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Rapid Tranquillization
Training Programme
(for medical and nursing staff)
Updated July 2011
Aims of RT Training Programme
 To understand the basic principles of RT
 To review the medication used including
drug selection, doses and routes
To understand potential complications of
RT (and solutions)
To review patient monitoring requirements
To review local policy & further information
sources
Basic principles
 Rapid tranquillization (RT) is the short term
use of tranquillizing medication to control
potentially destructive behaviour.
 RT should only be considered once deescalation/other methods have failed.
 RT is used to avoid prolonged physical
intervention
 Tranquillization means calming without
sedation (sedation is not the optimal result)
Basic principles continued
Aim is to safely and quickly calm the patient,
without sedation to ↓ risk of imminent
violence.
RT does not aim to treat the underlying
cause of aggression or violence.
Underlying condition does not always predict
the response to RT
Physical health of patient and concurrent
medication must be considered before using
RT
Medication aims
 Reduce suffering of patient, both
psychological or physical (for example self
harm)
 Reduce risk of harm to others (safe
environment)
 To do no harm
 Document reason for prescribing RT &
prescribing plan
Medication
Need to consider;
 Advance directives
 Contra-indications, warnings, precautions
of individual drugs
 Co-existing medical illness/allergies
(liver/renal/cardiac/seizures/pregnancy)
 Concurrent meds, alcohol, illicit drugs
 Previous exposure to neuroleptic drugs
 Previous response to RT
Medication continued
 Need rapid onset of action
 Frequent small doses are safer and
more effective than single large doses
(but risk of accumulation)
 Always offer oral medication first
 Main groups used are antipsychotics
and benzodiazepines (alone or in
combinations)
Drug selection
 Traditionally antipsychotics have been used for RT
(now choice of 1st generation or 2nd generation)
 Antipsychotics are not used in RT for their
antipsychotic action
 Benzodiazepines are commonly used (advantages
over antipsychotics e.g. side-effects, toxicity)
 Combination therapy may give better results and
often allows lower doses of each drug to be used
 Consider Mental Health Act (form T2/T3/section
62)
 Follow SPT policy
Rapid Tranquillization Policy (SPT)



Three separate flow charts (one for children and
adolescents, working age, one for over 65yrs)
Step 1 - non pharmacological methods
Step 2 - oral treatment with lorazepam and/or
olanzapine or haloperidol
Oral can be repeated if ineffective after 45 minutes
 Step 3 - I/M medication (baseline monitoring if
possible)
 Patients over 65-use lower doses
Consider co-existing medical illnesses
No antipsychotics in dementia with Lewy bodies
Caution olanzapine in dementia/vascular disease
Algorithm 1 - Children and Adolescents
Algorithm 3.
-
NON-PHARMACOLOGICAL MEASURES
De-escalation, distraction, seclusion etc
Step 1
Step 2
Oral
Treatment
(If oral is
refused
consider going
to step 3)
CAMHS
[a,b]
Olanzapine
<12 years: N/A
>12 years: 5mg
(Max. 20mg/day)
`
Consult any Advance Directives
Check Consent has been given
PSYCHOTIC ILLNESS
+/Promethazine
<12 years: 5 -10mg
(Max 25mg/day)
>12 years: 10 -25mg
(Max 50mg/day)
OR
NON-PSYCHOTIC ILLNESS
Lorazepam
<12 years: 0.5-1mg
>12 years: 1 -2mg
(Max. 4mg/day)
Lorazepam
<12 years: 0.5 -1mg
>12 years: 1 -2mg
(Max 4mg/day)
OR
Promethazine
<12 years: 5 -10mg
(Max 25mg/day)
>12 years: 10 -25mg
(Max 50mg/day)
- ALLOW AT LEAST 45 MINUTES FOR ORALMEDICATION TO WORK
- IF INEFFECTIVE, REPEAT ORAL MEDICATION AT SAME DOSES
- ALLOW AT LEAST 45 MINUTES FOR REPEATED ORAL MEDICATION TO WORK
Step 3
I/M
Treatment
[c,d]
Ensure baseline measurements are recorded where possible: TEMPERATURE, PULSE, BP, RESPIRATORY RATE before IM administration, and reapeat every 5 10 minutes for 1 hour, then half -–hourly until patient is ambulatory. Use pulse oximetry if patient asleep or unconscious.
+/MONITOR
PATIENT
CLOSELY!
Olanzapine [e,f]
<12 years: N/A
>12 years: 5mg
(Max. 20mg/day)
Promethazine [g]
<12 years: 5 -10mg
(Max 25mg/day)
>12 years: 10 -25mg
(Max 50mg/day)
OR
Lorazepam
<12 years: 0.5-1mg
>12 years: 1-2mg
(Max. 4mg/day)
Lorazepam
<12 years: 0.5 -1mg
>12 years: 1 -2mg
(Max 4mg/day)
[g]
OR
Promethazine
<12 years: 5 -10mg
(Max 25mg/day)
>12 years: 10 -25mg
(Max 50mg/day)
1. ALLOW AT LEAST 30 MINUTES FOR I/M LORAZEPAM TO WORK.
IF INEFFECTIVE, REPEAT AT SAME DOSES AND ALLOW A FURTHER 30
MINUTES FOR EFFECT.
2. A REPEAT DOSE OF I/M OLANZAPINE MAY BE GIVEN BUT NOT WITHIN
.
TWO HOURS OF THE FIRST.
Caution – See note [e].
DO NOT PROCEED
FURTHER WITHOUT
ADVICE FROM
CONSULTANT
IF INEFFECTIVE, SEEK SPECIALIST ADVICE FROM
CONSULTANT
NB,Max doses stated are for
.
oral and IM combined
[a-g] see notes.
Notes:
a.
b.
c.
d.
e.
f.
g.
Choice depends on current treatment. If patient
is established on antipsychotics, lorazepam may
be used alone. If the patient uses ‘street drugs’
or already receives regular benzodiazepines, an
antipsychotic may be used alone. For the
majority of patients, best response will be with
combination therapy.
Ensure procyclidine injection is available.
Antipsychotic may cause acute dystonic
reaction. As in (a), either antipsychotic or
benzodiazepine may be used alone, but best
results are likely with combination therapy.
Ensure flumazenil injection is available to
reverse effects of lorazepam injection.
The maximum dose of olanzapine is 20mg/24
hours by any (combined) route(s) – this should
not be exceeded without obtaining specialist
advice – and not more than 3 I/M doses may be
given in any 24-hour period. Intramuscular
olanzapine and intramuscular lorazepam
must not be administered within 1 hour of
each other.
Olanzapine IM needs to be diluted before
administration in 2.1ml water for injection. It is
stable for up to 1 hour after reconstitution.
Lorazepam should be mixed 1:1 with water
before injecting.
The maximum dose of haloperidol is either 30mg
orally or 18mg by intramuscular injection.
Maximum doses will need to be adjusted if a
combination of both routes is used.The
bioavailable equivalence of haloperidol being
approximately 10mg oral: 6mg intramuscular.
Notes:
a.
Choice depends on current treatment. If patient is
established on antipsychotics, lorazepam may be
used alone. If the patient uses ‘street drugs’ or
already receives regular benzodiazepines, an
antipsychotic may be used alone. For the majority
of patients, best response will be with combination
therapy.
b.
Ensure procyclidine injection is available.
Antipsychotic may cause acute dystonic reaction.
As in (a), either antipsychotic or benzodiazepine
may be used alone, but best results are likely with
combination therapy.
c.
Ensure flumazenil injection is available to reverse
effects of lorazepam injection.
d.
The maximum dose of olanzapine is 20mg/24 hours
by any (combined) route(s) – this should not be
exceeded without obtaining specialist advice – and
not more than 3 I/M doses may be given in any 24
hour period. Intramuscular olanzapine and
intramuscular lorazepam must not be
administered within 1 hour of each other.
e.
Olanzapine IM needs to be diluted before
administration in 2.1ml water for injection. It is
stable for up to 1 hour after reconstitution.
f.
Lorazepam should be mixed 1:1 with water before
injecting.
g.
The maximum dose of haloperidol is either 30mg
orally or 18mg by intramuscular injection.
h.
Maximum doses will need to be adjusted if a
combination of both routes is used. The bioavailable
equivalence of haloperidol being Approximately
10mg oral: 6mg intramuscular.
Rapid Tranquillization Policy (SPT) Continued
 I/M olanzapine or haloperidol and/or lorazepam
(But allow one hour between I/M olanzapine and
lorazepam)
 Allow at least 30 minutes for I/M lorazepam and/or
I/M haloperidol to work
 If ineffective, repeat at same doses
 Repeat I/M olanzapine should not be given within 2
hours of the first
 Be aware of maximum doses in 24 hours
 Lorazepam can be used sublingually-?faster
absorption
 Velotabs/Quicklets-no faster absorption
Olanzapine
 Maximum licensed dose 20mg/24 hours
by ANY COMBINED route
 No more than 3 olanzapine injections in
24 hours (and for no longer than 3 days)
 Oral onset time 1 hour, time to max
plasma concentration 5-8 hours
 I/M onset time 15-30mins, max plasma
concentration 15-45mins
 A minimum of 2 hours between injections
Haloperidol
 Maximum licensed dose 30mg orally or
18mg I/M in 24 hours
 If combination of oral and I/M used then
maximum doses need to be adjusted
 Bioequivalence: 10mg oral:6mg I/M
 Oral time to onset >1hour (max plasma
concentration 2-6hours)
 I/M time to onset < 20mins (max plasma
concentration 1-2hours)
Lorazepam
 Maximum licensed dose oral 4mg/24 hours
 I/M- calculate according to body weight (30mcg/kg
adult, 15mcg/kg elderly)
 Oral time to onset 20-30mins (max plasma
concentration 2 hours)
 I/M time to onset <20-30mins (max plasma
concentration 60-90mins)
 If >BNF doses are used document risk/benefit
analysis & ↑ pt monitoring
 Dilution 1:1 with water
 Don’t forget it is stored in the Fridge!
In Summary
 Choice of drugs(s) depends on current
treatment/use of street drugs/individual
patient
 Prescribe oral and I/M separately
 Ensure procyclidine prescribed prn
 Ensure flumazenil is available
 Don’t mix 2 drugs of the same class for RT
 Routes other than oral/IM decided by
consultant only
Treatments used on specialist advice









Prescribed only by appropriate specialist
Unlicensed and often small evidence base
Aripiprazole I/M (licensed)
Midazolam I/M
Promethazine I/M
Levomepromzine I/M
Risperidone oral
Quetiapine oral
ECT
Potential complications




Benzodiazepines-loss of consciousness,
respiratory depression, cardiovascular collapse
Antipsychotics-loss of consciousness,
cardiovascular/respiratory complications &
collapse, seizures, akathisia, dystonia,
dyskinesia, NMS, excessive sedation
Antihistamines-excess sedation, painful
injection, antimuscarinic effects
Risks ↑ if pt highly aroused/drug misuse
/dehydrated/physically ill
Complications & Management
 Hypotension-Close monitoring, lie patient flat
 NMS-STOP ANTIPSYCHOTICS, seek medical team
advice (or call an ambulance if severe), monitor, urgent
creatine kinase level (if raised indicative of NMS)
 Acute dystonia- I/M procyclidine 5-10mg
 Arrhythmias-medical team advice
 Respiratory depression - if RR<10/min in patient who
has received benzodiazepines give flumazenil (IV –
doctors only)
 Disinhibition with benzodiazepines
 Consider patient/staff relationship
 Review regular and PRN medication frequently
Monitoring
Baseline observations if possible
Temperature, pulse, blood pressure,
respiratory rate every 5-10 minutes for the first
hour then every 30mins until ambulatory
If patient is asleep use pulse oximetery
If antipsychotic given-monitor for EPSE’s
ECG-recommended when antipsychotics are
administered especially in high doses
Fluid & electrolyte balance
PANSS-EC scoring
Physical monitoring
Patient’s name:
Gender:
D.O.B.
Ward:
IMPORTANT – If baseline monitoring cannot be undertaken, explain why in the comments box.
Time
Temp
Pulse
BP
Resp
Rate
Pulse*
Oximeter
Comments
(Baseline)
Repeat every 5 to 10 minutes for the first hour then every 30 minutes until the patient is walking around
*The pulse oximeter reading need only be taken if the patient is asleep or unconscious
Please retain the original in the patient’s notes. A copy must be made and reviewed by the team involved to reflect on whether the use of IM medication could
have been avoided. Please record any learning points overleaf and store on the ward for a minimum of two years.
Signature
Flumazenil
IV – Doctors must administer
 Benzodiazepine antagonist
 Give if RR<10/minute due to
benzodiazepine dosing
 Dose-200mcg IV over 15 seconds
 Repeat-100mcg over 10 seconds (if
needed) after 60 seconds
 Max dose 1mg in 24 hours
 Short half-life so repeated doses may be
needed.
QTc prolongation
Obtained from ECG
 If above normal limits may predict a risk
factor for Torsade de Pointes
 Normal limits;Men-440ms, women-470ms
 Many drugs associated with QTc
prolongation
 QTc prolongation can occur more
frequently with high doses, IV
administration, predisposed patients
Neuroleptic Malignant Syndrome
 Rare but potentially fatal
 Can occur with any antipsychotic
 Signs/symptoms-fever, muscle rigidity,
sweating, incontinence, raised temperature,
confusion, altered conciousness/BP/LFT’s,
tachycardia, leucocytosis, ↑ creatine kinase
 Risk factors-high potency typicals,
recent/rapid dose ↑ or ↓, dehydration
 Get advice regarding re-challenge
Further information/cross references
 SPT policy (on website)- Rapid
Tranquillization Policy
 NICE guidance (clinical guideline 25)
 BNF
 SPC’s available at www.medicines.org.uk
 Trust Resuscitation Policy
 Policy-Prevention & management of
violence & aggression(PMVA)
 Pharmacy Team
Thank you for your attention!
Any Questions?