Rapid Tranquillisation

By
Michael
Dixon (pharmacist) and Mark Regan (nurse)
 Quick Quiz
• 1. which is the safest RT medicine to give if
someone has COPD?
• 2. if someone needs a medication for violent
behaviour but they have known serious
cardiac condition what would you use?
• 3. if someone has never had an antipsychotic
before would you use IM haloperidol or IM
olanzapine for RT?
 Contents
• Definition
• NICE guidance
• Medication
• Injection sites
• Physical Health Monitoring– MEWS/Visual A-E
 Definition
• “the use of medication to treat disturbed or aggressive
patients who need to be calmed”.

• We will be discussing the use of medication for acutely

disturbed patients.

• There are non-drug techniques such as

- de-escalation techniques  
- seclusion
- restraint.
 Components of Agitation
• Motor and verbal overactivity
• Irritability → threatening gestures →
assaultiveness
• Impulsiveness
• Overwhelming fear / anxiety
• Poor judgement
• Personal distress
• Rapid fluctuations of mental state
 Psychiatric causes of agitation
Common causes are:
1. Psychosis
2. Mania
3. Delirium
4. Dementia
5. Agitated depression
6. Anxiety
7. Personality disorder
8. Akathisia
 Non-pharmacological approaches
Positive and safe care plans

• Primary

• Secondary

• Tertiary
 Points to consider
• How the patient is presenting?
• Cause of presentation? Use of drugs/alcohol?
• Physical health of patient
• Mental health act/mental capacity act status/advanced
statements
• Current prescribed medication?
• Allergies/adverse reactions to medicines
• Treatment options – what has worked well in the past
• Note - best predictor of behaviour/violence is past history –
consider this when prescribing
• Refer to senior doctor for advice if required
 NICE (1)
• MDT approach should be used for risk
assessment and management
• Take account previous episodes of
violence/aggression and what worked
• There should be a post RT review and debrief
• MDT including a pharmacist should review the
RT strategy for each patient at least weekly inc
target symptoms and drug choice/doses
 NICE (2)
• Make sure prn medicines don’t push doses above BNF
max. If necessary to increase above BNF seek advice from
senior doctors oncall
• Always include interval between prn doses when
prescribing. Prescribe oral and IM separately.
• If writing up IM medicines should specify muscle if
possible e.g. gluteal, deltoid
• Do not prescribe medicines prn routinely on admission.*
• *Only prescribe time-limited prn on admission if patient
very disturbed (ie max 3-4 days) esp if previous hx of
unpredictable escalation of aggressive behaviour
 Children /elderly
• Require smaller doses
• More sensitive to side effects of medication
• Trust rapid tranquillisation guidelines has
flowcharts for <18yrs, 18-65yrs and >65yrs old
 Trust Rapid Tranquillisation Guidance
• Oral Options
Lorazepam or promethazine
Haloperidol, aripiprazole, risperidone, quetiapine,
olanzapine

• Think what formulation to use – e.g.

- tabs,
- orodisperisible or liquid – these ensure compliance
not speed
 Oral Options
drug Time to peak Half life
Benzodiazepine/sedative
Lorazepam oral 2hrs 12-16hrs
Promethazine oral 2-3 hrs 10-19hrs

Antipsychotics
Aripiprazole oral 3-5hrs 75-146hrs
Haloperidol oral 2-6hrs 24hrs
Olanzapine oral 5-8 hrs 30hrs
Risperidone oral 1-2hrs 3-20hrs
Quetiapine tablets 1.5hrs 7hrs

Don’t normally use diazepam/clonazepam as long half life so

accumulate on repeated dosing
 Trust Rapid Tranquillisation guidance
• Moderately unwell
IM antipsychotic alone –
olanzapine/aripiprazole
IM lorazepam or promethazine alone

 Severely unwell
IM lorazepam + IM haloperidol
IM promethazine + IM haloperidol
 IM RT medicines
• All licensed for IM, not particular muscle unlike
depots which are either gluteal or deltoid
• NICE guidance recommends prescribing which
muscle is to be used e.g. gluteal, deltoid or other
muscle
• Never give lorazepam and promethazine together,
chose 1 of them only as the non-antipsychotic option
• If both prescribed in exceptional circumstances on
the medicine chart it should be clearly stated on the
prescription which is to be used 1st line and which is
2nd line
 IM options
Drug Time to peak Half life
Benzodiazepine/sedative
Promethazine injection 2-3 hrs 10-19hrs
Lorazepam injection 60-90 mins 12-16hrs

Antipsychotic
Haloperidol 5mg/ml short 20-40mins 24hrs
acting injection
Aripiprazole short acting 1hr 75-146hrs
injection
Olanzapine short acting 15-45mins 30hrs
injection

Zuclopenthixol acetate 24-36hrs 20 hrs

(acuphase – not classed as
RT)
 RT (1)
Lorazepam alone (1-2mg max 4mg/day, elderly
0.5mg, max 2mg/day)
- Preferable if already on antipsychotic or
cardiac problems
- Don’t use with patients with respiratory
problems or paradoxical agitation with
benzodiazepines.
- Peaks 60-90 mins
- Recommended by NICE as 1st line option
 RT (2)
Promethazine alone (25-50mg, max 100mg/day, elderly
12.5-25mg max 50mg/day)

• Peaks 2 hrs
• Useful if respiratory problems or paradoxical agitation
with benzodiazepines
• Longer acting than lorazepam
• BNF gives daily max of 50mg orally and 100mg IM. Oral
not licensed for rapid tranquillisation and we allow up to
100mg/day via oral or IM route.
 RT (3)
Haloperidol (5mg, max 20mg/day orally or 10mg/day IM,
elderly 0.5-1mg max oral 5mg/day, IM 3mg/day)
• IM dose approximately equivalent to 2/3 oral dose
• Usual IM dose in adult 5mg, antipsychotic naïve 2.5mg, elderly 0.5-1mg
• Always prescribe prn po/im procyclidine in case of EPSEs
• Requires mandatory ECG if possible e.g. at baseline then if on it regularly
after each dose increase
• SPC – contra-indicates it with other antipsychotics
• Avoid if cardiac problems or sensitive to EPSEs
• Can repeat dose 60mins
• Can use with lorazepam 1mg or promethazine 25-50mg in adults or half
dose in elderly
• Not used in child and adolescent Rapid tranquillisation protocol
 RT (4)
• IM Olanzapine (usual adult dose 5-10mg, elderly
2.5-5mg)
- Don’t give with benzodiazepines/promethazine
within 1hr
- Cant repeat within 2 hours
- Max 3 dose or 20mg in 24 hours
- Max effect within 15-45 mins
- Useful option for antipsychotic naïve patients or
people likely to have EPSEs
 RT (5)
• IM aripiprazole (usual adult dose 9.75mg -1.3ml, elderly
dose 5.25mg -0.7ml)
- can be used in combination with lorazepam (1-2mg)
- Do not repeat within 2 hours
- Max dose 3 injections or 30mg in 24 hours
- halve dose if on certain enzyme inhibitors e.g. fluoxetine
or give increased dose if on enzyme inducers e.g.
carbamazepine
- peaks at 60 mins
• Minimal EPSEs or sedation
 RT (5)
Haloperidol (5-10mg) + promethazine (25-50mg) combination
- if lorazepam alone hasn’t worked
- If patient has respiratory problems
- If patient needs an antipsychotic
- Max dose of haloperidol 10mg/24hrs & promethazine
100mg/24hrs
- Haloperidol peaks 15-45mins where as promethazine peaks
about 2hrs
- Prescribe prn procyclidine o/im
- Not good choice if cardiac problems
- Good choice if severe agitation/behavioural disturbance
 RT (6)
Haloperidol (5-10mg) + lorazepam (1-2mg) combination
- Max of lorazepam 4mg/24 hours & haloperidol
10mg/24 hours
- May need lower doses of each drug in combination
then if give either alone
- Prescribe prn po/im procyclidine
- Not good choice if cardiac problems
- Good choice if severe agitation/behavioural
disturbance
 Comparison side effects of Antipsychotics

Sedation EPSEs Hypotension Anticholinergic

Olanzapine Moderate Very low/low Low Low

Haloperidol Low High Low Low

Aripiprazole Low Low low low

 Deviation from RT guidance
• It is a guideline and deviation from it can occur with advice from senior medics ie
Consultant or Speciality Trainee. Examples of situations where deviation may be
considered include:
- risk versus benefits analysis supports prescribing
- it has not been practically possible to do a physical exam since admission
- it has not been to practically possible to do blood investigations since admission
- it has not been practical to do an ECG since admission
- benefits outweigh risks even in service users naïve to psychotropic medications.
• If deviating from this guideline there must be evidence of a robust attempt at
physically monitoring health parameters after administration of medication and
Visual A-E as a minimum when physical observations cannot be safely obtained.
Prescribing in antipsychotic naïve patients (1)

• More likely to get side effects

• Will respond to lower doses e.g.
Drug Min effective dose
1st episode multiple
Haloperidol po 2mg 4mg
Olanzapine po 5mg 7.5mg
Risperidone po 2mg 3mg

• Never use zuclopenthixol acetate

 Prescribing in antipsychotic naïve
adult patients (2)
• IM Options
– olanzapine 5mg
- haloperidol 2.5mg +/- lorazepam 1mg or
promethazine 25mg,
- Aripiprazole 5.25mg
 Drugs not recommended
• IM chlorpromazine – postural hypotension,
painful on injection
• IM diazepam – can accumulate/unpredictable
erratic absorption
• antipsychotics if patient has dementia
 Short acting antipsychotic
injections Antipsychotic long acting
(rapid tranquillisation): depot injections:

 Haloperidol 5mg/ml injection –no  Paliperidone depot –

muscle specified deltoid or gluteal
 Olanzapine 10mg injection– no  Risperidone consta depot – deltoid or gluteal
muscle specified  Olanzapine depot –
 Lorazepam 4mg/ml injection– no gluteal muscle
muscle specified  Aripiprazole depot –
 Aripiprazole 9.75mg injection– no gluteal or deltoid muscle
muscle specified  Zuclopenthixol decanoate depot – gluteal or

 Promethazine injection– no muscle lateral thigh muscle

 Flupentixol depot –
specified
 Zuclopenthixol acetate (acuphase) gluteal or lateral thigh muscle
 Haloperidol decanoate depot – gluteal
gluteal or lateral thigh muscle
muscle
 Fluphenazine depot –

gluteal muscle
Alternative sites-
To avoid use of prone restraint
Range of Volume for
Injection Site effective muscle absorption

 The dorsogluteal site: the injection is administered  1 to 3mls

into the gluteus maximus muscle in the buttock.
The upper outer quadrant of this area must be used
to avoid any damage to the sciatic nerve.
 1 to 3mls
 The vastus lateralis site: a large muscle in the thigh
free from major nerves and vascular structures.
 The deltoid site: this site, on the lateral upper  0.5 to 2mls
aspect of the arm, is used for the administration of
smaller volumes of solution.
 The ventrogluteal site: the injection is administered  1 to 3mls
into the gluteus medius and maximus muscles of
the hip area.
 Physical restraint
 Can only be used if there is a legal authority to treat without
consent.
 The use of restraint to administer non-emergency medication
should be avoided wherever possible, and should first be
discussed with the MDT and documented and justified in
patient’s notes.
 Wherever possible the use of prone restraint to administer IM
medication should be avoided
 NG 10 identifies 10 minutes as a prolonged restraint and
advises rapid tranquillisation (and/or seclusion) to be
considered to bring to an end as soon as possible
 Observation checks
• MEWs
• After oral – only if MDT decide its necessary
• After IM – MEWs obs every 15 mins for 1 hour
then every 15mins until ambulatory
• Review obs hourly
• Document on ward physical health
observation charts
• Use visual A-E chart if MEWS not possible
• IM meds – have obs for at least 1 hour
• Datix for everyone who has po/IM rapid tranq
 Post RT debrief
• A review should take place within 48hrs of
how RT went including nurse & dr
• review RT prescription for what to use if
needed in future and involve service user in
decision
• Weekly review of “prn” medicines involving
medic, nurse and pharmacist
• Debrief should take place with service user
within 48hrs
 Zuclopenthixol acetate (Acuphase)
• Not rapid-acting drug
• Sedation starts at 4 hours
• Onset of action 8 hours and peaks at 36 hours
• Duration of action = 2-3 days
• Max: dose 150mg per injection, 4 injections or
2 week course
• Senior doctor to prescribe/advise
• do observation sheet in guidelines for 24hrs
 Zuclopenthixol acetate (Acuphase)
• NICE 2005 says:
 Service user will be disturbed/violent over an
extended period of time
 Past history of good response
 Past history of repeated injections needed
 Cited in advance directive
 NEVER give if antipsychotic naïve
Complications of Rapid Tranquillisation
• Benzodiazepines – loss of consciousness, resp
depression, cardiovascular collapse
• Antipsychotics – loss of consciousness,
cardiovascular complications (arrhythmias/QTc
prolongation, postural hypotension) and
collapse, seizures, EPSEs, NMS
 COVID positive patients
• Avoid benzodiazepines due to likely
respiratory problems
• Do not use zuclopenthixol acetate (Acuphase)
as lasts 3 days, only use short acting IM
antipsychotics ie olanzapine, aripiprazole,
haloperidol (care as COVID can cause cardiac
problems)
• MEWs – patients with COVID can deteriorate
rapidly so may need to do more stringent
monitoring
 Flumazenil
• Benzodiazepine antagonist
• IV injection
• If respiratory rate less than 10 breaths/min
• Initial dose – 200micrograms over 15 secs
• Contra-indications – mixed intoxication,
• Cautions – epilepsy, long-term benzos
• Short half life (40-80 mins) – benzo may last
longer - monitoring
 Restrictive Interventions
• Complete Datix
• If giving IM medicines for rapid tranquillisation
or using oral medicines to restrict someone
 Any questions?
• Speak to your pharmacy department to clarify
anything
• Alternatively if not urgent email Michael Dixon
at michael.dixon1@nhs.net