & Therapeutic Sub
Committee).
The Executive Management Team will provide policy approval and
ratification.
The Drug & Therapeutic Sub Committee will consider the monitoring
evidence put before them and request actions as appropriate.
General Managers are responsible for ensuring that dissemination and
implementation of the policy occurs within their own area of responsibility. In
addition, they are responsible for providing relevant support for the training
required around RT as outlined in the training needs analysis.
Ward Managers must ensure staff have access to training on RT (see appendix
13 training needs analysis and training matrix, Section 1 of the Medicine
Code).
As well as training on RT there must be staff trained on the use of oxygen,
pulsoximetry and defibrillators on the wards when RT is employed.
Definitions and Principles
Rapid Tranquillisation (RT) is used when JARP – a justifiable appropriate
reasonable and proportionate action has failed to de-escalate disturbed behaviour.
Disturbed behaviour can occur in psychiatric illness, physical illness, substance
abuse or personality disorder and may be secondary to psychotic symptoms.
See the SWYPFT Policy on Managing Violence and Aggression (Physical
Intervention) for further details on physical intervention. These interventions are
management strategies and are not regarded as primary treatment techniques. The
intervention selected must be a reasonable and proportionate response to the risk
posed by the in-patient - JARP.
2.2
Ideally the decision to use RT should be a MDT decision and thus refer to this
guidance. A specialist mental health pharmacist should be a member of the wider
MDT and should be involved at the earliest opportunity where RT is used.
2.3
This decision, along with a statement as to how long RT should continue before the
use of RT is reviewed, must be recorded in notes, as well as commencing use of the
SWYPFT ‘Rapid Tranquillisation Episode – Criteria and Review Pathway’
(appended). Reviews of RT should be recorded in the notes, including the decision
to cease RT.
2.4
The ward manager must be made aware at the next opportunity that an RT regimen
has been used. The ward manager must have systems in place to ensure that a team
review to consider the reasons, the effects, any problems and future plans and that
this should be recorded in the notes. If possible the patient should be involved in the
review.
2.5
The aims of the management of the acute psychiatric emergency are to:
 Calm the patient quickly, rather than to sedate to unconsciousness.
7
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Control extreme agitation, aggression and potential violent, behaviour that
may place the patient or others at risk of physical harm.
Reduce psychological suffering.
Maintain a safe environment for the patient and others.
Prescribe safe regimens and monitor physical health. Sudden cardiac death
has been associated with the use of antipsychotic medication especially in
young, fit, struggling individuals.
Above all cause no harm.
2.6
The use of medication in RT is not underpinned by a strong evidence base so
recommendations are based on a mixture of research, theoretical considerations and
clinical experience. It is inappropriate to prescribe medicines ‘just in case’ unless a
need has been specifically identified.
2.7
RT should not be routinely employed and is not intended to treat the underlying
condition. Such medications tend not to be part of the regular treatment since it is
an interim management instigated by staff in a pro-active manner, rather than at the
request of the patient. Such treatment should therefore only be given for the
minimum time needed to control the patient’s behaviour and should be followed
with the normal planning and giving of care.
2.8
Patients may occasionally require physical restraint to prevent violence to
themselves or others. Swift, safe and effective drug treatment may then be needed
to effect RT and to allow subsequent evaluation and appropriate management.
Medication should be used in the context of a combination of approaches to the
management of the agitated patient and at all stages continue talking and using nondrug approaches and use oral rather than IM medication if the patient will accept it.
When IM medication is used ensure the rapid tranquillisation assessment and
progress chart is completed. Copies are available in the ward RT file.
Patients should not be prescribed haloperidol in the event of it being required in the
future for RT. It should only be prescribed when the MDT has determined it is
required or very likely to be required.
2.9
Some antipsychotics have been withdrawn when reviews of their safety data
identified the risk of prolonging the QT interval in the cardiac cycle. This may lead
to Torsade de Pointes which can then advance on to ventricular tachycardia
(palpitations, dizziness, fainting), ventricular fibrillation and sudden death. Other
medications may also have this effect including phenothiazines, chlorpromazine and
butyrophenones such as haloperidol (see section 12, page 20, for list of medications
which increase the QT interval). Care is always needed in using these medications
particularly in high doses or in combination and consideration given to the physical
status of the patient (see section 12.2, page 21, maximum dose chart).
2.10
The benzodiazepine of choice for rapid tranquillisation is lorazepam. At times
lorazepam intra muscular injection has become unavailable. In January 2013
lorazepam intra muscular injection is available again. Both midazolam IM injection
and lorazepam IM injection are available to purchase. The preferred benzodiazepine
is lorazepam IM injection which is available as 4mg/ml ampoule and requires
dilution before use (see appendix 8 page 32).
8
2.11
When considering the medication to be used in the emergency situation, besides
efficacy and safety concerns, also relevant are time of onset of action and possible
route of administration. The actual choice of medication will depend upon the drug
history of the person being treated. Review current and past known drug therapy
and rationalise appropriately. Review the diagnosis – this may indicate the required
treatment e.g. in delirium tremens prescribe benzodiazepines rather than
antipsychotics.
2.12
It is essential, when dealing with psychiatric emergencies that a multidisciplinary
approach is taken and that all factors are considered.
 Seek advice from the duty Consultant or responsible clinician if initial measures
have not been successful.
 Review the Mental Health Act Status of the patient.
 Review any ‘PRN’ drugs charted and increase or start regular oral
antipsychotics if indicated.

If a patient’s response to medication in an emergency is known it may be
advisable to give what has worked before. See the previous medication history
of the service user and always consider the current medication administered on
the in-patient prescription chart.
 Any current advance directive should be considered prior to RT commencing.
2.13
Older people, the elderly and other groups may require smaller doses of medication.
Particularly consider:
a) Altered levels of metabolism
b) Existence of physical illness
c) Use of concurrent medications
2.14
All medical staff, ward based qualified nursing staff and pharmacists should be
familiar with the use and dangers of RT, the medications used in RT as well as those
used to reverse the effects (e.g. flumazenil in respiratory depression).
2.15
All professionally qualified staff should be trained to CPR, Basic Life Support and
Advisory De-fibrillation. They should be trained to use the oxygen available on the
ward and in puloximetry.
9
3
Preparation Guidance - Information on medicines
Route &
Pharmacokinetics
Medicine/Dose
Major Side Effects
Practice Points
Respiratory depression
IM absorption is the same as oral absorption, but is
more rapid in an active patient.
Preparation
Lorazepam
Dose
Adult 1 - 2mg
Elderly 0.5 -1mg
Max dose in 24 hours
Adult 4mg
Elderly 2mg
The only reason to
give lorazepam IM is
if the patient refuses
oral.
Oral tablets
1mg
Onset 10-30mins
Peak 60-90mins
IM injection
4mg/ml
Half-life 8-25hrs
see instructions
for preparation
Appendix 8, page
32)
The pharmacokinetics of
lorazepam are similar
whether given orally or
IM.
Disinhibition
(more likely to occur in those
with organic brain disease,
including learning difficulties,
the under 18s and the over 65s
and, perhaps, those with impulse
control problems).
The injection should be diluted 50:50 with water
for injections before administration.
There is no accumulation of lorazepam with repeated
doses or in impaired liver function.
A wide therapeutic index.
Respiratory depression is readily reversed with the
specific antagonist flumazenil.
Oral and IM doses are
equivalent
MIDAZOLAM INJECTION ONLY TO BE USED AS PER APPENDIX 9 WHEN LORAZEPAM IM INJECTION IS NOT AVAILABLE
Midazolam
Store in Controlled drug Cupboard.
IM injection
Onset 10-30mins
Dose
This product is unlicensed and
Adult 2.5 to 7.5mg
5mg/5ml
Peak within 30 minutes.
Caution in the elderly or in those with physical
only to be used when
Elderly 1-2mg
illnesses.
lorazepam IM is unavailable
Half-life 2-3 hours (may
Max dose in 24 hours .(see appendix
9 page 33)
Adults 15mg
be prolonged to 10 hours
Side effects as for lorazepam but Repeated doses may lead to accumulation of
Elderly 7.5mg
or more in the elderly
with additional risk of retrograde midazolam and increased risk of adverse effects,
and concurrent physical
amnesia following
including respiratory depression. If renal, hepatic,
illness.
administration.
Always ensure that emergency recovery medication
cardiovascular or
(ie flumazenil) is present before administration.
respiratory function is
impaired dose as for
elderly
10
Medicine/Dose
Route &
Preparation
Pharmacokinetics
Major Side Effects
Practice Points
Oral tablets /
capsules
0.5 mg
1.5 mg
5mg
Oral
Onset 1-2 hrs
Peak 4hrs
Half life 21 hrs
EPSE Hypotension NMS
Increased QT
Arrhythmias
Seizures
Sudden Death
Risk of acute dystonias.
IM
Injection
5mg/ml
IM
Onset 20 mins
Peak 1 hr
Half life 21hrs
Baseline ECG recommended in
all patients, especially in the
elderly and in those with
positive family or personal
history of cardiac disease or
abnormal findings on cardiac
clinical examination.
The bioavailability of both formulations is different
and this must be taken into account when considering
the total dose per 24 hr period.
i.e. 5mg PO = 3mg IM
Hypotension
Bradycardia
Syncope
Not licensed for use in dementia-related psychosis/
behavioural disturbances
Not licensed for use in children/ adolescents.
Haloperidol
Dose
Oral
Adult 1.5-5mg
Elderly 1-2.5mg
IM
Adult 2-5mg
Elderly 1-2.5mg
Max dose in 24 hours
Oral 20mg
IM 12mg
Avoid giving more
than 5mg in elderly
patients without
consultant advice
See instructions in
Appendix 6,page
30
Can be advisable to administer an antimuscarinic agent
such as procyclidine with the first dose of haloperidol
to avoid EPSE.
Use SEPARATE LINES on the prescription sheet for
each route of administration. Not recommended for IV
use because of the risk of arrhythmias.
Olanzapine
Dose
Adult 5-15mg
Elderly 2.5-5mg
Max dose in 24 hours
20mg by any route
Oral tablets /
orodispersible
tablets
2.5mg, 5mg
7.5mg, 10mg
15mg, 20mg
IM injection
10 mg
Oral
Onset 5-8hrs
Peak 5-8hrs
Half-life 32-50hrs
IM
Onset 15-45mins
Peak 15-45mins
See instructions in Half-life 30hrs
Less likely to cause EPSE than haloperidol.
N.B. IM must not be given
within 1 hour of injected
benzodiazepines
IM route results in initial maximum plasma
concentration 5 times higher than same dose given
orally.
Appendix 7 page
31.
11
Route &
Preparation
Pharmacokinetics
Major Side Effects
Practice Points
IM injection
7.5mg/ml
Onset 45mins-2hrs
Peak 1-3hrs
Not suitable in combination with
other antipsychotics
see instructions
for preparation
Appendix 5 page
29
Half-life 75 - 146hrs
Not likely to cause sedation
Comes as 9.75mg in 1.3ml (7.5mg/ml)
The recommended initial dose is 9.75mg (1.3ml) as a
single IM dose.
Range is 5.25mg (0.7ml) to 15mg (2ml) as a single
injection.
A lower dose of 5.25mg (0.7ml) may be given on the
basis of clinical need.
A second injection may be administered 2 hours after
the first injection, on the basis of clinical need,
No more than three injections should be given in a 24hour period.
Oral tablets /
orodispersible
tablets
500microgram
1mg, 2mg
Oral solution
1mg/ml
Peak 2hrs
Half-life 18hrs
EPSE
Risk of Hypotension
Dose
25-50mg oral or by
deep IM
Oral tablets
25mg
Oral
Onset / Peak 2-3hrs
Half-life 7-15hrs
Max dose in 24hours
100mg.
IM injection
25mg/ml
Medicine/Dose
Aripiprazole
Dose
IM only for RT
5.25mg to 15mg.
Max dose in 24 hours
30mg by any route
Oral not used in RT
Risperidone
Dose
Adult 2mg
Elderly 1-2mg
Dementia 250-500
micrograms
Max dose in 24hrs
2mg/day
Use in Dementia is licensed.
Use for other indications is unlicensed.
Use recommended where Risperidone prescribed
routinely
Promethazine
Prolonged sedation
Seizures
Cardio respiratory depression
Antimuscarinic effects
Use is unlicensed.
Limited evidence for efficacy but may be of use in
patients who are benzodiazepine tolerant.
IM
Onset / Peak 1-2hrs
Half-life 7-15hrs
12
The following drugs are not used routinelyin RT but have been used in specialist circumstances (not routinely stocked on wards).
Medicine/Dose
Route
Pharmacokinetics
IM
Onset 2-8hrs
Peak 24-36hrs
Major Side Effects
Practice Points
EPSE
Sudden death
Cardiac arrest
Arrhythmias
Give by deep IM injection into the gluteal muscle,
taking care not to give into a vein, as it can be fatal.
Zuclopenthixol Acetate
Dose
Adult 50- 150mg
Elderly 50-100mg
Max dose
150mg as a single dose
400mg over 14 days
Half-life 60hrs
Can be repeated after
2 to 3 days
Never use in pregnancy, in those who are neuroleptic
naïve, who are struggling, who are sensitive to EPSE,
those with cardiac disease, hepatic or renal
impairment.
Monitor for 48 hours
after each injection
using appendix 4 page
28
This is not an appropriate
drug for use in RT due to
long duration of action.
It may occasionally be used as part of a medium term
strategy.
Chlorpromazine
Dose
Oral
Adult 50-100mg
Elderly25-50mg
Oral
IM not recommended but
25-50mg has been used in
adults
IM
Peak 2-4 hrs
Half life 16-30hrs
Hypotension
Arrhythmias
Seizures
Prolonged sedation
Cardiac arrest
Sudden death
No longer recommended in RT
Not normally given IM because of the risk of severe
hypotension and prolonged unconsciousness, as well
as the reported association of high doses with sudden
death.
Painful at injection site
Diazepam
Dose range 2-10mg–lower
range in the elderly
IM do not use
Oral
I.V must be
given by a Dr
Peak 60mins
Half life 24-48hrs
Respiratory depression
IM not recommended due to variable absorption
Disinhibition
Lorazepam is the benzodiazepine of choice.
Peak 8mins
13
The following drugs are not used routinely in RT but have been used in specialist circumstances(not routinely stocked on wards).
Medicine
Route
Pharmacokinetics
Major Side Effects
Practice Points
IM
Peak 30-40mins
This product is poorly tolerated
and is associated with high
incidence of cardiac arrhythmias
Only for specialist use.
Highly sedating
Hypotension
Arrhythmias
Seizures
Prolonged sedation
Cardiac arrest
This is used occasionally in RT when a sedating effect
is required but should not be used without Consultant
Psychiatrist and Senior Clinical Pharmacist advice.
Paraldehyde
5-10ml initially
Can repeat after 2 hrs if
necessary
Max daily dose 20ml
Max 3 injections
Avoid prolonged contact with rubber or plastics.
Levomepromazine
(Methotrimeprazine)
Dose
Oral
Adult 25-50mg
Elderly not suitable
Oral
IM has been used 12.525mg in adults
IM
14
4
Risks of Rapid Tranquillisation
Prescribers should understand the cardiovascular effects of the acute administration of the
tranquillising drugs and the need to titrate the dose with caution.
All staff involved in administering or prescribing rapid tranquillisation, or monitoring
patients to whom injected rapid tranquillisation has been administered, should receive
yearly training to a minimum of basic life support (including CPR, Automated External
Defibrillator and Suction Machine).
Best practice (NICE guidelines) recommended the presence of a practitioner trained in
Immediate Life Support throughout the use of rapid tranquillisation.
Resuscitation equipment (including an automatic external defibrillator, an ambu-bag mask,
oxygen suction, first line resuscitation medications and Flumazenil) should be available
immediately in healthcare settings where rapid tranquillisation, physical intervention and
seclusion might be used. The equipment should be maintained and checked weekly by
Ward Managers and Pharmacy staff.
RISK IS INCREASED BY COMBINING RAPID TRANQUILLISATION
WITH PHYSICAL RESTRAINT
4.1
Medication for RT, particularly in the context of physical intervention, should be
used with caution owing to the following risks:a)
b)
c)
d)
e)
f)
g)
loss of consciousness instead of tranquillisation
sedation with loss of alertness
loss of airway
cardiovascular and respiratory collapse
interaction with medicines already prescribed or illicit substances taken
possible damage to patient-staff relationship
underlying coincidental physical disorders
There are specific risks associated with the different classes of medications that are
used in RT. The specific properties of the individual drugs should be taken into
consideration. When combinations are used, risks may be compounded.
4.2
Benzodiazepines:
a)
b)
c)
4.3
Loss of consciousness
Respiratory depression or arrest
Cardiovascular collapse (e.g. in service users receiving both clozapine and
benzodiazepines)
Antihistamines:
a)
b)
c)
Excessive sedation
Painful injection
Additional anti-muscarinic effects
15
4.4
Antipsychotics:
a)
b)
c)
d)
e)
f)
g)
h)
5
Loss of consciousness
Cardiovascular and respiratory complications and collapse – QT prolongation
Seizures
Subjective experience of restlessness (akathisia)
Acute muscular rigidity (dystonia)
Involuntary movements (dyskinesia)
Neuroleptic malignant syndrome
Excessive sedation
Carrying out Rapid Tranquillisation
Complete the rapid tranquillisation assessment and progress chart.
5.1
The ward doctor or duty doctor, depending on the time of day, should be called to
the location of the psychiatric emergency as soon as is practicable.
5.2
The advice of the senior psychiatrist or consultant should be available at all times
and should be used accordingly.
5.3
The patient should be able to respond to communication throughout.
5.4
The aim is to achieve a state of calm sufficient to minimise the risk posed to the
patient or to others.
5.5
Keep the drug regimen simple and document the treatment plan.
5.6
The initial doses of medicine should be small and within the recommended BNF
limits unless the patient is categorically known from previous episodes to require
larger doses.
5.7
Sufficient time must be allowed for the therapeutic response before doses are
repeated.
5.8
When a patient is transferred between units, a full medical history, including the
patient’s response to medications, any adverse effects, and an advance directive
should accompany them. Where possible, the patient’s account of their experience
of RT should also be included.
5.9
On discharge, all such information should be filed in their healthcare record and be
subject to regular review.
6
Oral therapy for Rapid Tranquillisation
6.1
Oral medication should be offered before injectable medication as far as possible.
6.2
All medication given in the short-term management of disturbed/violent behaviour
should be considered as part of RT (Inc PRN taken from an agreed RT protocol or
as part of an advance directive).
16
6.3
The bioavailability differs between routes of administration so prescriptions for oral
and intramuscular medications should be prescribed separately and the abbreviation
of PO/IM should not be used.
6.4
When the behavioural disturbance occurs in a non-psychotic context it is preferable
to initially use oral lorazepam alone or intramuscularly if necessary.
6.5
To achieve early onset of calming/sedation, or to achieve a lower dose of
antipsychotic, an oral antipsychotic in combination with oral lorazepam, should be
considered in the first instance. Combinations may be beneficial because it reduces
the dose of the more toxic antipsychotic that is required. It has been suggested that
the two classes of the drug have a synergistic action and that benzodiazepines may
counteract the lowering of seizure threshold by antipsychotics (Bottalgia et al,
1997).
6.6
Antipsychotics are best avoided in those with cardiovascular disease,
benzodiazepines are best avoided in those with compromised respiratory function
and haloperidol is best avoided in those who are neuroleptic naïve or who have a
history of severe extrapyramidal side effects.
6.7
MHRA has warned against the use of risperidone or olanzapine in the treatment of
behavioural symptoms of dementia, due to increased risk of stroke and death.
6.8
Sufficient time should be allowed for clinical response between oral doses of
medication for RT.
7
Injectable therapy for Rapid Tranquillisation
7.1
If injectable treatment proves necessary when oral therapy is refused, the
intramuscular route is preferred over the intravenous route from a safety point of
view. Nursing staff in the Mental Health Services in th Trust are not normally
trained to administer IV injections.
7.2
The patient should be transferred to the oral route of administration at the earliest
opportunity.
7.3
Lorazepam should be considered as first choice.
There have been difficulties
purchasing lorazepam injection. If this is unavailable it may be suitable to use IM
midazolam.
7.4
Olanzapine can be used where an antipsychotic is required in moderate disturbance
with psychosis (IM lorazepam should not be given within 1 hour of IM olanzapine).
7.5
Where haloperidol is to be used there should ideally be recent ECG. If there is not
one available and it is not possible to get one the D&T recommend that patient’s
pulse, BP and respiration should be monitored regularly and extreme caution should
be taken to ensure doses do not escalate above BNF maximum (see haloperidol
communication). When using IM haloperidol for managing disturbed/violent
behaviour, an antimuscarinic agent such as procyclidine should be immediately
available to reduce the risk of dystonia and other extrapyramidal side effects.
7.6
Aripiprazole can be considered only by IM injection.
17
7.7
Care must be taken when giving IM injections particularly to highly aroused and/or
violent individuals. The provision of adequate staff trained on the Trust Managing
Aggression and Violence Teamwork course should always be on standby even when
patients agree to IM treatment, as there are the inadvertent risks of intra-arterial
injection, bolus dosing, nerve damage, bruising, needle breakage in patients who
may struggle or are resistive, and also a higher than expected absorption rate due to
the increased blood flow to the muscles in a highly aroused individual
7.8
Zuclopenthixol acetate (Clopixol Acuphase) IM should be only used in specific
circumstances only. See section 8 for further information.
7.9
Sufficient time should be allowed for clinical response between IM doses of
medications for RT.
7.10
The use of two drugs of the same class for the purpose of RT should not occur.
7.11
Medications should never be mixed in the same syringe.
7.12
The manufacturers warn that the use of medication outside the SPC may increase the
risk of fatality and medication should only be given intramuscularly or intravenously
according to the manufacturer’s recommendations.
7.13
The IV administration of benzodiazepines or haloperidol should not be considered.
Absorption of diazepam by the IM route is erratic and this should be avoided if
possible.
8
The use of zuclopenthixol acetate injection (Clopixol Acuphase)
8.1
Zuclopenthixol acetate injection is not recommended for RT due to its significantly
delayed onset and relatively long duration of action. Onset of action is about 8
hours and it reaches peak levels in between 24 to 36 hours. The effects of sedation
usually begin after about 2 hours and peak after 12 hours.
8.2
However, it may be considered as an option in the management of RT when:a)
b)
c)
d)
8.3
8.4
Initial calming has been achieved and it is likely that repeated doses of IM
antipsychotics will be necessary.
It is clearly expected that the patient will be disturbed/violent over an extended
period of time and will refuse oral medication.
A patient has a past history of good and timely response to it.
An advance directive indicates that it is the treatment of choice.
If prescribed, it is important to consider the pharmacokinetics of other drugs
previously administered e.g. caution is necessary in a patient who has recently
received a dose of depot antipsychotic which has not yet reached peak levels.
Zuclopenthixol acetate SHOULD NOT BE USED on individuals who:
a) Are antipsychotic (neuroleptic) naïve i.e. patients without any previous
exposure to antipsychotic medication
b) Are sensitive to extrapyramidal side effects
c) Have cardiac disease
d) Have hepatic or renal impairment
18
e)
f)
g)
Are struggling
Are pregnant
Are not detained under the Mental Health Act
8.5
Prior to administering zuclopenthixol acetate (Clopixol Acuphase) to an informal
patient, consideration must be given to the risk of the patient leaving the ward before
the effect of the medicine can be fully established. Adverse reactions such as
extrapyramidal side effects (EPSE) or hypotension may not peak until 24 hours after
giving the injection. A minimum of 48 hours should elapse following the
administration of Acuphase before any leave is considered. Informal patients
wishing to leave within the 48 hours must be assessed under the Mental Health Act.
Evidence that the patient is not suffering any adverse reactions to the medication
must be documented in the case notes prior to the patient being granted any leave,
regardless of time elapsed following an injection of Acuphase.
Complete the 48 hour monitoring chart.
8.6
There is no such thing as “a course of Acuphase”. Once a first dose has been
prescribed the treatment plan should clearly document the circumstances when
further doses may be administered. Subsequent doses should not be written up on
the drug chart until the patient has been reassessed by a clinician and it has been
decided that they are going to be required.
8.6
Doses of 50-150mgs (elderly 50-100 mg) may be given up to a maximum of
400mgs in 2 weeks (and a maximum of 4 separate injections), with at least 24 hours
between doses.
9
Medications Not Recommended for Rapid Tranquillisation
a)
b)
c)
d)
e)
IM or oral chlorpromazine due to risk of hypotension and problems at
injection site.
IM diazepam due to erratic absorption.
IM depot antipsychotics.
Risperidone and in particular risperidone long acting injection – Risperdal
Consta®.
Antipsychotics in the management of disturbed/violent behaviour in service
users with dementia.
10
Doses for Rapid Tranquillisation
10.1
When using RT there may be certain circumstances in which the current BNF uses,
limits and SPC may be knowingly exceeded. This decision should not be taken
lightly and the risks should not be underestimated. A risk-benefit analysis should be
recorded in the case notes (or on RiO) and a rationale should be recorded in the care
plan. Where the risk-benefit is unclear, advice should be sought from clinicians not
directly involved in the patient’s care. If current BNF or SPC doses are exceeded,
frequent and intensive monitoring is needed along with important regular checks of
airway, level of consciousness, pulse, blood pressure, respiratory effort, temperature
and hydration.
10.2
In all circumstances of RT, the prescriber and medication administrator should pay
attention to:
The total dose of medication prescribed.
19
Arrangements for review.
Issues of consent, BNF and SPC and physical and mental status of the patient.
The progress of the service user, following the rapid tranquillisation assessment and
progress chart.
10.3
The dose of antipsychotic medication should be individualised for each patient.
This will be dependent on several factors including:
a)
b)
c)
Age (older patients generally require lower doses).
Concomitant physical disorders (such as renal, hepatic, cardiovascular or
neurological).
Concomitant medication.
11
Circumstances for special care (extra care)
11.1
11.2
The presence of congenital prolonged QT syndromes.
The concurrent prescription or use of other medication that lengthens QT intervals
both directly and indirectly.
The presence of certain disorders affecting metabolism, such as hypo- and
hyperthermia, stress and extreme emotions, and extreme physical exertion.
11.3
12
Medicines which may prolong the QT interval
12.1 Within normal dosage range
Moderate effect Tricyclic antidepressants Lofexidine
Buprenorphine (Subutex) Methadone
Thioridazine
Pimozide
High Effect
The QT prolongation effect is dose dependant; therefore any
above recommended doses should be considered a risk.
Antibiotics
Erythromycin
Clarithromycin
Ampicillin
Moxifloxacin
Norfloxacin
Antimalarials
Chloroquine
Mefloquine
Quinine
Antiarrythmics
Quinidine
Disopyramide
Procainamide
Sotalol
Amiodarone
Chlorpromazine
Quetiapine
Sertindole
antipsychotic used at
Others
Amantadine
Ciclosporin
Diphenhydramine
Hydroxyzine
Nicardipine
Tamoxifen
NB: many psychoactive illicit substances and over the counter herbal remedies
can have effects on cardiac function.
This is not an exhaustive list; for further information contact med.information@swyt.nhs.uk
20
12.2
High Dose antipsychotics and combinations of antipsychotics
Antipsychotic Maximum Dose chart
This table gives the maximum dose - these may be greater than those used in day to
day practice.
Drug
Trade Name
Maximum dose in Maximum depot dose
24 hours oral (mg) (mg/
Asenapine
Sycrest
20
Chlorpromazine Largactil
1000
Flupenthixol
Depixol
18
400 every 1/52
Fluphenazine
Modecate
20
100 every 2/52
Haloperidol
Serenace
20
300 every 4/52
Pimozide
Orap
20
Sulpiride
Dolmatil
2400
Trifluoperazine Stelazine
Not stated , Maudsley suggests 50mg
Zuclopenthixol
Clopixol
150
600 every 1/52
Amisulpride
Solian
1200
Aripiprazole
Abilify
30
Olanzapine
Zyprexa
20
Paliperidone
Zeplion
12
150 every 4/52
Quetiapine
Seroquel
750
Risperidone
Risperdal
16
50 every 2/52
Clozapine
Clozaril
900
(Seek advice if a patient on clozapine requires emergency psychiatric treatment as
there is an increased risk of respiratory depression with benzodiazepines)
Drug charts should show what people have actually had in 24 hours with the
maximum allowable dose. Consider what oral medications have been taken
and also consider whether a depot has been given. If you are looking at a rewritten chart please ask to check any discontinued charts.
13
Physical monitoring before, during and following Rapid Tranquillisation
13.1
BEFORE RT
Before prescribing RT, the prescribing doctor should:

Scrutinise the patient’s notes with regard to his/her general medical history
and consider the possibility of a physical examination.

Check for recent ECG, U&Es and urine drug screen results, a previous
history of severe extrapyramidal effects, previous response to RT or other
methods of managing imminent violence.

Review current prescribed medication and recently administered medication,
taking note of administrations of PRN prescriptions.

Every effort should be made to obtain baseline measurements of
temperature, blood pressure, pulse rate, respiratory rate and the level of
consciousness prior to the administration of drugs.

Those patients who are heavily sedated or using illicit drugs or alcohol
should not be secluded.

If seclusion is used there should be an increased vigilance.
21





13.2
If the patient is on regular antipsychotics, antidepressants and lithium as
combination therapies there is an increased risk of CNS toxicity.
Caution with young male patients as they are prone to dystonic reactions
(consider antimuscarinic i.e. procyclidine).
Older patients (ie greater than 65 years) should commence on no more than
half the recommended adult dose, and special care is required.
Lower doses may be needed if alcohol/drug abuse is suspected, if patients
are naïve to antipsychotics, older patients and with learning disabilities.
Emergency resuscitation equipment, procyclidine injection and flumazenil
injection must be available before treatment. Ensure the patient is monitored
using assessment and progress chart.
DURING RT
During RT the patient should be monitored by trained staff

Close monitoring (observation of patient within eyesight) by nursing staff is
required. Observations should be particularly frequent when a patient is
sedated.

After administration by injection, the monitoring of blood pressure, pulse,
temperature and respirations are essential.

Suggested every 15 minutes for 1 hour then half hourly until the patient is
ambulatory (the minimum screening time is 2 hours).

Some observations may be difficult if a patient remains agitated or
aggressive. Problems in this regard should be clearly documented and
discussed with the prescriber or the clinical team.

It is particularly important to ensure that well being is maintained if the
patient is asleep or appears to be asleep, then the monitoring of vital signs
including oxygen saturation via pulsoximetry continues.
13.3
FOLLOWING RT
The following should be recorded regularly in the patient’s notes, on RiO and using
assessment progress chart, at the intervals agreed by the multidisciplinary team, until the
patient becomes active again.
a) Alertness
b) Pulse
c) Respiratory rate
d) Blood pressure
e) Temperature
f)
Hydration





Fluid balance and electrolyte balance should be monitored as clinically
indicated.
ECG monitoring is recommended when injected antipsychotics have been
given in high doses.
If a patient is unconsciousness continuous pulse oximetry is recommended.
Following the episode of RT there should be a review meeting held and the
reasons for the RT and any activities required to prevent the need occurring
documented.
Actions should be taken that could prevent future episodes of RT.
22
14
Managing side
Tranquillisation
Complications
Acute dystonias
including
oculogyric crisis
Hypotension
(orthostatic or
<50mmHg
diastolic)
effects
and
Symptoms/Signs
Severe painful
muscular stiffness and
Parkinsons
complications
occurring
during
Rapid
Management
Procyclidine 5-10mg I.M (if not severe oral
may be given).
Fall in blood pressure
Lie patient flat and raise legs Monitor closely.
Seek medical advice.
Neuroleptic
Malignant
Syndrome
(NMS)
Increasing
temperature,
fluctuating blood
pressure, muscular
rigidity, confusion,
altered consciousness
Withhold antipsychotics.
Monitor closely.
Liaise with general medical team.
Arrhythmias
Slow (<50/minute) or
irregular pulse
An ECG should be done.
Withhold antipsychotics.
Monitor closely and liaise with specialist
medical team immediately.
Respiratory
Depression
Reducing respiratory
rate, reducing
consciousness
Give oxygen.
Raise legs.
If necessary ventilate mechanically.
14.1
If respiratory rate drops below 10/minute or Oxygen Saturation <90% ring
emergency services as per cardiopulmonary resuscitation procedures.
If patient has received benzodiazepines e.g. lorazepam it is important to have
flumazenil available. Flumazenil is required to be given by IV injection so this is
only possible by trained medical personnel.
How to give flumazenil:
1) 200 micrograms IV over 15 seconds.
2) If consciousness is not resumed within 60 seconds give 100 micrograms over
10 seconds.
3) Repeat at 60 second intervals. Maximum dose 1mg/24 hours.
Continue to monitor after respiratory rate returns to normal.
Flumazenil has a short duration of action so further doses may be required. Patients
may become agitated or anxious on awakening.
15
Rapid Tranquillisation in Older People
23
As RT of older patients is infrequent and it is advisable to contact the patient’s Consultant
or the Duty Consultant if there is any uncertainty over their management. Check for
treatable causes of the crisis and initiate treatment as soon as possible.
It is important to consider that older people may:






15.1






Require smaller doses of medication.
Have altered levels of metabolism and may be more frail.
Have pre-existing general medical illnesses and taking several medications (check
medical history up to date).
Be more likely to develop extrapyramidal side effects.
If suffering from dementia, be more likely to develop increased cognitive
impairment with high doses of medication.
Be naïve to antipsychotics and/or benzodiazepines.
Prescribing in dementia
Haloperidol can be unsuitable in patients with Lewy Body Dementia and should also
be avoided if the patient is suffering from Parkinson’s disease.
Lorazepam is usually the most appropriate initial medication, but care if known or
suspected respiratory disease, and if used it must be monitored more closely.
Lorazepam should be used as a monotherapy where possible.
If possible, use of antipsychotics should be discussed with the patient’s consultant
before initiating in this group.
Both haloperidol and procyclidine can increase cognitive impairment in patients
with dementia.
Use of antipsychotics should be discussed with the patient’s consultant before
initiating in this group. Both haloperidol and procyclidine can increase cognitive
impairment in patients with dementia.
Following MHRA advice, the use of antipsychotics is no longer recommended in
people with a previous history of cardiovascular disease, TIA or stroke. They are
not to be used in dementia-related psychosis or behavioural disturbance.
16
Rapid Tranquillisation in people with a Learning Disability
16.1
Additional care needed with those with Cerebral Palsy as they may be at risk of
postural deformities and hip dislocation.
There may be a higher rate of under detected visual and hearing problems
in the learning disability population.
A high proportion of people with learning disabilities may have an altered pain
threshold.
Many have an increased risk of certain physical health complications such as
cardiac and respiratory disorders, which contribute to potential hazards associated
with restraint.
The choice between using physical intervention and rapid tranquillisation as a
method of managing violent behaviour in those with a learning disability should be
part of an overall care plan.
16.2
16.3
16.4
16.5
24
Appendix 1
RAPID TRANQUILLISATION EPISODE
CRITERIA AND REVIEW PATHWAY, SWYPFT
NAME
WARD
RiO NUMBER
MHA STATUS
Inf/5(2), 4, 3, 2, other
ETHNICITY
DOB
(OR AFFIX LABEL HERE)
Criteria of Need for RT episode:
The patient currently is suffering from: (ring all episodes)
Severe Aggression
Severe Agitation
Severe Disinhibition
There is an immediate risk to self or others (tick box)
Non-pharmacological interventions not de-escalated behaviour
There is an immediate need for Rapid Tranquillisation
Joint medical and nursing consultation agree Nurse – name, grade
commencement of RT
RT commenced
Doctor – name, grade
Signed
Signed
Date
Time
Reviews of need for RT
(enter next due review and time after each review so long as RT continued)
Date & time review Actual review Continue RT Nursing
Medical
due
time
Yes/No
signature
signature
RT documentation reviewed by Ward Manager/ Deputy within 6 (signed – WM)
hours of commencement of RT?
RT documentation copied within 48 hours of ending RT to Ward (signed – WM)
Managers, Pharmacy and Senior Manager
25
Appendix 2
PP
RAPID TRANQUILLISATION – ASSESSMENT AND PROGRESS CHART
Patient name
RiO Number
Before RT commences, the following has been considered
Physical examination
Recent U & E
Recent Drug Screen
Recent ECG
History of EPSE
Past response to RT
This review led to these investigations or actions (specify any deemed necessary)
Step
Actual date and
time
Temp
BP
Pulse
bpm
Resprn.
Per min
RASS
score*
Comments
Signature
Pre-RT
Review
num 1*
2
3
4
5
6
7
8
9
10
11
12
13
14
* Every 15 minutes for first hour then half hourly until patient is ambulatory (minimum screening time 2hrs)
26
Appendix 3
The Richmond Agitation – Sedation Scale (SWYPFT adaptations)
Score Term Description
+4 Combative:
Overtly combative or violent; immediate danger to staff
+3 Very agitated
Frequently irritable/aggressive. damaging property.
+2 Agitated
Marked restlessness such as pacing, some irritability.
+1 Restless:
Anxious or apprehensive but movements not aggressive or vigorous
0 Alert and calm
-1 Drowsy:
Not fully alert, but has sustained (more than 10 seconds) awakening,
with eye contact to voice
-2 Light sedation:
Briefly (less than 10 seconds) awakens with eye contact to voice
-3 Moderate sedation:
Any movement (but no eye contact) to voice
-4 Deep sedation:
No response to voice, but any movement to physical stimulation
-5 Unarousable:
No response to voice or physical stimulation
Procedure
1. Observe patient. Is patient alert and calm? (score 0)
Does patient have behaviour that is consistent with restlessness or agitation?
2. If patient is not alert, in a loud speaking voice state patient’s name and direct patient to
open eyes and look at speaker. Repeat once if necessary.
Can prompt patient to continue looking at speaker.
27
Appendix 4
48 hour Intramuscular Clopixol Acuphase Monitoring Chart
Date of injection……………………………..Time of injection…………………………..Dose………………..
Date
Time
Temp
Pulse
Resp
BP
EPSE’s
Comment/Action
Within 2 hours
1
4 hourly onwards
2
3
4
5
6
7
8
28
Appendix 5
Guidance on the Preparation and Administration of
Aripiprazole (Abilify®) Intramuscular (IM) Injection

Indicated for the rapid control of agitation and disturbed behaviours in patients with
schizophrenia or in patients with manic episodes in Bipolar I Disorder, when oral
therapy is not appropriate.

For intramuscular use only. Do not administer intravenously or subcutaneously.

The aripiprazole injection strength is 7.5mg/ml

The aripiprazole vial contains 9.75mg in 1.3ml

The recommended initial dose for aripiprazole solution for injection is 9.75 mg (1.3
ml), administered as a single intramuscular injection.

The effective dose range of aripiprazole solution for injection is 5.25-15 mg as a
single injection. Patients with hepatic impairment should be managed cautiously.

A lower dose of 5.25 mg (0.7 ml) may be given, on the basis of individual clinical
status, which should also include consideration other medication already
administered either for maintenance or acute treatment.

A second injection may be administered 2 hours after the first injection, on the basis
of individual clinical status.

No more than three injections should be given in any 24-hour period.

The maximum dose in 24 hours of aripiprazole is 30 mg (including all formulations
of aripiprazole).

The following shows the volume required for doses of aripiprazole injection:
Dose of aripirazole required
5.25mg
9.75mg
15mg
Volume of aripiprazole inj.
(7.5mg/ml)
0.7ml
1.3ml (complete vial)
2ml (2 vials needed)
29
Appendix 6
HALOPERIDOL ADMINISTRATION – ORAL and INTRAMUSCULAR EQUIVALENT DOSES
Intramuscular doses generally have a greater bioavailability than oral doses, therefore the maximum recommended daily dose
for each route of administration is different. Use separate lines on the treatment sheet for each route of administration
.
Maximum oral dose in 24 hours is 20mg
Maximum IM dose in 24 hours is 12mg
Any doses above these should be monitored according to High Dose Antipsychotic
guidance
If a patient has received both haloperidol IM and oral in the last 24 hours. Use the conversion chart below to calculate how much the
patient has received in total:
APPROXIMATE EQUIVALENT DOSES (mg)
Oral Haloperidol
0.5
1
1.5
2.5
4.2
5
7.5
8.3
10
12.5
16.7
20
IM Haloperidol
0.3
0.6
0.9
1.5
2.5
3
4.5
5
6
7.5
10
12
For example:
Patient has been given 1 x 5mg haloperidol IM, followed 30 minutes later by 5mg orally, then 30 minutes later by another 5mg orally.
Convert to all oral doses, i.e. 8.3mg + 5mg + 5mg = 18.3mg oral equivalent
OR
Convert to all IM doses, i.e. 5mg + 3mg + 3mg = 11mg IM equivalent
Therefore the patient may receive a further 10mg oral equivalent or 5mg IM equivalent haloperidol within the 24 hour period.
References - Psychotropic Drug Directory 2012
eMC – SPC Haloperidol 5.5.04
Medicines Bulletin Number 3 Writing Prescriptions: Providing a Clear Record of Drug Therapy
30
Appendix 7
Guidance on the Preparation and Administration of
Olanzapine (Zyprexa®) Intramuscular (IM) Injection

Indicated for the rapid control of agitation and disturbed behaviours in patients with
schizophrenia or manic episode, when oral therapy is not appropriate.

For intramuscular use only. Do not administer intravenously or subcutaneously.

Administration is a maximum of three consecutive days.

The maximum dose in 24 hours is 20mg (including all formulations of olanzapine).

The recommended initial dose is 10mg. A lower dose (5mg or 7.5mg) may be given, on the
basis of individual clinical status (e.g. renal and/or hepatic impairment).

A second injection, 5-10mg, may be administered 2 hours after the first injection.

Not more than three injections should be given in any 24-hour period.

Patients receiving olanzapine intramuscularly should be closely monitored for the first 4
hours following the injection for hypotension, bradyarrhythmia and hypoventilation.

Intramuscular olanzapine and intramuscular lorazepam must not be administered within 1
hour of each other.

If olanzapine IM is prescribed as part of rapid tranquillisation ALWAYS follow the Rapid
Tranquillisation Policy, including patient monitoring parameters.
The following shows the volume required for doses of olanzapine injection:
Dose of olanzapine required
2.5mg
5mg
7.5mg
10mg
Volume of olanzapine inj.
5mg in ml
0.5ml
1.0ml
1.5ml
2.0ml
Reconstitution
1. Withdraw 2.1ml of water for injection into a sterile syringe. Inject into a vial of olanzapine.
2. Rotate the vial until the contents have completely dissolved, giving a yellow coloured
solution. Inspected visually for particulate matter prior to administration.
3. The vial contains 11 mg olanzapine as a solution of 5mg/ml.
4. Discard the syringe and any unused solution in accordance with appropriate clinical
procedures.
5. Use the solution immediately within 1 hour of reconstitution.
31
Appendix 8
Advice on the Preparation and Administration of Lorazepam
(Ativan®) Intramuscular (IM) Injection

IM lorazepam must only be administered diluted 1:1 with sodium chloride 0.9% or
water for injection.

IM Lorazepam must not be mixed with any diluents other than sodium chloride
0.9% or water for injection.

Lorazepam injection is only manufactured as one strength: 4mg in 1ml.

The following shows the volume required for doses of lorazepam injection 4mg in
1ml:
Dose required
0.5mg
1mg
2mg
3mg
4mg

Vol. of lorazepam
=
=
=
=
=
0.125ml
0.25ml
0.50ml
0.75ml
1.00ml
+
+
+
+
+
Vol. of diluent
0.125ml
0.25ml
0.50ml
0.75ml
1.00ml
Example:
For a prescription of lorazepam 2mg IM
Draw up 0.5ml of lorazepam 4mg in 1ml and 0.5ml of sodium chloride 0.9% or
0.5ml water for injection
Always remember to mix lorazepam 1:1 with diluent

If lorazepam IM is prescribed as part of rapid tranquillisation ALWAYS follow the
Rapid Tranquillisation Policy, including patient monitoring parameters.
Lorazepam injection MUST be stored in the FRIDGE
32
Appendix 9
Policy for the use of midazolam
injection in rapid tranquillisation
Introduction
This policy outlines the use of intramuscular midazolam for rapid tranquillisation, or the
treatment of agitation or aggression. This is only to be considered for action on receipt of a
memorandum from either the Chief Pharmacist, the Deputy Chief Pharmacist or the
Principal Pharmacist for Wakefield and Forensic. declaring an official shortage of
lorazepam injection and authorising the use of intramuscular midazolam
Midazolam is a benzodiazepine available as an intramuscular injection. It is not licensed for
agitation, but has been investigated in a randomised trial.
All formulations of midazolam were changed to controlled drug (schedule 3) status in 2008.
Within the trust this means that it should be stored in the controlled drugs cupboard
(midazolam does not need to be stored in a refrigerator) and all receipt and administration
of midazolam must be recorded in the ward controlled drugs register.
Prescribing and administering midazolam
Where an intramuscular benzodiazepine is required, in the event of an official shortage of
lorazepam, midazolam should be prescribed instead.
The recommended dose in adults is 2.5mg (2.5ml), or 5mg (5ml) if judged to be clinically
appropriate. A further dose may be given 30 minutes later if required. This may be titrated
up to 5mg or 7.5mg according to response.
The maximum cumulative dose should not exceed 15mg in 24 hours.
In elderly patients the initial dose should be 1 to 2mg (1 to 2ml). In working age adults
where renal, hepatic, respiratory or cardiac impairment is judged to be significant enough to
compromise the patient’s well-being, this starting dose can also be employed.
This may be repeated after 30 minutes.
The maximum cumulative dose should not exceed 7.5mg in 24 hours.
Midazolam is available at a strength of 1mg /1ml in either a 2ml or 5ml injection. It does
not require dilution before administration. Administration must be recorded in the
controlled drug register.
Wards must ensure they have access to flumazenil injection before administration. After
administration patients must be monitored according to the requirements of the rapid
tranquillisation policy, for four hours post dose.
33
Explanatory Notes
Repeated episodes of supply failure of lorazepam injection mean that an alternative
intramuscular (IM) benzodiazepine may be needed. Diazepam is inappropriate for use as an
intramuscular injection, despite this route being listed in the British National Formulary
(BNF) and manufacturer’s literature. Absorption following an IM injection is inconsistent,
leading to unpredictable therapeutic effect.
Midazolam is a benzodiazepine available as an intramuscular injection. It is indicated for
sedation before or during diagnostic or therapeutic procedures; premedication before
anaesthesia; induction of anaesthesia; and sedation in intensive care units. It has also been
investigated in rapid tranquillisation in randomized trials (TREC, 2003)
Doses used in these studies range from 2.5mg to 15mg, however higher doses led to a large
proportion of patients being asleep within 20 minutes. The risk of respiratory depression
with midazolam is thought to be greater than with lorazepam, so a more cautious approach
to initial doses is reasonable.
Absorption from intramuscular sites is rapid and complete, with peak plasma concentrations
reached within thirty minutes. Onset of sedation and subsequent arousal has been reported
to be quicker than lorazepam1. Elimination is also rapid, but repeated administration can
lead to accumulation, and increased risk of adverse effects such as respiratory depression.
Monitoring of the patient should continue for at least four hours after administration, using
the monitoring chart in the rapid tranquillisation policy.
Following IM administration patients may experience anterograde amnesia, with the patient
not able to remember events which occurred when the product was at maximum effect.
Midazolam products were reclassified as controlled drugs (schedule 3) on 1st January 2008.
This means that it is subject to controlled drug procedures, and receipt and administration
must be recorded in the controlled drug register.
The National Patient Safety Agency produced a Rapid Response Report concerning risks of
overdose caused by confusion between the different strengths of midazolam injection
(NPSA, 2008). The only strength which should be used in the trust for rapid tranquilisation
is the 1mg per ml preparation.
34
Appendix 10
Implementation
Dissemination
This policy will be implemented and disseminated throughout the organisation immediately
following approval and will be published on the Trust Intranet site. A hard copy will be
circulated to the in-patient areas. Staff will be alerted to changes to the policy through the
Trust management briefing process.
Associated Documentation:
1. The antipsychotic prescribing guidelines:
Aripiprazole communication
Haloperidol communication
2. Cardiopulmonary resuscitation policy.
3. Management of violence and aggression.
Review
The Drug and Therapeutics Sub Committee will review this policy 2 years after the
implementation, although it may be fully or part reviewed on any occasion prior to this
formal review in response to legislative changes or significant procedural changes in
nursing, medical or pharmacy practice. The D&T will however continuously monitor its
implementation and practice through an agreed programme of clinical audit as well as
reviewing annual reports, incident reports and minutes.
Compliance will be checked via the following audit parameter on each in-patient ward
These will include:
1. Rapid Tranquillisation episode criteria and review pathway.
2. Rapid Tranquillisation – assessment and progress chart.
3. Training via training records.
This will be carried out by the clinical governance sub-group of the D&T with each
locality/area being subject to audit at least every two years.
Appendix 11 - Equality Impact Assessment Tool
35
To be completed and attached to any policy document when submitted to the Executive Management Team for
consideration and approval.
Yes/No
1.
Comments
Does the policy/guidance affect one group less or
more favourably than another on the basis of:
 Race
 Ethnic origins
travellers)
No
(including
gypsies
and
No
 Nationality
No
 Gender
No
 Culture
No
 Religion or belief
No
 Sexual orientation including lesbian, gay
and bisexual people
No
 Age
Yes
Older people may require lower
doses of medication
 Disability - learning disabilities, physical
disability, sensory impairment and mental
health problems
Yes
People with physical disability
may require different doses of
medicines
2.
Is there any evidence that some groups are
affected differently?
Yes
Older people and people with a
physical disability
3.
If you have identified potential discrimination,
are any exceptions valid, legal and/or justifiable?
Yes
4.
Is the impact of the policy/guidance likely to be
negative?
NO
5.
If so can the impact be avoided?
N/A
6.
What alternatives are there to achieving the
policy/guidance without the impact?
N/A
7.
Can we reduce the impact by taking different
N/A
action?
If you have identified a potential discriminatory impact of this policy, please refer it to the Director of
Corporate Development or Head of Involvement and Inclusion together with any suggestions as to the action
required to avoid/reduce this impact.
For advice in respect of answering the above questions, please contact the Director of Corporate
Development or Head of Involvement and Inclusion.
36
Appendix 12 - Checklist for the Review and Approval of Procedural Document
To be completed and attached to any policy document when submitted to EMT for consideration and
approval.
Title of document being reviewed:
1.
2.
4.
5.
Comments
Title
Is the title clear and unambiguous?
Yes
Is it clear whether the document is a guideline,
policy, protocol or standard?
Yes
Rationale
Are reasons for development of the document
stated?
3.
Yes/No/
Unsure
Yes
Development Process
Is the method described in brief?
Yes
Are people involved in the development identified?
Yes
Do you feel a reasonable attempt has been made to
ensure relevant expertise has been used?
Yes
Is there evidence of consultation with stakeholders
and users?
Yes
Content
Is the objective of the document clear?
Yes
Is the target population clear and unambiguous?
Yes
Are the intended outcomes described?
Yes
Are the statements clear and unambiguous?
Yes
Evidence Base
Is the type of evidence to support the document
identified explicitly?
Yes
Are key references cited?
Yes
Are the references cited in full?
Yes
Are supporting documents referenced?
6.
Approval
Does the document identify which committee/group
will approve it?
Yes
If appropriate have the joint Human Resources/staff
side committee (or equivalent) approved the
document?
7.
Dissemination and Implementation
Is there an outline/plan to identify how this will be
done?
Yes
Does the plan include the necessary training/support
to ensure compliance?
Yes
37
Title of document being reviewed:
8.
9.
10.
11.
Yes/No/
Unsure
Comments
Document Control
Does the document identify where it will be held?
Yes
Have archiving arrangements for superseded
documents been addressed?
No
Process to Monitor Compliance and
Effectiveness
Are there measurable standards or KPIs to support
the monitoring of compliance with and
effectiveness of the document?
Yes
Is there a plan to review or audit compliance with
the document?
Yes
Review Date
Is the review date identified?
Yes
Is the frequency of review identified? If so is it
acceptable?
Yes
Overall Responsibility for the Document
Is it clear who will be responsible for
implementation and review of the document?
Lynn
Haygarth,
Chief
Pharmacist
38
Appendix 13
TRAINING NEEDS
1. Medical staffing
1.1. All medical staff working within the Trust will be directed to the rapid
tranquillisation guidance on the intranet at induction.
1.2. All medical staff are required to be trained on the use of rapid tranquillisation.
Junior medical staff will be required to undertake training annually. Middle grade
medical staff will be required to attend an update every 2 years. Consultant
Psychiatrists will be required to attend an update every 2 years.
2. Nursing Staff
2.1. There will be a rapid tranquillisation policy on each in-patient area and a laminated
copy of the algorithm in the clinic room.
2.2. Rapid tranquillisation will form part of the induction programme for the nursing
staff, including locum and agency staff.
2.3. Band 5+ nursing staff who work in the areas defined below.
2.3.1. They will be required to attend training on rapid tranquillisation annually
2.3.2. Although rapid tranquillisation is only suitable to be carried out on in-patient
areas it is important for staff working in crisis teams to be aware of the
processes.
2.3.3. It is the responsibility of the BDUs and the ward manager to ensure staff are
trained in the use of rapid tranquillisation.
3. Pharmacists
3.1. Rapid tranquillisation will form part of the induction programme for the
pharmacists including locum and agency staff.
3.2. All pharmacists who work in mental health are required to be trained on the use of
medicines in rapid tranquillisation. They will be required to attend training
annually.
4. Records of training will be held on the Trusts Education and Training
Management system.
39
Areas identified as requiring mandatory training in Rapid Tranquillisation
Calderdale
Beechdale
Elmdale
Ashdale
Kirklees
8 Fox View
Ward 19
Ward 18
Enfield Down
Wakefield
Chantry
Horizon Centre
Priory
Trinity 1
Trinity 2
Sycamores
Poplars
Saville Park View House
Castle Lodge
Forensic Services
Low Secure
The Bretton Centre:
Sandal, Thornhill, Ryburn and Almondbury
Newhaven
Medium Secure
Appleton
Bronte
Chippendale
Gaskell
Hepworth
Priestley
Waterton
Barnsley
Melton Suite (PICU)
Clark Ward (Female acute)
Beamshaw (Male Acute)
Willow (older adult)
Intensive Home Based Treatment staff to be trained in all localities, this training is
considered essential for this group.
Oct 2011
40
Appendix 14 - Version Control Sheet
This sheet should provide a history of previous versions of the policy and changes made
Version
Date
Author
Status
Comment / changes
1
2002?
Lynn Haygarth,
Professor Curran,
David
Hargreaves,
Professor Wattis,
Nisreen Booya
2
August
2005
Updated by Lynn
Haygarth and
David Hargreaves
Updated to include olanzapine IM injection
3
September
2008
Used principles in
Bradford District
Care Trust policy
with consent.
Updated by Lynn
Haygarth
Updated to include aripiprazole IM injection
and requirement for ECG when prescribing
haloperidol
Format brought in line with trust
requirements.
4
June 2010
Updated in line
with new
guidance
Updated by Lynn
Haygarth
 The introduction of a flow chart.
 Increase use of the forms for assessment
and progress and the consideration of the
process as a rapid tranquillisation
pathway.
 Appendices have been introduced for the
administration of the IM injectables.
5
Nov 2011
Updated to
include practice
in Barnsley.
Updated by Mark
Payne
5.1
December2
012
Updated to
include
Lorazepam IM by
Paul Hardy
 Change in the therapeutic positioning of
midazolam IM
 Addition of risperidone oral as treatment
option
 Amended interval for post-intervention
monitoring
 Reformatting of flow chart
 Lorazepam IM injection has recently
become available again. To enable either
Lorazepam IM or Midazolam IM to be
used within the Trust.
5.2
January
2013
Updated to stand
down midazolam
memo by Lynn
Haygarth
 Following D&T it was decided that
lorazepam to be IM benzodiazepine of
first choice and that midazolam 1mg/1ml
injection to be removed from wards
5.3
September
2013
Updated The
Richmond
Agitation –
Sedation Scale
Paul Hardy
 Updated the Richmond Agitiation
Sedation Scale for ease of use.
5.3.1
September
2014
Mark Payne
 Updated doses for haloperidol in line with
changes to BNF / SPC
41
References
SWYMHT Guidelines for Rapid Tranquillisation in adult acute psychiatric emergency Aug 2003
NICE Clinical Guideline 1: Schizophrenia. Core interventions in the treatment management of schizophrenia
in primary and secondary care.
National Institute of Clinical Excellence, December 2002. At www.nice.org.uk
NICE Clinical Guideline 25: Violence. The short term management of disturbed/violent behaviour in
psychiatric in-patient settings and emergency departments. National Institute for Clinical Excellence,
February 2005. At www.nice.org.uk
Bazire S
Psychotropic Drug Directory. London: Lloyd-Rheinhold, 2012
TREC Collaborative Group
Rapid Tranquillisation for agitated patients in emergency psychiatric rooms: a randomised trial of midazolam
versus haloperidol plus promethazine
British Journal of Psychiatry 2003; 327:708-13
McAllister-Williams RH, Ferrier IN.
Rapid tranquillisation: time for a reappraisal of options for parenteral therapy.
British Journal of Psychiatry 2002; 180:485-9.
Alexander J et al
Rapid Tranquillisation of violent or agitated patients in a psychiatric emergency setting
British Journal of Psychiatry 2004; 185:63-9
Kapur S et al
Evidence for onset of antipsychotic effects within the first 24 hours of treatment
Am J Psychiatry (2005); 162:939-46
MacPherson R et al
A growing evidence base for management guidelines
Re-visiting…Guidelines for the management of acutely disturbed psychiatric patients
Advances in Psychiatric Treatment (2005); 11:404-415
Davison S
The management of violence in general psychiatry
Advances in Psychiatric Treatment (2005); 11:362-370
Fenton M, Coutinho ESF & Campbell C
Zuclopenthixol acetate in the treatment of acute schizophrenia and similar serious mental illnesses.
The Cochrane Library, Issue 2, Chichester, UK: John Wiley & Sons, 2002.
Taylor D, Paton C & Kapur S
The Maudsley Prescribing Guidelines 11th Edition. London: Wiley-Blackwell, 2012
Pharmaceutical Press
British National Formulary July 2014 (Accessed online, http://www.BNF.org)
Summaries of Product Characteristics (SPC) (http://www.medicines.org.uk)
SWYPFT Cardiopulmonary Resuscitation Policy (Director of Nursing) 2010
42