MMP011 RAPID TRANQUILISATION POLICY

The current version of any policy, procedure, protocol or guideline is the version held on the NHFT internet. It is the responsibility of all staff to ensure that they are following the current version

MMP011 Rapid tranquillisation Policy - (Apr19 - Apr22) amended v1.2.docx

1 of 39 Implementation Date: April 2019

MMP011 RAPID TRANQUILISATION POLICY

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Table of Contents Why we need this Policy .................................................................................................... 4

What the Policy is trying to do ........................................................................................... 4

Settings ......................................................................................................................... 4

Age ................................................................................................................................ 5

Which stakeholders have been involved in the creation of this Policy ................................ 5

Any required definitions/explanations ............................................................................... 5

Rapid tranquilisation ..................................................................................................... 5

Advance decision: .......................................................................................................... 5

Advance statement:....................................................................................................... 5

De‑escalation: ............................................................................................................... 5

PRN: .............................................................................................................................. 6

Seclusion: ...................................................................................................................... 5

Restrictive interventions: ............................................................................................... 5

BNF ............................................................................................................................... 6

IM ................................................................................................................................. 6

NHFT …………………. ......................................................................................................... 6

AED ............................................................................................................................... 6

PICU ............................................................................................................................. 6

UTI ................................................................................................................................ 6

Key duties.......................................................................................................................... 6

The Medicine Management Committee ......................................................................... 6

Clinical Directors and Nursing Staff Managers ................................................................ 7

Nurse in charge of shift .................................................................................................. 7

Doctors .......................................................................................................................... 7

Senior Doctor or the Responsible Clinician or Consultant in Charge ............................... 8

Specialist Pharmacists.................................................................................................... 9

General Principle for Rapid Tranquilisation .................................................................. 10

Guidelines for the Use of Pharmacological Treatments ................................................ 12

1st Line Treatment: Lorazepam………………..…………………………………………………………………12

2nd Line Option 1: Promethazine………………………………………………………………………………...12

2nd Line option 2: Haloperidol and promethazine combination ................................... 13

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3rd Line option…………………………………………………………………………………………………………….13

Alternate medications for RT consideration under exceptional circumstances ............. 14

Rescue Medication for Benzodiazepines ...................................................................... 16

Medications not appropriate and not approved by the Trust for Rapid Tranquilisation 16

Patient Monitoring/Observation Requirements ........................................................... 17

Summary of Remedial Measures in Rapid Tranquilisation ............................................ 18

Post Rapid Tranquilisation Debriefing .......................................................................... 19

Rapid Tranquilisation in Older Adults ........................................................................... 19

Rapid Tranquilisation in Pregnancy and perinatal period .............................................. 20

Legal Aspects ............................................................................................................... 20

Training requirements associated with this Policy ............................................................ 22

Mandatory Training ..................................................................................................... 22

Specific Training not covered by Mandatory Training ................................................... 22

How this Policy will be monitored for compliance and effectiveness ................................ 22

Equality considerations ................................................................................................... 24

Document control details ................................................................................................ 27

APPENDIX 1 - COMPLICATIONS OF RAPID TRANQUILISATION AT USUAL DOSES (GOLDBERG

ET AL) .............................................................................................................................................. 28

APPENDIX 2 - NEWS ........................................................................................................................ 29

APPENIDX 3 - FORM T7 .................................................................................................................... 32

APPENIDX 4 – RAPID TRANQUILISATION FLOWCHART ..................................................................... 34

APPENDIX 5 – GUIDELINES FOR USE OF FLUMAZENIL INJECTION ..................................................... 37

APPENDIX 6 – PHARMACOKINETIC INFORMATION .......................................................................... 38

APPENDIX 7 POST RAPID TRANQUILISATION OBSERVATIONS SUMMARY CHART ............................. 39

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Why we need this Policy The management of disturbed/violent behaviour is deemed as a psychiatric emergency in

that such behaviour may be a serious risk to the health and safety of the patient or of others

and it frequently involves interventions such as: physical handling, rapid tranquilisation,

and/or seclusion to which an individual does not or cannot consent.

Medication, skilfully given (in the context of good clinical care and milieu), can safely and

effectively be used to manage disturbed /violent behaviour.

The use of rapid tranquilisation is a form of restraint reserved to the last resort after other

less restrictive attempts to de-escalate or defuse the aggressive/disturbed behaviours have

been unsuccessful or have been considered not appropriate in the situation or circumstance

being managed.

Driven by patient safety, positive engagement and patients’ dignity and based on NICE

guidance of the management of violence and aggression NG10, 2015, the recommendations

within this policy highlights the consensus views of the Trust Clinicians and the Medicines

Management Committee. All staff should follow the suggested treatment approaches for

rapid tranquilisation in this policy.

What the Policy is trying to do The purpose of this policy is to ensure that rapid tranquilisation is used safely and effectively

to manage disturbed/violent behaviour in line with agreed standards and guidelines. The

aim is not to induce sleep or unconsciousness and the patient should be sedated but still

ideally be able to participate in further assessment and treatment

Settings

Rapid tranquilisation should only be undertaken within in-patient psychiatric settings in

Northamptonshire Healthcare NHS Foundation Trust.

Even though acute behavioural and aggressive disturbances may occur either in a non-

psychotic context or within the context of psychosis, evidence suggests that higher level of

aggression occurs in inpatient psychiatric units, in comparison to other health and social care

settings.

Settings such as Planned Care and Recovery, Early Intervention, Urgent Care and Assessment

have low to medium risk for violence and aggression incidents and are excluded from using

rapid tranquilisation to control violent or aggressive behaviours. Staff members working in

excluded Northamptonshire Healthcare Foundation Trust units are advised to utilise the

routine safe and therapeutic approaches and conflict resolution techniques skills to de-

escalate the situation and where necessary arrange for immediate transfer of the person to

an in-patient setting for further management and or contacting the police. Refer to the

CLP060 - Policy on use of Physical Interventions

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Age

This guideline covers the use of rapid tranquilisation in patient aged 18 and over. See

MMP018 Rapid Tranquilisation Policy for use in Children and Young People aged 12 – 18

years.

Which stakeholders have been involved in the creation of this Policy All staff in service areas that support mental health patients who may require rapid

tranquilisation.

Any required definitions/explanations

Rapid tranquilisation

Is the use of medication by the parenteral route (usually intramuscular or, exceptionally,

intravenously) to manage disturbed/violent behaviour, and urgent sedation with medication

is needed (NICE Guideline NG10).

A state of calm is preferred, with the patient remaining conscious as the aim is not to induce

unconsciousness. An optimal response would be a reduction in agitation or aggression

without sedation, allowing the patient to participate in further assessment and treatment.

Advance Decision: To Refuse Treatment:

A written statement made by a person aged 18 or over that is legally binding and conveys a

person's decision to refuse specific treatments and interventions in the future. An Advanced

Decision cannot be used to request specific treatments or interventions. An advanced

decision will not apply if the treatment in question is for a mental disorder and the person is

detained under the Mental Health Act (1983).

Advance statement:

A written statement that conveys a person's preferences, wishes, beliefs and values about

their future treatment and care. An advance statement is not legally binding. However the

information will contribute to the best interests process and must be taken into account.

De-escalation:

A range of techniques to defuse or resolve the situations (also referred to as ‘defusing’)

involving the use of various psychosocial short-term techniques aimed at calming disruptive

behaviour and preventing disturbed/violent behaviour from occurring

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prn (when required): with respect to this guideline, refers to the prudent use of

medication to prevent escalation to a heightened state of arousal as part of de‑escalation

process in situations that may lead to violence or aggression. It does not include the use of

IM medication for rapid tranquilisation. When required (prn) medication can be used as part

of de-escalation strategy but prn medication used alone is not de‑escalation. When a

medication is written up in injection form on the prn section of the drug chart, the indication

must be specified as ‘rapid tranquilisation’.

Seclusion:

In accordance with the Mental Health Act 1983 Code of Practice: 'the supervised

confinement of a patient in a room, which may be locked. Its sole aim is to contain severely

disturbed behaviour that is likely to cause harm to others’.

Restrictive interventions:

Are interventions that may infringe a person's human rights and freedom of movement,

including observation, seclusion, manual restraint, mechanical restraint and rapid

tranquilisation. Restrictive intervention must be undertaken in a manner that complies with

the Human Rights Act 1998 and the relevant rights in the European Convention on Human

Rights

BNF –British National Formulary

IM – Intra Muscular

NEWS 2 – National Early Warning Score 2

NHFT –Northamptonshire Healthcare NHS Foundation Trust

AED – Automated External Defibrillators

PICU – Psychiatric Intensive Care Unit

UTI – Urinary Tract Infection

Key duties

The Medicine Management Committee

The committee is responsible for:

• Approving the policy prior to being ratified by the Policy Board

• Ensuring the effective implementation and dissemination of this policy

• The practice of rapid tranquilisation within the Trust will also be subject to on-going

monitoring through the existing incident reporting mechanisms.

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Clinical Directors and Nursing Staff Managers

Are responsible for:

• Raising awareness of the existence of the policy to all service areas and

disseminating amongst all the staff any information regarding development or

review of the policy

• Making sure that staff have read, understood and adhere to the policy

• Ensuring all staff are up to date with training related to this policy. Medical and

Qualified nursing staff working in In-Patient Psychiatric Wards must be trained in

Immediate Life Support Medical staff, Qualified Nursing staff and Managers of In-

Patient Psychiatric wards must be trained in Rapid Tranquilisation Training.

• Maintaining all necessary equipment and medicines related to the policy and

ensuring they are fit for purpose (including checks that flumazenil is available and in

date)

• Ensuring the policy is implemented in clinical practice

• Responding to requests for local practice data from the medicines management

committee.

Nurse in charge of shift

Is responsible for:

• Assessing the risk and implementing the policy when appropriate

• Ensuring that prn medications are considered in addition to other non-

pharmacological methods to defuse potentially aggressive or violent situations,

where appropriate

• Ensuring that a doctor is notified to attend the ward when a patient needs rapid

tranquilisation (see also Junior Doctor on call policy) and that RT medication is

prescribed (if not already prescribed)

• Administering the prescribed medication for RT, within a comprehensive care plan

for existing known in-patients or where the person has not responded to all previous

de-escalation techniques (non-pharmacological and prudent prn medicines use) and

there is need to prevent prolonged physical handling, ‘where practicable and within

the bounds of safety when considering the situation at hand, having weighed up the

risks and benefits’

• Allowing sufficient time for clinical response between doses of medications used

within de-escalation procedures and or for rapid tranquilisation

• Ensure the agreed level and frequency of monitoring as per the policy is undertaken

appropriately, unless otherwise advised by the attending doctor

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• Ensuring appropriate handover to the subsequent shift nurse in charge and

registered nurses on the shift

• Ensuring appropriate information follows the patient to another unit/ward where

patient moves to another unit

• As part of improving patient experience, encourage patients to participate at all

stages, including post-incident de-brief and documentation

• N.B. Ensuring that all cases of rapid tranquilisation are documented

comprehensively in the patient records and complete a DATIX(the DATIX record will

include a record of the time a doctor was called to attend the ward and the time

they arrived and the medication and dose given to the patient).

Ensure a Rapid Tranquilisation Checklist is completed and given to Ward Manager

The Rapid Tranquilisation Checklist which can be found on The Staffroom

Doctors

All doctors involved in rapid tranquilisation should have up to date resuscitation training up

to Immediate Life Support level.

Are responsible for:

• Attending promptly in person to the request for rapid tranquilisation review, ideally

within 30 minutes. (A verbal or e-mail message for medication for rapid

tranquilisation is not acceptable)

• During out of hours, the Duty Doctor must attend the ward as soon as possible. The

expectation is that this would be within 30 minutes of the call (see also Junior

Doctor on Call Policy CLP005)

• Remaining on the ward once the patient has received rapid tranquilisation

medication until it is clinically and medically safe to leave the patient in the sole care

of the nursing team

• Appropriately prescribing ‘as required’ prn medication as part of de-escalation

strategy including specifying the indication, dosing intervals and maximum dosage in

24 hours

• Clearly stating the indication as rapid tranquilisation for medicine(s) prescribed for

rapid tranquilisation on the Trust’s prescription and administration record

• Ensuring the care plan exists for the management of an individual prescribed rapid

tranquilisation medication. A specific rapid tranquilisation care plan can be found

on SystmOne

• Individualising the medication regime by tailoring doses to patient’s condition and

other medical conditions, taking the following into consideration:

the severity of symptoms,

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the patient’s age

pre-existing physical health problems and or non-psychiatric causes behavioural

disturbances (e.g. hypoglycaemia, delirium, substance abuse (drug / alcohol

intoxication, degree of frailty) allergies and adverse drug reactions

patient’s preferences or advance statements and decisions, previous response

to these medications, including adverse effects

potential for interactions with other medications (psychotropic or non-

psychotropic)

the total daily dose of medications prescribed and the amount of previous

medications already administered within the last 24 hours

the patient’s legal status , for example, Mental Health Act 1983 or presence of

Advance Decision, as this may impact on the choice and dose requirements

• Agreeing and advising on the frequency of monitoring post rapid tranquilisation as

per Trust policy

• Ensuring that medications for prn use are not routinely prescribed on admission for

all patients, and when prn medications are prescribed as part of a strategy to de-

escalate violent and aggressive behaviours, that they are tailored to individual need

and reviewed weekly

• Reviewing regularly (at least weekly) prn medications that are prescribed as part of

de-escalation strategy

• Ensuring that the nurse in charge is fully aware of any decisions regarding

medication

• Remaining available to attend an alert by staff members

• Where RT is utilised, undertaking review of patient’s response to all medications at

least once a day, until the next multidisciplinary meeting when a full review of care

plan led by the responsible clinician takes place

• Clearly and accurately documenting, in the patients clinical records, of the decisions

made and care plans reviewed or initiated during the RT incident

• Consulting or seeking advice of a senior colleague/Consultant (or consultant on-call

out of hours) when unsure or if initial plans to control the situation prove

ineffective.

Senior Doctor or the Responsible Clinician or Consultant in Charge

• Approves the individual medications regimen for the rapid tranquilisation episode

and or prn medication to reduce levels of arousal in patients who are at risk of

violence and aggression as soon as possible, in order to reduce the risks of repeated

doses of medication being administered or the risks of unintentional high dose

prescribing

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• Undertake full review of the patient and prescribed medications proposed or used

for rapid tranquilisation to ensure the appropriateness as soon as possible

• Complete all the appropriate and legal documentation including Form T7 where

applicable (The Responsible Clinician).

Specialist Pharmacists

http://www.nice.org.uk/guidance/cg136/chapter/1-guidance

• Provide advice on pharmacological plans with respect to rapid tranquilisation

• Prompt for appropriateness of care plans where rapid tranquilisation is involved and

prompting where appropriate for review of prn medications indicated for de-

escalation of violent behaviours risks

• Via quarterly reports and annual audits, provide reports regarding this policy

implementation and incidents of rapid tranquilisation to the Medicines Management

Committee

• Provide opportunities for patients/carers to discuss medication choices and any

associated risks and benefits.

RAPID TRANQUILISATION PROCESS

General Principle for Rapid Tranquilisation

All prescribing and administration of medications for rapid tranquilisation must be clear,

transparent and comply with MMP001 - Control of Medicines Policy. The suggested

treatment approaches for rapid tranquilisation in this policy (MMP011) must be followed.

Staff members are advised to comprehensively document a rapid tranquilisation incident

to justify if there are reasons that these approaches could not be followed.

Other non-pharmacological interventions should, where possible, also be explored, for

example increasing the level of observations of the patient, increasing the level of staffing,

changing the patients setting. This may include transfer to a Psychiatric Intensive Care Unit

(PICU). Patients should be treated with pharmacological treatments only after an

assessment of risk and when it has been established that the risk of not doing so is greater

than the risk of acute and rapid pharmacological treatment.

The intramuscular route is preferred over the intravenous one from a safety point of view

and oral treatment should succeed intramuscular administration as soon as possible.

Intravenous administration should only be used in exceptional circumstances and by suitably

trained / experienced staff.

Medication intended for rapid tranquilisation should be written up on the PRN section on

the inpatient chart with the indication clearly stating “for rapid tranquilisation”.

http://www.nice.org.uk/guidance/cg136/chapter/1-guidance

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Where clinically appropriate, on the basis of past experience of patient response to

medications, care plans for the management of an individual, should be developed in

advance of the episode of acutely disturbed behaviour. If medication for the indication of

rapid tranquilisation is prescribed, a care plan must be in place. Ward doctors must

complete a care plan when the decision is made to prescribe medication for RT. The care

plan should indicate the choice of the medication and take into consideration advance

statements or advance decisions, where available. Where more than one medication is

prescribed, the care plan should also specify the stage at which the medication should be

used, including the order in which they should be administered. If RT is required the doctor

must be called prior to any medication being administered to alert them to the fact that

the patient requires rapid tranquilisation to manage their violent/aggressive behaviour and

that they need to attend the ward to review the patient. If medication for rapid

tranquilisation has been prescribed, RT can be administered in accordance with the care

plan prior to the doctor attending the ward however; this course of action must be agreed

between the doctor and the nurse during the telephone discussion and documented on

SystmOne. The doctor must attend the ward to review the patient and their response to

medication. This should happen preferably within 30 minutes of the Doctor receiving the

call.

Where there is no care plan for rapid tranquilisation in place and a patient is acutely

disturbed to the extent of needing as a last resort rapid tranquilisation after non-drug

related de-escalation techniques and existing prescribed as required medicines (prn) has

been considered and used appropriately or felt to be in-appropriate, then a doctor must be

called to attend immediately and informed of the situation, background and urgency of the

situation by the nurse in charge.

Where a patient has not previously been assessed for rapid tranquilisation and medication

has not already been prescribed and a care plan is not in place, the patient must be

reviewed by a doctor before RT can be given. It is vital that the attending doctor obtains as

much history as possible from the patient and other sources before medication is given, as

the opportunity to make a diagnosis may be lost if the patient is sedated before an

understanding of their mental state is reached.

Decisions may be made to prescribe from the list of Trust approved rapid tranquilisation

medicines in the absence of detailed relevant information such as pre-existing medical

illnesses and current ECG, whilst expeditious approaches to obtaining and collating other

necessary information continues at the same time (e.g. pre-existing medical illnesses,

allergies, current drug details, arrangements made for all necessary tests as soon as able).

This is in order to avoid delaying putting treatment plans in place and this process should be

documented in the patient’s record.

The attending doctor must remain on the ward once the patient has received rapid

tranquilisation medication until it is clinically and medically safe to leave the patient in the

sole care of the nursing team.

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An initial multidisciplinary review of rapid tranquilisation medication should be carried out

as soon as practically possible during which the response to prescribed medication will be

discussed and or reviewed and documented.

If a service user is secluded, the potential complications of rapid tranquilisation should be

taken seriously. Refer to the CLP007 - Seclusion Policy and Appendix 1 (Goldberg et al.1989)

of this Policy.

Guidelines for the Use of Pharmacological Treatments

(Please refer to the flow chart at Appendix 4)

Polypharmacy within a class of medication (e.g. antipsychotics) should, where at all possible,

be avoided.

For full prescribing information, for a specific drug, refer to the Summary of Product

Characteristics at www.medicines.org.uk

Where a patient has already received antipsychotic medication within the last 24hours, this

must be taken into consideration. The total doses of all the antipsychotics should not

normally exceed the BNF maximum.

The minimum effective dose of any treatment should be used. The BNF (current version or

preferably the online version) recommendations for the maximum doses should be adhered

to unless exceptional circumstances arise. When these are exceeded, high dose protocols

should be followed. Please refer to MMG012 - Guidelines for the use of high dose

antipsychotics.

In all circumstances the decision to exceed current BNF limits must be taken in consultation

with a Consultant /Specialty trainee.

When selecting a treatment for management of the acute aggressive situation, it is

important to know how long the medication will remain in the system to allow appropriate

monitoring of physical health, mental health and adverse effects to take place. Decisions on

time intervals to repeat the administration of a medication and or to make a decision about

its therapeutic response/effect should be guided by a combination of the patient’s physical

observations, the half-life and time to maximum plasma concentration of individual

medicines.

First line treatment: Lorazepam

Lorazepam alone should be considered as first line treatment and is particularly

recommended where there is insufficient information to guide the choice of medication for

rapid tranquilisation, or when the service user has not taken antipsychotic medication

before (antipsychotic naive).

If there is a partial response to intramuscular lorazepam, consider a further dose, monitoring

both therapeutic and any adverse reactions.

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Benzodiazepines are commonly misused with other street drugs, so standard doses may be

ineffective in some tolerant users, and it might be better to avoid using benzodiazepines in

such circumstances.

Dose: IM Lorazepam 1mg- 2mg up to a maximum of 4mg in 24 hours (all dose forms). Repeat

after 30-60 minutes if necessary. Reduce dose in elderly – BNF maximum dose in elderly is

2mg in 24 hours.

Advantage: Favourable benefit/harm profile

Caution: contraindicated or inappropriate: Benzodiazepine hypersensitivity, respiratory

depression, CNS depression – see BNF Online for up-to-date information

Key points on Administration

Lorazepam should be mixed in a 1:1 ratio with water for injections before administration and

should not be mixed with other injections.

Oxygen and Flumazenil must be available for benzodiazepine-induced respiratory depression

2nd Line option 1: Haloperidol as single agent

NOTE: A pre-treatment/recent ECG is recommended

If there is no response to intramuscular lorazepam, the use of haloperidol as single agent

should be considered.

Recommended best practice is to use a single agent at a time, and only proceed to

administer haloperidol if and after lorazepam is not effective

Dose: 5mg repeated hourly if required. In the majority of patients, doses of up to 15mg are

sufficient. The maximum dose is 20mg in 24 hours.

Older adults: 2.5mg, up to a maximum of 5mg in 24 hours.

Doses above 5 mg in 24 hours should only be considered in patients who have tolerated

higher doses and after reassessment of the patient's individual benefit-risk profile.

Advantage: Can be considered for patients with respiratory disease (less risk of respiratory

depression), in patients tolerant to lorazepam or in patients who are not neuroleptic naïve

(risk of EPSE’s must be low).

Caution: As extrapyramidal symptoms including acute dystonic reactions can occur with

haloperidol an anticholinergic (e.g. Procyclidine 5-10mg IM) should also be prescribed as prn

but not to be administered unless signs or symptoms of extrapyramidal side effects are

observed.

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2nd Line option 2: Haloperidol and promethazine combination

Caution: cardiovascular disease, including a prolonged QT interval, or where there is no

access to recent electrocardiogram.

If there is evidence of cardiovascular disease, including a prolonged QT interval, or no

electrocardiogram has been carried out, avoid intramuscular haloperidol combined with

intramuscular promethazine and use intramuscular lorazepam instead.

Contraindication: Promethazine should be avoided within 14 days of MAOI used.

Dose: IM Haloperidol 5mg and IM Promethazine 50mg. Maximum doses: 20mg Haloperidol

in24 hours and 100mg Promethazine in 24 hours.

Older adults: IM 2.5mg haloperidol up to a maximum of 5mg in 24 hours. The dose of IM

promethazine should be reduced to between one half and one third of the adult dose

according to individual’s physical health status (see section on ‘Rapid Tranquilisation in Older

Adults’).

Promethazine has a slow onset of action. Wait 1-2 hours to assess effect before repeating

dose.


Dilution is not required for Promethazine IM injection.

Procyclidine would not normally be required when promethazine is administered with

haloperidol, because of promethazine’s anticholinergic effects. This anticholinergic effect

mitigates the risk of movement-related and extra-pyramidal side effects, especially in

comparison to when haloperidol is used alone or used with lorazepam.

3rd line option:

If there is a partial response to intramuscular haloperidol combined with intramuscular

promethazine, consider a further dose of the combination, after a minimum of two hours.

If there is no response to intramuscular haloperidol combined with intramuscular

promethazine, consider intramuscular lorazepam if this hasn't been used already during this

episode. If intramuscular lorazepam has already been used, arrange an urgent team meeting

to carry out a review and seek a second opinion if needed.

If there is no response to the treatment recommended in these guidelines advice should be

sought from the patient’s Responsible Clinician (or on-call consultant).

Alternate medications for RT consideration under exceptional circumstances

After careful evaluation of clinical status, IM Aripiprazole or IM Olanzapine may be

prescribed following consultation with senior medical staff. These medicines are reserved for

use in patients who have failed to respond to the above list of medicines (IM Lorazepam, IM

Haloperidol, or combination of IM Haloperidol and Promethazine) or where there are on-

going manufacturers supply issues with the standard medications.

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Intramuscular Aripiprazole

The manufacturer of aripiprazole recommends the use of lorazepam for service users

requiring sedation as well as calming.

Indication: for the rapid control of agitation and disturbed behaviours in patients with

schizophrenia or in patients with manic episodes in Bipolar I Disorder.

Dose: 9.75mg as a single dose

Range: 5.25mg (0.7ml). 9.75 mg (1.3 ml), 15mg (2ml) administered as a single intramuscular

injection

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 daily dose of aripiprazole is 30 mg (including all formulations of

aripiprazole).

Precautions for use

Simultaneous administration of injectable antipsychotics and parenteral benzodiazepine

may be associated with excessive sedation and cardiorespiratory depression. If parenteral

benzodiazepine therapy is deemed necessary in addition to aripiprazole solution for

injection, patients should be monitored for excessive sedation and for orthostatic

hypotension. Use with caution in patients with known cardiovascular disease (history of

myocardial infarction or ischaemic heart disease, heart failure, or conduction abnormalities),

cerebrovascular disease, conditions which would predispose patients to hypotension

(dehydration, hypovolemia, and treatment with antihypertensive medicinal products) or

hypertension, including accelerated or malignant. A VTE risk assessment is required due to

VTE risks associated with antipsychotic medication.

IM Olanzapine

Dose: 10mg

Patient should be closely monitored for excessive sedation and cardiorespiratory depression.

Olanzapine rapid acting intramuscular injection may only be administered up to a maximum

of 3 injections per episode.

Intramuscular lorazepam should not be given within 1 hour of i/m olanzapine.

IM Midazolam

Where there have been supply difficulties and or in the absence of IM lorazepam but where

a benzodiazepine is required, the use of midazolam may be considered. Midazolam is not

licensed for the acute management of disturbed/ violent behaviour.

The recommended dose of Midazolam is 2.5mg by intra-muscular injection and may be

repeated after 30-60 minutes if necessary. Upward titration of dose may be considered

according to response following discussion with the consultant

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One quarter to half (¼ - ½) of the recommend dose of midazolam should be used for the

elderly (>60 years), chronically (physically) ill patients, patients with impaired renal, hepatic

or cardiac function and patients with chronic respiratory insufficiency.

Special caution must be exercised when administering midazolam to these patient groups.

Full details of contraindications, cautions and side effects can be found in the Summary of

Product Characteristics for Hypnovel Injection. Repeated doses may lead to accumulation of

midazolam and increased risk of adverse effects, including respiratory depression

Patients should be monitored regularly for at least 4 hours after the last dose of midazolam

is administered in case of excessive sedation, respiratory depression or hypotension.

Following IM midazolam, anterograde amnesia of short duration may occur with the patient

not remembering events that occurred during the maximum activity of the compound.

Contraindication: severe respiratory failure or acute respiratory depression


Midazolam does not need to be mixed with water for injection prior to administration

Rescue Medication for Benzodiazepines

Flumazenil

Indication for use of intravenous Flumazenil is where the respiratory rate drops below

10/min due to benzodiazepine administration. Even though Flumazenil are stocked in all

units where rapid tranquilisation can be carried out, the emergency services should also be

called immediately when a drop in respiratory rate is observed.

Flumazenil may only be administered as intravenous treatment by a medic medic who is

competent in administering IV or emergency services.. The initial dose of flumazenil is 200

micrograms IV over 15 seconds. Repeated doses may be required as it is short acting. See

Appendix 5 for the guidelines on use of flumazenil.

Caution: Flumazenil is best avoided in epileptic patients, due to the risk of inducing seizures

– start mechanical ventilation instead and call the emergency services.

Important safety information

Should only be administered by, or under the direct supervision of, personnel experienced in

their use

See Appendix 5 for further information on the use of flumazenil

Medications not appropriate and not approved by the Trust for Rapid

Tranquilisation

Zuclopenthixol Acetate (Clopixol Acuphase) is an antipsychotic with intermediate length of

action and not considered appropriate for rapid tranquilisation. For guidance on the use of

Zuclopenthixol acetate injection see MMG006 - Guidelines for Use of Zuclopenthixol acetate

injection (Clopixol Acuphase).

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Patient Monitoring/Observation Requirements

Drugs for rapid tranquilisation, particularly in the context of restraint, should be used with

caution because of the following risks: -

• Heightened state of arousal that may lead to physiological changes • Loss of consciousness instead of sedation • Over sedation with loss of alertness • Positional Asphyxia • Existing impairment of physical health status e.g. Obesity, cardio vascular problems • Specific issues of distress in relation to diagnosis • Possible damage to the therapeutic partnership between service user and clinician. It is essential that rapid tranquilisation be used in such a way that ensures the safety of

service users, hence the need for the specified monitoring following administration of Rapid

tranquilisation. Monitoring arrangements in all cases should be determined by individual

care plans.

Constant visual observation of the patient should be maintained. This should be in

compliance with CLP 008 - Policy for Observation of Patients.

In addition for monitoring for medication specific side effects, the following vital physical

status should be monitored every 15 minutes, for the first hour and recorded on the NEWS2

chart:-

Blood pressure

Pulse

Temperature

Respiratory rate,

Oxygen Saturation

Level of Consciousness

Hydration status: (When assessing hydration status staff should consider the pre rapid

tranquilisation fluid intake of the client and also look for signs of dehydration such as thirst,

dry mouth, lips and eyes and a reduction in urine output and documented in the blank line

at the bottom of page one of the NEWS form (See appendix 2).

Level of consciousness: The following system is widely used and should be recorded on the

NEWS2 form every 15 minutes.

A – Alert (no further observation required)

C – New confusion

V – Responds to voice (contact Dr for urgent review, nurse in recovery position)

P – Responds to pain (nursed in recovery position, contact Dr and ambulance)

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U – Unresponsive (nursed in recovery position, contact Dr and ambulance)

After the first hour of physical observations following Rapid Tranquilisation if the patient is

alert and the NEWS2 chart is not indicating any deterioration in physical state then physical

observations may be discontinued. The reasons for discontinuing observations must be

clearly documented in the patient’s electronic patient record.

If the patient’s Level of Consciousness is Alert and Qualified Nursing staff or a Medic feel that

Post Rapid Tranquilisation observations should continue, as long as the NEWS2 chart does

not indicate deterioration in physical state or a need for increased physical observations to

be taken, the vital signs and observations can be reduced to hourly for four hours and then

discontinued.

If the patient has fallen asleep following Rapid Tranquilisation then the patient’s vital signs

should be monitored every 15 minutes for the first hour. After the first hour, as long as the

NEWS2 chart does not indicate a deterioration in physical state and a need for increased

physical observations to be taken, the vital signs and observations can be reduced to hourly

until the patient is ambulatory. However, if after 4 hours Post Rapid Tranquilisation the

patient is still not awake and / or has abnormal vital signs at this time, then increase these

observations to half-hourly until the patient is awake and has normal vital signs and the

patient requires medical review.

If at any time during the Post Rapid Tranquilisation observation period drops from Alert

then:-

Patients at level Voice and Pain should be nursed in the recovery position with airway

maintained. The Duty Dr should be informed. The emergency services should be contacted

by calling 9999

If the level of consciousness drops to Unresponsive or if there is a sudden deterioration in

any of the basic observations of temperature, pulse, BP or oxygen saturation which indicates

a deterioration in physical state on the NEWS2 chart then the emergency services should be

contacted by calling 9999.

An ECG should be performed at the earliest opportunity post rapid tranquilisation and where

assessment of QTc interval is above 440msec, specialist medical advice should be sought.

Hydration status should be documented in the blank line at the bottom of the page one of

the NEWS form. The NEWS form must be scanned into the patient’s notes at the earliest

opportunity post rapid tranquilisation incident.

If patient is asleep oxygen saturation by pulse oximetry must be continuously monitored

until patient is ambulatory.

For patient in seclusion or 136 suite and where it is deemed there is a risk to staff in entering

the room to complete physical observation, observing staff will maintain regular

communication with the patient to ascertain the effect of the medication using the ACVPU

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scale in those situations and documented report made at least every 15 minutes post rapid

tranquilisation for a patient in seclusion.

Resuscitation equipment and medication, including Flumazenil, must be available and easily

accessible and staff should be familiar with their use (See Trust Training Needs Analysis)

Summary of Remedial Measures in Rapid Tranquilisation

Problem Remedial Measure

Acute dystonia (including oculogyric crises) Give Procyclidine 5-10mgs IM

Reduced respiratory rate (<10/min) or oxygen saturation <90%)

Give Flumazenil if Benzodiazepine induced respiratory depression suspected. Initial dose 200micrograms IV over 15 seconds (See appendix 5)

Call the emergency services

If induced by any other sedative agent, ventilate mechanically

Irregular or slow (<50/min) pulse Refer to specialist medical care immediately

Fall in blood pressure (orthostatic or <50mmHg diastolic)

Lie patient flat, tilt bed towards head

Monitor closely

Increased temperature Withhold antipsychotics (Risk of NMS & perhaps Arrhythmias)

Post Rapid Tranquilisation Debriefing

Full documentation of the reason for any clinical decision during the interventions necessary

to manage individual’s disturbed/violent behaviour is vital.

With growing awareness that involuntary procedures produce traumatic reactions in

patients, especially following the use restrictive interventions such as rapid tranquilisation, a

suitable opportunity to discuss the incident and experiences should be provided. This should

be done by a staff member who is able to answer questions about the process, preferably

someone who was directly involved in the incident

A clear explanation of the reasons for the episode of compulsory treatment including rapid

tranquilisation should be offered to the patient and this should be discussed with the patient

and documented in the patient record system.

Support and time should also be offered to other people on the ward who are distressed by

the events to discuss their experience and should be offered the opportunity to document

their experiences and any disagreements with healthcare professionals.

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If a patient has not made any advanced decision or statements about the use of restrictive

interventions, staff to encourage them to do so as soon as possible.

If a patient is unable or unwilling to participate, they should be offered the opportunity

when they recover to review and revise the plans.

Patients should also be given the opportunity and the appropriate support to write their

account of their experience of rapid tranquilisation.

Rapid Tranquilisation in Older Adults

Similar principles as for adult patients should be applied. Particular care should be given to

co-existing medical states and prescribed medication, the risk of accumulation of sedatives

and the possibility of delirium. De-escalation techniques and where necessary, prn

medication should be used as part of this de-escalation process. Refer to the CLP060 - Policy

on physical interventions for adults.

In elderly patients physical causes e.g. chest infection, UTI, constipation etc. should always

be considered as a possible cause for disturbed behaviour and treated concomitantly.

The dosage of the medication for rapid tranquilisation in general should be 1/2 to 1/3 of the

dose used for younger adults depending on the patient's general physical condition and

health.

Older patients will absorb medications more slowly and so there will be a slower onset of

action, be sure to take this into consideration before repeating doses.

Older patients may also have an effectively larger volume of distribution which leads to a

longer duration of action, this needs to be considered so as to avoid accumulation.

There is a higher incidence of adverse effects in older patients; in particular paradoxical

disinhibition is much more likely with benzodiazepines than in working age patients and

elderly are particularly susceptible to the anticholinergic effects and confusion due to

promethazine.

In the elderly anticholinergics may be prescribed but should only be given in the event of the

patient developing extrapyramidal side effects.

In situations where dementia with Lewy bodies are present/cannot be ruled out, lorazepam

is probably the drug of choice and if antipsychotics is needed then low dose Haloperidol is

the drug of choice. In patients with Parkinson disorders, haloperidol should be avoided. The

dose of Haloperidol is a critical factor when determining the likelihood of severe adverse

effects.

Benzodiazepines should be used with caution in patients who have significant respiratory

impairment. Promethazine may confer anticholinergic action likely to affect cognitive

function in older/frail/dementia patients, but lower risks than alternative choice

(midazolam).

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Rapid Tranquilisation in Pregnancy and perinatal period

Pregnant women should not be secluded following rapid tranquilisation. Adapt restraint

techniques to avoid possible harm to foetus. Choose antipsychotics or benzodiazepines with

shorter half-lives. Manage care in close consultation with paediatrician and anaesthetist.

Legal Aspects

If administering rapid tranquilisation against the patient’s wishes then their legal status and

mental capacity must be taken in to account.

Detained patients:

Rapid tranquilisation will only be administered in emergency situations, therefore it will not

be provided under Section 58 Mental Health Act 1983 (MHA). Section 62 MHA will provide

the legal authority for administration provided that the treatment is immediately necessary

to:

• save the patient’s life;

OR

• prevent a serious deterioration of the patient’s condition, and the treatment

does not have unfavourable physical or psychological consequences which

cannot be reversed;

OR

• alleviate serious suffering by the patient, and the treatment does not have

unfavourable physical or psychological consequences which cannot be

reversed and does not entail significant physical hazard;

OR

• prevent patients behaving violently or being a danger to themselves or

others, and the treatment represents a minimum interference necessary for

that purpose, does not have unfavourable physical or psychological

consequences that cannot be reversed and does not entail significant

physical hazard

The Responsible Clinician must complete a Form T7 – (Appendix 3) which is only applicable

for patients who have been detained for over 3 months.

Informal patients

If it is intended to treat an informal patient with rapid tranquilisation and the patient is

assessed as lacking capacity then this would be administered using the principles of the

Mental Capacity Act 2005 (MCA) and accompanying Code of Practice. NHFT Policy CLP023 -

Mental Capacity Act (2005).

An assessment of capacity must be completed followed by a best interests’ decision checklist

to establish that it is in the persons’ best interests to be treated with rapid tranquilisation.

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This should be clearly recorded in the person’s clinical records using the NHFT Assessment of

Capacity Form and Best Interests Checklist.

In an emergency situation there may not be time or it may not be possible to follow the best

interests’ process in respect of consultation with others. If this is the case this should be

clearly documented along with reasons why.

It is unlikely that one treatment of rapid tranquilisation would lead to the need for a

Deprivation of Liberty Safeguards. If the need for this treatment is likely to be on-going then

consideration should be given to requesting a Mental Health Act Assessment.

If an informal patient is assessed as having capacity the MCA will not apply. Rapid

tranquilisation can be administered using the common-law doctrine of necessity and a

Mental Health Act assessment should be requested as a matter of urgency.

Please note:

• Rapid tranquilisation should only ever be used as a last resort when all other

attempts to address the patient’s needs have been unsuccessful.

• Any interventions used when administering rapid tranquilisation should be of the

least restrictive nature possible.

Training requirements associated with this Policy

Mandatory Training

Training required to fulfil this policy will be provided in accordance with the Trust’s Training

Needs Analysis. Management of training will be in accordance with the Trust’s Statutory and

Mandatory Training Policy. All staff involved in administering or prescribing rapid

tranquilisation, or monitoring patients to whom parenteral rapid tranquilisation has been

administered, should receive on-going competency training to a minimum of Immediate Life

Support and one-off NEWS2 training.

Specific Training not covered by Mandatory Training

Ad hoc training sessions based on an individual’s training needs as defined within their

annual appraisal or job description.

How this Policy will be monitored for compliance and effectiveness The table below outlines the Trust’s monitoring arrangements for this document. The Trust

reserves the right to commission additional work or change the monitoring arrangements to

meet organisational needs.

In addition to the reporting through the Datix reporting, the practice of rapid tranquilisation

will be formally audited within the Trust as part of the on-going cycle of monitoring of NICE

guidance across mental health services.

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Formal audit activity and reports in respect to this issue will be brought to the attention of

both the Medicines Management Committee and the Clinical Audit and Effectiveness

Committee Group to ensure robust review and action planning.

Aspect of

compliance or

effectiveness being

monitored

Method of

monitoring

Individual

responsible

for the

monitoring

Monitoring

frequency

Group or

committee

who receive

the findings

or report

Group or

committee or

individual

responsible for

completing any

actions

Duties To be addressed by the monitoring activities below.

Compliance with

Trust and NICE

guidance (i.e.

physical health

monitoring,

documenting,

completing care

plans, prescribing

appropriate

medication for RT)

Quarterly

monitoring

reports

Specialist

Pharmacist

Quarterly Medicines

Management

Committee

Medical Director

Prescribing

guidelines with

regard to Rapid

tranquilisation

Audit of

prescription

charts of all

patients

receiving RT

Specialist

Pharmacist

Annually Medicines

Management

Committee

Medical Director

How physical health

observations are

recorded, including

timeframes when

patients have

received rapid

tranquilisation

Audit of all

documentation

of post RT

monitoring

within System-

One

Specialist

Pharmacist

Annually Medicines

Management

Committee

Medical Director

Staff have

completed training

associated with this

policy in line with

Training will be monitored in line with the Statutory and Mandatory Training Policy.

of 39

Training Needs

Analysis

Equality considerations See Control of Medicines Policy MMP001

Reference Guide

Allen MH, Currier GW, Carpenter D, Ross RW, Docherty JP. The expert consensus guideline

series. Treatment of behavioral emergencies 2005. J Psychiatr Pract. 2005;11 Suppl 1:5-108;

quiz 10-2.

Atakan, Z. and Davies,T. (1997a) ABC of Mental Health – Mental Health Emergencies. British

Medical Journal. Jun 14;314(7096):1740-2.

BALDACARA, Leonardo; SANCHES, Marsal; CORDEIRO, Daniel Cruz and JACKOWSKI, Andrea

Parolin. Rapid tranquilization for agitated patients in emergency psychiatric rooms: a

randomized trial of olanzapine, ziprasidone, haloperidol plus promethazine, haloperidol plus

midazolam and haloperidol alone. Rev. Bras. Psiquiatr. [online]. 2011, vol.33, n.1, pp. 30-39.

ISSN 1516-4446. http://dx.doi.org/10.1590/S1516-44462011000100008

British National Formulary Online Version

Davies, T. (1999) Management of the Acutely Disturbed Patient. Prescribers Journal. 1999,

Vol 39: No. 3: 129 – 135

Dollery. (1998) Therapeutic Drugs 2nd Edition. [s.l.] Churchill Livingstone

Dubin J. (1986) Journal of Clinical Psychopharmacology, 6, 210-22

Dubin J. (1988) Journal of Clinical Psychiatry, 49 (Supp 12), 5-11

Kerr, I. and Taylor, D. (1997) Acute Disturbed or Violent Behaviour: Principles of Treatment.

Journal of Clinical Psychopharmacology, 11 (3), 271-277

Goldberg et al. (1989) Complications of Rapid Tranquilisation in [Anon] Clinical

Neuropharmacology [n.d.] [s.l.] [s.n]

Martindale: The Complete Drug Reference. (2017). Promethazine. Online: accessed

06/10/2020

Mental Capacity Act Code of Practice 2005 Policy including Deprivation of Liberty

Safeguards. January 2015 (CLP023)

http://dx.doi.org/10.1590/S1516-44462011000100008

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National Institute for Clinical Excellence (May 2015). Violence and aggression: short-term

management in mental health, health and community settings NICE guideline (NG10)

Available from: http://www.nice.org.uk/guidance/ng10

National Institute for Clinical Excellence (2007; Feb 2020) Antenatal and postnatal mental

health Clinical Management and Service Guidance CG192: NICE Available from

https://www.nice.org.uk/guidance/cg192

National Patient Safety Agency. (2010) Rapid Response Report RRR018 Preventing fatalities

from medication loading doses. [online] [s.l.] s.n.]. Available from: www.nrls.npsa.nhs.uk

https://improvement.nhs.uk/resources/learning-from-patient-safety-incidents/ (updated in

June 2018)

The recognition, prevention and therapeutic management of violence in mental health care,

(2002) London: United Kingdom Central Council for Nursing, Midwifery and Mental Health

Visiting

Paton C, Barnes TR, Cavanagh M-R, Taylor D, Lelliott P. High-dose and combination 5

antipsychotic prescribing in acute adult wards in the UK: the challenges posed by 6 prn

prescribing. The British journal of psychiatry. 2008; 192:435-39

Rocca P, Villari V, Bogetto F. Managing the aggressive and violent patient in the psychiatric

emergency. Prog Neuropsychopharmacol Biol Psychiatry. Jun 2006;30(4):586-98].

Stephen Bazire Psychotropic Drug Directory. 2018 The Professionals’ Handbook and Aide

Memoire

Summary of Product Characteristics (Lorazepam tablets) – Genus Pharmaceuticals. Accessed

24/09/2020 https://www.medicines.org.uk/emc/product/6137

Summary of Product Characteristics (Lorazepam injection) – Pfizer Ltd (Activan). Accessed

24/09/2020 https://www.medicines.org.uk/emc/product/5473/smpc

Summary of Product Characteristics (Olanzapine tablets) – Accord Healthcare Ltd. Accessed

24/09/2020 . https://www.medicines.org.uk/emc/product/6082/smpc

Summary of Product Characteristics (Haloperidol injection) – ADVANZ Pharma Accessed

02/10/2020 https://www.medicines.org.uk/emc/product/514/smpc

Summary of Product Characteristics (Aripiprazole tablets) – Otsuka Pharmaceuticals.

Accessed 02/10/2020 https://www.medicines.org.uk/emc/product/7969/smpc

Summary of Product Characteristics (Aripiprazole injection) – Otsuka Pharmaceuticals.

Accessed 02/10/2020 https://www.medicines.org.uk/emc/product/7962/smpc

Summary of Product Characteristics (Promethazine tablets) – Sanofi. Accessed 02/10/2020

https://www.medicines.org.uk/emc/product/5587/smpc

Taylor, D. Barne, T. Young, A. (2018) The Maudsley Prescribing Guidelines in Psychiatry, 13th

Edition. WILEY Blackwell.

http://www.nice.org.uk/guidance/ng10

https://www.nice.org.uk/guidance/cg192

http://www.nrls.npsa.nhs.uk/

https://improvement.nhs.uk/resources/learning-from-patient-safety-incidents/



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Yap, Y.G. and Camm, J. (2000) Risk of Torsades de pointes with non cardiac drugs. British

Medical Journal. 320, 1158-1159

Related Trust Policy

MMP001 - Control of Medicines Policy

MMG012 - Guidelines for the use of High Dose Antipsychotics

MMP018- Rapid Tranquilisation Policy for Children and Young people

CLP002 - Resuscitation and Related Medical Emergencies Policy

CLP008 - Policy for Observation of Patients

CLP023 – Mental Capacity Act (2005) & Deprivation of Liberty Policy

CLP007 - Seclusion Policy

CLP060 – Policy on Physical Interventions for adults.

CRM002 – Policy for management of Incidents

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Document control details

Author: Michaela Cox, Chief Pharmacist

Approved by and date: 09.04.19 – Trust Policy Board Amended March 2020 Amended November 2020

Responsible committee: Medicines Management Committee

Any other linked Policies: MMP001 - Control of Medicines Policy

MMG012 - Guidelines for the use of High Dose Antipsychotics

MMP018- Rapid Tranquilisation Policy for Children and Young people

CLP002 - Resuscitation and Related Medical Emergencies Policy

CLP008 - Policy for Observation of Patients

CLP023 – Mental Capacity Act (2005) & Deprivation of Liberty Policy

CLP007 - Seclusion Policy

CLP060 – Policy on Physical Interventions for adults.

CRM002 – Policy for management of Incidents

Policy number: MMP011

Version control: 1.2

Version No.

Date Ratified/ Amended

Date of Implementation

Next Review Date

Reason for Change (e.g. full rewrite, amendment to reflect new legislation, updated flowchart, minor amendments, etc.)

1.0 19.03.19 09.04.19 30.04.22 Review

1.1. 17.03.20 17.03.20 30.04.22 Minor amendments; addition of RT checklist

1.2 08.12.20 08.12.20 30.04.22 Minor amendments: clarification of wording relating to Mental Health Act regarding Advanced decisions to refuse treatment, Advanced Statement and Consent to treatment; replacement of NEWS chart with NEWS2 chart and amendment of wording relating to NEWS2 processes; clarification of procyclidine dose and posology

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APPENDIX 1 - COMPLICATIONS OF RAPID TRANQUILISATION AT USUAL DOSES (GOLDBERG

ET AL)

1. Local bruising pain or extravasation = up to 30% of patients. 2. Respiratory complications = 2% 3. Cardiovascular complications = 3%. Quinidine like effects of phenothiazines contra-

indicate these in patients with pre-existing dysrhythmia. Haloperidol is preferred but be aware of postural hypotension, bradycardia and QT prolongation.

4. Seizures particularly in non-compliant epileptics – avoid high dose Chlorpromazine. 5. Treat and evacuate patients with sustained convulsion (status epilepticus). PR or IV

Diazepam may be required along with airway control. 6. Neuroleptic malignant syndrome – heat exhaustion and heat stroke can arise

particularly in neuroleptic naïve patients. Close observation of temperature should be carried out and if suspected, arrange transfer to the General Hospital. CPK levels may be elevated due to intramuscular routes being used. This information should be passed to medical team.

7. Sudden (unexplained) death which, if it occurs, is often 2 to 3 minutes after intravenous injection. Most have toxic blood concentrations of neuroleptics. This is a particular hazard when patients have been unresponsive to intramuscular dosing and when BNF limits are exceeded.

8. Extra pyramidal symptoms, especially acute dystonia. This may affect 30% of patients in the first 24 hours and up to 50% of young males later on. It is painful and distressing and responds best to intravenous Procyclidine and Diazepam if required. It should prompt the review of future neuroleptic type and dose. It is particularly likely to occur when Haloperidol is used. Respiratory arrest can occur due to both dystonia and to excessive use of Diazepam. If untreated, hypoxic brain injury and cardiac arrest may follow. Appropriate resuscitation should begin and transfer to the General Hospital be arranged.

9. Aspiration of stomach contents may occur during prolonged restraint, tranquilisation or if consciousness is lost due to, for example, convulsion or withdrawal reaction and may lead to airway obstruction or respiratory distress, pneumonia or cardiac arrest due to vagal stimulation. Appropriate resuscitation should begin on the ward and the patient be transferred to the General Hospital.

10. Toxic megacolon, paralytic ileus and unstable blood sugar, thermo-regulation and anaphylactic reactions are rare but have been reported following rapid tranquilisation and rarely intramuscular administration may lead to inadvertent venepuncture which may be rapidly fatal.

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APPENDIX 2 – NEWS2

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Clinical Response to NEWS2 Triggers

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**Where NEWS2 is used in areas where a Registered Nurse is not part of the staffing, another appropriate registered professional must initiate the appropriate response**

If a decision is made not to follow the clinical response guidance above, this MUST be documented in the patient’s records with the rationale for the decision.

Nothing in this scheme should prevent a practitioner making an appropriate response based upon their clinical judgment.

SBAR Medical Handover template

Situation

Background

Assessment

Recommendation

Identify yourself, ensure you have called the right person

Identify the patient and their presenting problem

Give reason for current referral

Give background information on the patient

Give latest set of observations

Give status of ABCDE (Airway, Breathing, Circulation, Disability, Exposure) and your concerns

Give Early Warning Score

State clearly what you want the person you are calling to do (e.g. to visit or to give advice about patient management)

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APPENIDX 3 - FORM T7

Mental Health Act 1983 Section 62(1) MHA/Chapter 24 COP

Certificate of Administration of Urgent Treatment - Medication

I

(full name ) Northamptonshire Healthcare NHS Foundation Trust

and address)

The Responsible Clinician, certify that

(full name and

address of

patient)

Requires the following treatment as described under Section 62(1) of the Mental Health Act 1983 (give description of treatment)

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

I certify that the patient is: (* delete as appropriate)

a) * not capable of understanding the nature, purpose and likely effects of the above treatment: or

b) * has not consented to the above treatment

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In my opinion the treatment is immediately necessary to:

save the patient’s life; OR

prevent a serious deterioration of the patient’s condition, and the treatment does not have unfavourable physical or psychological consequences which cannot be reversed; OR

alleviate serious suffering by the patient, and the treatment does not have unfavourable physical or psychological consequences which cannot be reversed and does not entail significant physical hazard; OR

prevent patients behaving violently or being a danger to themselves or others, and the treatment represents a minimum interference necessary for that purpose, does not have unfavourable physical or psychological consequences which cannot be reversed and does not entail significant physical hazard.

Signed ……………………………………………. Date ………/………/………

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APPENIDX 4 – RAPID TRANQUILISATION FLOWCHART

MO

NIT

OR

VIT

AL

SIG

NS

Following the decision to use rapid tranquilisation (intramuscular medication)

Consider the prn medication(s) already administered, especially in the last 24hours.

Review notes for previous medical history and recent investigations

Consider physical examination

Is it necessary to use section 62?

If necessary consult with a more senior doctor at any stage if unsure

Choice of intramuscular medications.

Clinical variables to guide the choice of medicine.

See maximum dose guidance below

1st line

IM Lorazepam

Caution: Benzodiazepines are commonly misused with other street drugs, so standard doses may be ineffective in tolerant users

Consider:

If the patient is established on regular antipsychotics or has cardiovascular disease, including a prolonged QT interval,

If no ECG result available Dose

IM Lorazepam 1mg-2mg up to a maximum of 4mg in 24 hours (all dose forms).

Repeat after 30-60 minutes if necessary,

Oxygen and Flumazenil must be available for benzodiazepine-induced respiratory depression

2nd line

Option1

Haloperidol

initial dose of 5 mg

Avoid: Where the patient is known to be a cardiac patient and no recent ECG result

Caution:

In antipsychotic naive patients

If previous exposure to psychotropic unknown, because of immediate risk of acute dystonic reactions

Consider:

If the patient is benzodiazepine-tolerant or has respiratory disease

Patient’s risk of extrapyramidal side effect is not high Dose: 5mg repeated hourly if required. In the majority of patients doses of up to 15mg are sufficient. The maximum dose is 20mg per day Older adults: 2.5mg, up to a maximum of 5mg in 24 hours

Prophylactically prescribe Procyclidine 5 -10mg IM, minimum interval of 30 minutes, up to a maximum of 20mg in 24 hours up to 3 times in 24 hrs to be administered prn for EPSEs (acute dystonia)

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2nd line

Option2

Haloperidol

+ (plus)

Promethazine

Consider:

If there is no response to intramuscular lorazepam

In benzodiazepine tolerant patients

In high risk of movement-related side effects Avoid:

In patients taking monoamine oxidase inhibitors up to 14 days previously

Patient have contraindication to use of promethazine

Patient is known to be a cardiac patient and no recent ECG result Dose: IM Haloperidol 5mg and IM Promethazine 50mg. Maximum

doses: 20mg Haloperidol in 24 hours and 100mg Promethazine in 24

hours.

Older adults: IM 2.5mg haloperidol up to a maximum of 5mg in 24

hours. The dose of IM promethazine should be reduced to between

one half and one third of the adult dose according to individual’s

physical health status (see section on ‘Rapid Tranquilisation in Older

Adults’).

Promethazine has a slow onset of action. Wait 1-2 hours to assess

effect before repeating dose.

3rd line

If there is a partial response to intramuscular haloperidol combined with intramuscular promethazine, consider a further dose of the combination, after a minimum of two hours.

If there is no response to intramuscular haloperidol combined with intramuscular promethazine, consider intramuscular lorazepam if this hasn't been used already during this episode.

If intramuscular lorazepam has already been used, arrange an urgent team meeting to carry out a review and seek a second opinion if needed.

IM Aripiprazole or Olanzapine: are reserved for use in patients who have failed to respond to the above list of medicines or where there are on-going manufacturers supply issues with the standard medications

If there is no response to the treatment recommended in these guidelines advice should be sought from the patient’s consultant (or consultant on-call out of hours). The reason(s) for using IM aripiprazole or olanzapine for rapid tranquilisation (i.e. outside of this guideline) MUST be clearly documented in the patient’s notes.

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Once tranquilisation has been administered

Maintain monitoring of physical (Vital Signs) and mental state according to policy

Review causes of violence, diagnosis and consider on-going management. This is likely to require a review of continuing pharmacological treatment.

Document episode.

Complete incident form (DATIX), if tranquilisation administered

Conduct post incident debriefing of patients, staff and other witnesses. Offer the patient an opportunity to describe his or her experience in the notes.

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APPENDIX 5 – GUIDELINES FOR USE OF FLUMAZENIL INJECTION

Indication For benzodiazepine induced respiratory depression, if rate falls to below 10 breaths/min

Cautions and contra-indications Epileptic patients on long term benzodiazepines. Titrate dose in hepatic impairment

Dose and route Initial: 200micrograms IV over 15 seconds

If required level of breathing not reached after 60 seconds, then subsequent dose: 100micrograms over 10 seconds

Dose may be repeated at 60 second interval

Maximum dose 1mg in 24 hours (one initial dose and 8 subsequent doses)

Side effects Patients may become anxious, agitated or fearful on awakening. Seizures may occur in regular benzodiazepine users. Side-effects usually subside.

Monitoring Monitor respiratory rate continuously until rate returns to baseline level. Flumazenil has short half-life so rate may return to normal then deteriorate again

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APPENDIX 6 – PHARMACOKINETIC INFORMATION

Oral Intramuscular

Comments Time to Peak

Half life Time to

Peak Half life

Lorazepam 2 hours 12 hours 60-90 mins 12-16 hours

IM absorption is as

slow as oral, but quicker in an active

patient.

Olanzapine 5-8 hours 33.8 hours 15-45 mins 33.6 hours

IM produces a max

concentration 5 times greater than oral administration.

No need for ECG. Half-life is altered in

smokers.

Haloperidol

2-6 hours

20 hours 30-45 mins 20 hours

1mg oral approximately

equal to 0.5mg IM.

Aripiprazole 3-5 hours 75 – 146 hours*

1-3 hours 75 – 146 hours*

*Elimination half live is 75 hours in extensive

metabolisers of CYP2D6 and 146 hours in poor

metabolisers of CYP2D6.

There is no pharmacokinetic

difference between different oral formulations.

Promethazine

2 – 3 hours 4 – 6 hours

2 – 3 hours

5 – 14 hours

Onset of action after oral promethazine is believed to be 15-30

minutes. Oral promethazine

undergoes extensive first pass metabolism.

Only 25% reaches systemic circulation

unchanged.

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APPENDIX 7 - POST RAPID TRANQUILISATION OBSERVATIONS SUMMARY CHART Until

Undertake RT

observations

hourly

Undertake RT

Observations

every 15

minutes

Continue physical

observations &

call Junior Doctor

to review

Stop obs

Obs normal &

pt awake

Still

consciousness

level P & U after

4 hours or Obs

Abnormal

Rapid

Tranquilisation

medication

administered 1st Hour

Call Dr if obs

worsening

Call Dr if obs

worsening

Observations

normal & pt

awake

No

Yes

No

Yes

Yes

MMP011 RAPID TRANQUILISATION POLICY

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