Download Guidelines for Safe Pharmacological Treatments Disturbed/Violent

Affiliated Teaching Hospital
Index No: MMG24 (Replaces MM24)
Guidelines for Safe Pharmacological Treatments Disturbed/Violent Behaviour
Non-psychiatric Setting
[Admissions and Emergency Care Settings]
Version:
3
Date ratified:
March 2015
Ratified by:
(Name of Committee)
Medicines Management Committee
Name of originator/author, job title and
department:
Ajibola Gbadebo
Pharmacist Advanced Mental Health
Director Lead (Trust-wide policies)
Associate Medical Director (local
Policies)
Clinical Management Team /
Directorate Applicable to
Name of responsible committee for the
policy:
Medical Director
Trustwide
Medicines Management Committee
Date issued for publication:
March 2015
Review date:
December 2017
Expiry date:
(Date 3 months following review date)
March 2018
Equality impact assessed by:
(name, job title and department)
Michaela Cox
Pharmacist Team Manager
(Mental Health) March 2010
Registration Requirements Outcome
Number(s) (CQC)
Related documents
National Health Service
Authority standard 5.10
Litigation
National Institute for Health and Clinical
Excellence CG25/CG82
 Prevention and management of
violence and aggression (B.5.2) KGH
Policy Index No B52 POLICY –
MANAGING
VIOLENCE
AND
AGGRESSION
 KGH Resuscitation Policy
 Resuscitation and Anaphylaxis Policy
 Resuscitation & Basic Life Support
with Defibrillation Essential Training
Schedule
MMG24 Version 3
Guidelines for Safe Pharmacological Treatments Disturbed/Violent
Behaviour Non-psychiatric Setting
[Admissions and Emergency Care Settings]
Page 1 of 19
Chairman: Graham Foster JP
Chief Executive: David Sissling
Affiliated Teaching Hospital
CONTRIBUTION LIST
Individuals involved in developing the document
Name
Designation
Ajibola Gbadebo
Pharmacist Advanced Mental Health
Dr Shruti Lodi
Consultant Psychiatrist for older People
(Acute Hospital Liaison Service (AHLS)
Dr Hiral Hazari
(Consultant Psychiatrist/Clinical Tutor/ Crisis
Resolution/Home Treatment Team)
Circulated to the following individuals for consultation
Name
Designation
Mandy Blackman
Lead Nurse A&E
Dr Rashid Khan
MH Liaison Consultant, NHFT
Sue Bates
MHA/MCA Advisor Mental Health, NHFT
MMG24 Version 3
Guidelines for Safe Pharmacological Treatments Disturbed/Violent
Behaviour Non-psychiatric Setting
[Admissions and Emergency Care Settings]
Page 2 of 19
Chairman: Graham Foster JP
Chief Executive: David Sissling
Affiliated Teaching Hospital
Index No.
MMG24
Approval and Authorisation
Completion of the following signature blocks signifies the review and approval of this
process.
Name
Job Title
Signature
Date
Local Committee approval (where applicable)
Name of Committee
Name of
Chairperson
Date of Approval
Medicines Management Committee
Robin Lee
11/03/2015
Change History
Version
Date
Author
Michaela Cox,
Specialist
Clinical
Pharmacist
Team Leader
Current version
Ajibola Gbadebo
MMG24 Version 3
Guidelines for Safe Pharmacological Treatments Disturbed/Violent
Behaviour Non-psychiatric Setting
[Admissions and Emergency Care Settings]
Page 3 of 19
Reason
Initial draft document
(policy) ratified by the
Quality Governance Board,
Medicines Management
Committee September 2012
Based upon rapidly
expanding clinical
evidences and emerging
best practice outcomes, the
document was redefined as
short term management of
violent and aggression
(Rapid Tranquillisation)
guideline to cover:
Chairman: Graham Foster JP
Chief Executive: David Sissling
Affiliated Teaching Hospital

Legal aspect of
common law doctrine
of Mental Capacity
Act

Management of
patients who have
not been diagnosed
with mental health
disorders as
reflecting on the
different type of
patients attending
Medical Admission
Units and Accident
&Emergency Units.
Up to date wider variety of
available antipsychotics
approved for management
of aggressive behaviours
MMG24 Version 3
Guidelines for Safe Pharmacological Treatments Disturbed/Violent
Behaviour Non-psychiatric Setting
[Admissions and Emergency Care Settings]
Page 4 of 19
Chairman: Graham Foster JP
Chief Executive: David Sissling
Affiliated Teaching Hospital
CONTENTS PAGE
1.0
Introduction
6
2.0
Definition
6
3.0
Legal aspects of utilising rapid tranquillisation
6
4.0
Aim
6
5.0
General principles for safe pharmacological management RT
7
6.0
Choosing medication for RT
7
6.1 Benzodiazepines
8
6.2 Antipsychotics
8
6.3 Antihistamines
10
7.0
Doses
10
8.0
Administration Routes
11
9.0
Monitoring Requirements Post RT
11
10.0
Debriefing & Documentation
12
11.0
Training
12
12.0
Monitoring Compliance with this Document
13
13.0
References
14
Appendix 1 –
16
Remedial Measures for potential side effects during RT
Appendix 2 – RT Age 18 to 60
17
Appendix3 – RT For Patients with Cortical
Dysgenesis/Destruction
18
Appendix 4 – RT Age 60+
19
MMG24 Version 3
Guidelines for Safe Pharmacological Treatments Disturbed/Violent
Behaviour Non-psychiatric Setting
[Admissions and Emergency Care Settings]
Page 5 of 19
Chairman: Graham Foster JP
Chief Executive: David Sissling
Affiliated Teaching Hospital
1.0 Introduction
It is recognised that incidents of violence and aggression in acute admission and
emergency settings can come from a number of sources outside of patients
experiencing mental health crisis, whereby a single case may be a culmination of
mixed profile of causative factors such as confusion, frustration, intoxication, antisocial/angry/social isolation or distressed/frightened states. Recommendations in this
guideline are largely driven by patient safety, positive engagement and dignity. Other
methods, including verbal de-escalation (without, and then with, the presence of
security personnel), must have proven unsuccessful, before employment of
pharmacological management of acutely agitated patients.
2.0 Definition
Rapid Tranquillisation is the administration of varying amounts of medications
(benzodiazepine, antipsychotic or antihistamine) over a brief period of time in a
patient exhibiting acutely disturbed or violent behaviour.
An optimal response is reduction in agitation or aggression and allowing the patient
to participate in further assessment and treatment.
3.0 Legal Aspects of utilising rapid tranquillisation
It may be necessary to consider rapid tranquilisation for a person if their behaviour is
posing a risk of serious physical harm or psychological distress to themselves or
physical harm to others and all other interventions or attempts to manage the
situation have been unsuccessful.
If the patient lacks capacity to give consent then the treatment could be given in the
persons best interests following the guidance of the Mental Capacity Act (2005).
Please refer to policy M101 - MCA Policy for KGH.
If the patient is deemed to have capacity and is refusing consent then it may be
necessary to use the Common Law Doctrine of Necessity.
In all cases the decision to administer rapid tranquilisation should be a last resort
and a proportionate response to the situation if all other less restrictive interventions
have failed and must be clearly and accurately documented.
If the person is not detained under the Mental Health Act (1983) consideration must
be given as to whether a Mental Health Act assessment is required.
4.0 Aim
This guideline provides information and guidance for the safe use of medications for
the management of violent and or aggressive patients, particularly when the patient
is highly aroused, restless, aggressive, agitated or destructive.
MMG24 Version 3
Guidelines for Safe Pharmacological Treatments Disturbed/Violent
Behaviour Non-psychiatric Setting
[Admissions and Emergency Care Settings]
Page 6 of 19
Chairman: Graham Foster JP
Chief Executive: David Sissling
Affiliated Teaching Hospital
5.0 General principles
Tranquillisation)
for
safe
pharmacological
management
(Rapid
Medications should only be prescribed after attempts to defuse the situation likely to
cause physical harm or psychological distress to themselves or others using other
de-escalation techniques have failed.
Regardless of the aetiology of the acute disturbing behaviour, whilst the decision to
initiate and apply the necessary clinical interventions are being a made, where all the
necessary information including the relevant pre-existing medical illnesses, current
drug details for interactions and allergies, renal or hepatic impairment, recent
investigation such as ECGs, electrolytes and urine drug screens are not available, it
is vital that approaches to obtaining necessary information should be expeditious.
Common medical problems, including infection, electrolyte imbalances, and
intoxication or withdrawal from alcohol, drugs, and other substances, must be ruled
out as causative factors before the use of intervention of rapid tranquillisation to calm
down patients.
Where the behaviour is due to intoxication from substance misuse, the most
appropriate approach is to physically isolate the patient until the effects of the
ingested substance(s) wears off
Special care is needed in patients who are known to have:
- history of seizure
- learning disabilities
Any outcome associated with rapid tranquillisation use is to be planned for.
Resuscitation equipment (normal ward cardiac arrest trolley or equivalent) should be
immediately available where rapid tranquillisation is administered.
A Crash bag (including an automatic external defibrillator – with monitoring ECG
leads, a bag valve mask, oxygen, cannulas, fluids, airways, pulse oximeter, vital
signs monitor, and suction and first-line resuscitation medications) is required to be
available.
6.0 Choosing appropriate medications for RT (See appendices 2-4 for doses in
specific groups)
The pharmacological approaches to rapidly control patients with no previous history
of mental health illness differs from patients previous diagnosed with mental health
illness and differs for patients diagnosed with cortical dysgenesis or destruction (as
in mental retardation, dementia and trauma), hypofrontal dis-inhibition,
encephalopathy or delirium.
To individualise the patient, the following points are to be taken into account
 Age
 Pre-existing physical health problems
 Patients’ preferences or advance statements and decisions
MMG24 Version 3
Guidelines for Safe Pharmacological Treatments Disturbed/Violent
Behaviour Non-psychiatric Setting
[Admissions and Emergency Care Settings]
Page 7 of 19
Chairman: Graham Foster JP
Chief Executive: David Sissling
Affiliated Teaching Hospital

previous compliance and response to these medications, including adverse
effects
 potential for interactions with other medications
Appropriate medication regime to rapidly control an aggressive person is vital for
patient safety and experience during and after the incidence.
6.1 Benzodiazepines choice
Lorazepam is recommended as first line rapid tranquillisation therapy in all cases,
except when there is a benzodiazepine contraindication or when patients have
cortical dys-genesis or destruction (as in mental retardation, dementia and trauma).
Benzodiazepines Specific Risks include loss of consciousness, respiratory
depression or arrest, cardiovascular collapse (particularly in patients already
receiving clozapine) and dis-inhibition. Midazolam carries higher risks than
Lorazepam and particular caution should be exercised if considering use of
midazolam in elderly, frail or physically unwell patients.
Caution: PARENTERAL BENZODIAZEPINES SHOULD NOT BE GIVEN WITHIN
AT LEAST ONE HOUR BEFORE OR AFTER INTRAMUSCULAR OLANZAPINE
6.2 Antipsychotics choice
Antipsychotics in this context of rapid tranquillisation episode are for gently and
rapidly calming and sedating effects.
If adequate doses benzodiazepine or antihistamine medications have failed to calm
down the patient or the patient still poses danger to him/herself or other people
around, a minimum of 30 to 40 minutes must be observed before administering an
antipsychotic and a minimum of one to two hours interval must be allowed, where
injectable Olanzapine is to be administered.
To reduce incidents of side effects, including extrapyramidal symptoms, low doses
of newer generation antipsychotics are to be prescribed for patients with no previous
diagnosis of mental health disorders or those who are antipsychotic naïve and for
older adults aged over 60years of age.
The doses of antipsychotics to be prescribed should take into consideration, the
concomitant effects of these medications, on the central nervous systems and the
physical state of the patient.
Patients with previously diagnosed mental health illness
Incidents of acute psychiatric emergency (APE) in patients already diagnosed with
mental health illnesses, usually occurs as a result of non- compliance with
prescribed medications, so for a patient already prescribed an antipsychotic(s) for
their condition, consideration should be given to re-initiating the previously
prescribed antipsychotics (if known) instead of introducing a new antipsychotics.
MMG24 Version 3
Guidelines for Safe Pharmacological Treatments Disturbed/Violent
Behaviour Non-psychiatric Setting
[Admissions and Emergency Care Settings]
Page 8 of 19
Chairman: Graham Foster JP
Chief Executive: David Sissling
Affiliated Teaching Hospital
Where ascertaining the previously prescribed antipsychotics is not feasible,
adequate doses of oral Olanzapine or Risperidone orodispersible, is
recommended. But if non-compliant to oral formulation, intramuscular formulations of
Olanzapine or Aripiprazole may be considered. Unless patient is known to have
previously responded well to a specific dose in the past, adequate antipsychotics
doses within the BNF ranges advised.
Haloperidol is not recommended for first line use. The practice of administering
haloperidol and benzodiazepines to achieve rapid tranquillisation also causes
combined increased side effects, higher risks of causing extra pyramidal side effects,
and usually with the need to administer Procyclidine for the patients should be desist
6.2.1 Patients with cortical dysgenesis or destruction (see Appendix 3)
To rapidly calm aggressive behaviours in people with cortical dysgenesis or
destruction (as in mental retardation, dementia and trauma), hypofrontal disinhibition, encephalopathy or delirium, low dose of Olanzapine or Risperidone
orodispersible, is recommended.
Persons with behavioural dys-control and disinhibition in the context of mental
retardation, dementing processes, personality disorder, or history of traumatic brain
injury (TBI) are similarly recommended low dose atypical antipsychotic such as
Olanzapine or Risperidone orodispersible, reviewed every twenty four hours.
Use of low dose atypical antipsychotics (Risperidone or Olanzapine) medications
rather than benzodiazepines are justified in these patients because benzodiazepines
are hypothesized to increase dis-inhibitory potential and worsen delirium.
People already identified with specific symptoms of lewy body dementia or Parkinson
disorders are very sensitive to antipsychotic medications, so if they need to be given
antipsychotics, the smallest effective dose should be used with adequate monitoring
and medication review planned at the earliest opportunity.
6.2.2 Patients with cardiovascular risks
Where a patient is known to have cardiovascular impairments, including prolonged
QT intervals, and where electrocardiogram cannot be undertaken, the use of
intramuscular antipsychotics should be avoided
6.2.3 Injectable Antipsychotics
It is advisable that the prescriber be aware of the most recent ECG outcome before
prescribing intramuscular antipsychotic.
But where compliance cannot be achieved with oral formulations and it is inevitable
that intramuscular antipsychotic must be administered, ECG monitoring are strongly
recommended as soon as possible. The intramuscular formulation of Olanzapine or
Aripiprazole are recommended. Although Aripiprazole may be used in combination
with benzodiazepines, parenteral formulation of olanzapine SHOULD not be
administered concomitantly with any benzodiazepines.
Antipsychotics specific risks include loss of consciousness, cardiovascular /
respiratory complications and collapse, seizures, akathisia, dystonia, dyskinesia,
neuroleptic malignant syndrome, excessive sedation and extra pyramidal side
effects. ECG monitoring are strongly recommended whenever antipsychotics are
administered and especially where high doses or parenteral route are be used
MMG24 Version 3
Guidelines for Safe Pharmacological Treatments Disturbed/Violent
Behaviour Non-psychiatric Setting
[Admissions and Emergency Care Settings]
Page 9 of 19
Chairman: Graham Foster JP
Chief Executive: David Sissling
Affiliated Teaching Hospital
6.3 Antihistamine choice
Antihistamine recommended for use is promethazine. Promethazine may be
considered in patients who have developed tolerance to benzodiazepines or in those
known to have developed dis-inhibition as a result of benzodiazepine use.
Promethazine should be used with caution in patients with cortical dysgenesis or
destruction (as in mental retardation, dementia and trauma) because of its
anticholinergic and deliriogenic effects, with high risk of cognition impairment.
PROMETHAZINE INJECTION SHOULD NOT BE ADMINISTERED AT THE SAME
TIME OR WITHIN AN HOUR OF OLANZAPINE INJECTION DUE TO RISK OF
POSTURAL DROPS
Antihistamine specific risks include dry mouth, blurred vision, urinary retention
and constipation. Excessive sedation, painful injection and additional antimuscarinic
effects are also frequently observed.
7.0 Doses
Whatever the aetiology of the acute disturbing behaviour, delirium, psychosis, or
significant anger/rage, most patients respond to standard doses. (See appendices
2-4 for doses in specific groups).
Where antipsychotic is considered after adequate doses benzodiazepine, the doses
of antipsychotics to be prescribed should take into consideration, the concomitant
effects of these medications, on the central nervous systems and the physical state
of the patient.
Review plans for any of the medications indicated for RT must be within a maximum
of 24 hours. Medication for rapid tranquillisation should be prescribed on a STAT
DOSE and the effect of this daily dose should be monitored within a 24hour and
reviewed every 24 hours.
Limiting rapid tranquillisation prescribing to 24hour period is to avoid the risks of
repeated doses of medication being administered without adequate review and
reduce the risks of unintentional high dose prescribing.
Exceeding the BNF maximum daily dose must be a decision made by the medical
consultant or a specialist Registrar (in exceptional cases, where starting with the
minimum effective dose is known to be ineffective on the individual based on
previous experience).
For younger adults, depending on the patient's general physical condition and
health, the dosage recommended is half to one third (1/2 to 1/3) of the dose used for
general adults
MMG24 Version 3
Guidelines for Safe Pharmacological Treatments Disturbed/Violent
Behaviour Non-psychiatric Setting
[Admissions and Emergency Care Settings]
Page 10 of 19
Chairman: Graham Foster JP
Chief Executive: David Sissling
Affiliated Teaching Hospital
For older adults, depending on the patient's general physical condition and health,
the dosage recommended is half to one third (1/2 to 1/3) of the dose used for
general adults. There is higher incidence of adverse effects in older patients,
particularly due to slower rate of absorption of medications resulting in slower onset
of action. Older adults may also have an effectively larger volume of distribution
which leads to a longer duration of action.
8.0 Administration Routes
For antipsychotics, if parenteral treatment proves necessary, the intramuscular route
is preferred over the intravenous one from a safety point of view
Lorazepam IM injection should be diluted with an equal volume of water for injection
or physiological saline
Caution
The use of intravenous route is restricted to benzodiazepines only and is advised to
be undertaken only in exceptional cases as IV therapy carries additional dangers.
Duty doctor is required to contact the Responsible Consultant, before
proceeding with IV treatment.
9.0 Monitoring Requirements after Rapid Tranquillisation
All patients who become aggressive or violent and needing to be rapidly tranquillised
should be referred to mental health liaison services for psychiatric assessment as
soon as possible.
In order to identify any adverse effects as quickly as it occurs, continuous
monitoring of basic vital signs including oxygen, respiratory rate, heart rate,
blood pressure is to be recorded at least every 15 minutes for the first four
hours following parenteral administration of any drug for RT, thereafter, they
should be recorded at half–hourly intervals until the patient is fully
ambulatory.
Monitor side effects and the service user's blood pressure, temperature, level of
hydration and level of consciousness at least every hour until there are no longer any
concerns.
Where the patient is unconscious or asleep, is known to have taken illicit drugs or
alcohol, has pre-existing physical health problem or has experienced any harm as a
result of any restrictive intervention, the same monitoring should take place so far as
is possible, pulse-oximetry should also be used, where it is practical to do so.
ECG and haematological monitoring are strongly recommended whenever
antipsychotics are administered and especially where high doses or parenteral route
are be used. High stress levels, restraint, agitation, and hypokalaemia all place the
patient at high risk of developing cardiac arrhythmias
MMG24 Version 3
Guidelines for Safe Pharmacological Treatments Disturbed/Violent
Behaviour Non-psychiatric Setting
[Admissions and Emergency Care Settings]
Page 11 of 19
Chairman: Graham Foster JP
Chief Executive: David Sissling
Affiliated Teaching Hospital
10.0 Debriefing and Documentation after Rapid Tranquillisation
Documentation of the incidents processes including where offer of oral formulations
was rejected is important.
Post incident review should be conducted at all times when RT interventions take
place. The reason (indications) for use of any medications should be clearly stated
and response or outcomes accurately and appropriately documented and
communicated where remedial actions are necessary. Review plans for any of the
medications indicated for RT must be within a maximum of every 24 hours.
11.0 Training
All staff involved in in RT must be adequately trained in the maintenance of patients’
airways, cardio-pulmonary resuscitation (CPR), the use of defibrillators and the use
of pulse oximeters. An understanding of the Trust policy on Prevention and
Management of Violence and Aggression is essential.
In addition to adequately being trained on disengagement techniques Clinicians’
familiarity and knowledge of therapeutic actions with the drugs used in rapid
tranquillisation is also essential.
Medical and non-medical prescribers, and Nursing Staff involved in the prescribing
and/or administration of medication for the management of violence and aggression
(in-patients, medical admission units and emergency department for patients 16
years and above).
Out-patients, visitors and staff can exceptionally be covered by this guideline but will
immediately thereafter become emergency department patients.
In every location, a named doctor, either the most senior or the most appropriately
qualified, must accept responsibility for the administration of rapid tranquillisation and
subsequent related patient care.
Advice can be sought from the liaison psychiatry team (during working hours) or oncall psychiatric doctor (middle grade doctor) at St Marys Hospital for incidents
occurring during out of hours.
Contacts
Crisis Team – 01536 494 876
St Mary’s Hospital – 01536 410 141
Acute Hospital Liaison Service (AHLS) – contact through KGH switchboard.
MMG24 Version 3
Guidelines for Safe Pharmacological Treatments Disturbed/Violent
Behaviour Non-psychiatric Setting
[Admissions and Emergency Care Settings]
Page 12 of 19
Chairman: Graham Foster JP
Chief Executive: David Sissling
Affiliated Teaching Hospital
12.0 Monitoring Compliance with this Document
In order to objectively analyse the problem of violence and decipher the likely
causative factors, regular reports on incidents of rapid tranquillisation as part of
restrictive interventions should be submitted to the Trust’s governing body.
MMG24 Version 3
Guidelines for Safe Pharmacological Treatments Disturbed/Violent
Behaviour Non-psychiatric Setting
[Admissions and Emergency Care Settings]
Page 13 of 19
Chairman: Graham Foster JP
Chief Executive: David Sissling
Affiliated Teaching Hospital
13.0 References
1) Violence - the Short Term Management of Disturbed/Violent Behaviour in
Psychiatric
in-Patient Settings and Emergency Departments (NICE 2005)
http://www.rcn.org.uk/__data/assets/pdf_file/0018/109800/003017.pdf
2) Clinical Guideline CG82 Core Interventions in the Treatment and Management
of
Schizophrenia
in
Primary
and
Secondary
Care
(NICE)
http://www.nice.org.uk/CG82
3) NICE Clinical Guidelines 103 Delirium- Diagnosis, Prevention and management
issued on July 2010.
4) 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].
5)
Stephen Bazire Psychotropic Drug Directory. 2014
6) Prescribing Guidelines 11th Edition, 2012. The South London and Maudsley
NHS Trust and Oxleas NHS Trust.
7) 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.
8)
British National Formulary No 67 September 2014 Chapter 4
9) The Design Council. Reducing Violence and Aggression in A&E. Design
Council. Nov.2011.
10) 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.
11) Mantovani C, Migon M, Alheira F, Del-Ben C. Management of the violent or
agitated patient. Rev Bras Psiquiatr. 2010; 32(Supl 2):96-103.
12) Allen MH, Currier GW, Carpenter D, Ross RW, Docherty JP. The expert
consensus guideline series. Treatment of behavioural emergencies 2005. J
Psychiatr Pract. 2005; 11 Suppl 1:5-108; quiz 10-2.
MMG24 Version 3
Guidelines for Safe Pharmacological Treatments Disturbed/Violent
Behaviour Non-psychiatric Setting
[Admissions and Emergency Care Settings]
Page 14 of 19
Chairman: Graham Foster JP
Chief Executive: David Sissling
Affiliated Teaching Hospital
13) James A, Madeley R, Dove A. Violence and aggression in the emergency
department.
Emergency
Medicine
Journal.
2006;23:431-34.
14) Mental Capacity Act Code of Practice 2005
15) NHFT Rapid Tranquilisation Policy (MMP011). Ratified on 07.05.13
MMG24 Version 3
Guidelines for Safe Pharmacological Treatments Disturbed/Violent
Behaviour Non-psychiatric Setting
[Admissions and Emergency Care Settings]
Page 15 of 19
Chairman: Graham Foster JP
Chief Executive: David Sissling
Affiliated Teaching Hospital
Appendix 1
Remedial Measures for potential side effects during Rapid Tranquillisation
Acute dystonia (including oculogyric crises)
Procyclidine 5-10mgs IM or IV
Reduced respiratory rate (<10/min) or oxygen saturation Flumazenil if Benzodiazepine induced
<90%)
depression suspected.
See BNF for full administrative instructions
Irregular or slow (<50/min) pulse
Refer to specialist medical care immediately
Fall in blood pressure
respiratory
Lie patient flat, tilt bed towards head
Monitor closely
Consider Neuroleptic Muscular Syndrome and perhaps
Arrhythmias. Withhold antipsychotics.
Increased temperature
MMG24 Version 3
Guidelines for Safe Pharmacological Treatments
Disturbed/Violent Behaviour Non-psychiatric Setting
[Admissions and Emergency Care Settings]
Chairman: Graham Foster JP
Chief Executive: David Sissling
Page 16 of 19
Affiliated Teaching Hospital
Appendix 2
RT Algorithm for 18-60 years (adult age)
If attempt to defuse the situation likely to cause physical harm or psychological distress to themselves
or physical harm to others using de-escalation technique fails

Offer oral medication
Lorazepam 1mg - 2mg
allow 45-60 mins for effect,
may be repeated after 2 hours
if no desirable effect (Max
4mg in 24 hrs)
Offer buccal
midazolam
2.5mg - 15mg as
monotherapy to avoid
need for IM treatment
Patients who are benzodiazepine
tolerant or sensitive: Promethazine
HCI oral 25mg - 50mg. (Slow onset
of action but highly sedating) up to a
maximum of 100mg/24 hours with at
least 2 hours dosing intervals
When oral medication measures have had limited effect offer a) or b)
a) IM Lorazepam (diluted) 1mg - 2mg stat.
Have O2 and Flumazenil at hand for benzodiazepine-induced respiratory depression
b) IM Promethazine 25mg - 50mg (peaks 2-3 hours). (BNF max: 100mg in 24 hours)
If behaviour remains uncontrolled despite the maximum dose of any of the above medications
1st choice of oral antipsychotic: Olanzapine oral dispersible 5mg. (BNF max: 20mg in 24 hours).
2nd choice of oral antipsychotic is dispersible formulation of Risperidone 2mg. (BMF max: 16mg
in 24 hours)
3rd choice antipsychotic is Haloperidol 5mg - 10mg. (BNF max: 12mg in 24 hours)
Caution: because of risk of acute dystonic reactions, ensure availability of Procyclidine 5mg - 10mg IM
or oral up to 3 times in 24 hours.
For those already diagnosed with mental health illness and already prescribed an antipsychotic, in
order to avoid concomitant use of two different antipsychotics, the currently prescribed antipsychotic
should be optimised before considering a different antipsychotic.
If non-compliant with oral or unable to take oral medications, consider intramuscular route as follows:
1st option: Olanzapine 5mg - 10mg (repeated after 2 hours up to BNF max: 20mg in 24 hours,
including oral)
Olanzapine IM must not be administered within 1 hour time period of any Benzodiazepine or
Promethazine injection.
OR: Aripiprazole 9.75mg - 15mg (repeated after 2 hours up to BNF max: 30mg, including oral, in 24
hours. Maximum of 3 doses/injections over 24 hours.
3rd option: Haloperidol 5mg - 10mg (repeated after 2 hours up to BNF max: 12mg in 24 hours,
caution if previous exposure to psychotropic unknown, because of immediate risk of acute dystonic
reactions, Procyclidine 5mg - 10mg IM or oral up to tds)
Avoid concomitant use of two different antipsychotics. The SPC recommends a pre-treatment
ECG before antipsychotics.
Continuously observe. Record vital signs
every 15 minutes for 1 hour, then every 30
minutes for 4 hours.
Document episode. Investigate underlying
cause. Complete incident form if tranquilisation
administered by any route.
MMG24 Version 3
Guidelines for Safe Pharmacological Treatments Disturbed/Violent
Behaviour Non-psychiatric Setting
[Admissions and Emergency Care Settings]
Page 17 of 19
Chairman: Graham Foster JP
Chief Executive: David Sissling
Affiliated Teaching Hospital
Appendix 3
RT Algorithm for Patients with Cortical Dysgenesis or Destruction
If attempt to defuse the situation is likely to cause physical harm or psychological distress to
themselves or physical harm to others using de-escalation techniques fails
Avoid benzodiazepine products in patients with cortical dysgenesis or destruction (as in mental
retardation, dementia and trauma), hypofrontal disinhibition, encephalopathy or delirium, to reduce
the risk of dis-inhibition reactions
Consider Oral antipsychotic, as listed below
1st choice: Olanzapine Velotab 5mg (BNF max: 20mg in 24 hours)
2nd choice of oral antipsychotic is orodispersible Risperidone 500mcg (BNF max: 16mg in 24
hours)
3rd choice antipsychotic is Haloperidol 500mcg - 10mg (BNF max:20mg in 24 hours).
Caution: if previous exposure to psychotropic unknown, because of immediate risk of acute
dystonic reactions, have Procyclidine 5mg - 10mg IM or oral up to 3 times in 24 hours available.
Lewy Body Dementia patients are sensitive to antipsychotics, very low doses should be used with
adequate monitoring and should be referred to Liaisons Psychiatric Services for behavioural
management.
Doses of oral antipsychotics should not be repeated for at least 60 minutes.
If non-compliant with oral or unable to take oral medications, consider intramuscular route as
follows:
1st option: Olanzapine 5mg - 10mg (repeated after 2 hours up to BNF max: 20mg in 24 hours,
including oral)
Olanzapine IM must not be administered within 1 hour of any benzodiazepine or Promethazine
injection.
Or Aripiprazole 5.25mg - 15mg (repeated after 2 hours up to BNF max: 30mg, including oral, in
24 hours.
Maximum of 3 doses/injections over 24 hours.
3rd option: Haloperidol 5mg - 10mg (repeated after 2 hours up to BNF max: 12mg in 24 hours.
Caution: if previous exposure to psychotropic unknown, because of immediate risk of acute
dystonic reactions, implication: Procyclidine 5mg to 10mg IM or oral up to tds.
Avoid concomitant use of two different antipsychotics. The SPC recommends a pretreatment ECG before antipsychotics.
Continuously observe.
Record vital sign every 15 minutes for
1 hour, then every 30 minutes for 2
hours.
Document episode.
Investigate underlying cause.
Complete incident form if tranquilisation
administered by any route.
MMG24 Version 3
Guidelines for Safe Pharmacological Treatments Disturbed/Violent
Behaviour Non-psychiatric Setting
[Admissions and Emergency Care Settings]
Page 18 of 19
Chairman: Graham Foster JP
Chief Executive: David Sissling
Affiliated Teaching Hospital
Appendix 4
RT Algorithm for age of 60+ years (Older Adult)
If attempt to defuse the situation is likely to cause physical harm or psychological distress to
themselves or physical harm to others using de-escalation techniques fails
Patient who are benzodiazepine tolerant or
sensitive: Promethazine HCI oral 25mg to
50mg in 24 hours. (Slow onset of action but
highly sedating) up to a maximum of
50mg/24 hours with at least 2 hours dosing
intervals
Lorazepam 0.5mg to 1mg in 24
hours allow 45-60 minutes for effect.
May be repeated after 2 hours if no
desirable effect. (Max 2mg in 24
hours)
When oral medication measures have had limited effect due to non-compliance: Offer a) or b)
a) IM Lorazepam (diluted) 0.5mg - 1mg stat.
(Have 02 and Flumazenil at hand for benzodiazepine-induced respiratory depression)
b) IM Promethazine 25mg - 50mg (peaks 2-3 hours) BNF max: 50mg in 24 hours
If behaviour remains uncontrolled despite dose increase of any of the above medications,
consider one of the following oral antipsychotics.
1st choice of oral antipsychotic: Olanzapine oral dispersible from 2.5mg - 5mg (BNF max:
10mg in 24 hours)
2nd choice of oral antipsychotic is dispersible formulation of Risperidone 500mcg - 2mg
(BNF max: 8mg in 24 hours)
3rd choice oral antipsychotic is Haloperidol 5mg - 10mg (BNF max: 20mg in 24 hours).
Doses of oral antipsychotics should not be repeated for at least 60 minutes and prescription
should be reviewed in 24 hours
Intramuscular route if non-compliant with oral or unable to take oral medications
1st option: Olanzapine 5mg - 10mg (repeated after 2 hours up to BNF max: 10mg in 24 hours,
including oral.
Olanzapine IM must not be administered within 1 hour time period of any benzodiazepine or
Promethiazine injection. May only be used for a maximum of 3 days.
Or Aripiprazole 5.25mg - 15mg (repeated after 2 hours up to BNF max: 15mg, including oral, in
24 hours. Maximum of 3 doses/injections over 24 hours.
3rd option: Haloperidol 5mg - 10mg (repeated after 2 hours up to BNF max: 6mg in 24 hours.
Caution if previous exposure to psychotropic unknown, because of immediate risk of acute
dystonic reactions, have Procyclidine 5mg to 10mg IM or oral up to tds available.
The SPC recommends a pre-treatment ECG consideration before antipsychotic treatment
Document episode. Investigate underlying
cause. Complete incident form if tranquilisation
administered by any route. Refer to Alzheimer’s
dementia screening.
Continuously observe.
Record vital sign every 15 minutes for
1 hour, then every 30 minutes for 4
hours.
MMG24 Version 3
Guidelines for Safe Pharmacological Treatments Disturbed/Violent
Behaviour Non-psychiatric Setting
[Admissions and Emergency Care Settings]
Page 19 of 19
Chairman: Graham Foster JP
Chief Executive: David Sissling