12
Rapid tranquillisation (RT) algorithm
This algorithm should be read in conjunction with the recommendations in the guideline
and the Summary of Product Characteristics (SPC) chart for rapid tranquillisation, available at [Link]/CG025
See also page 15 of this quick reference guide
All staff involved in RT should be trained according to the • Service users should be able to respond to communication
recommendations set out on pages 21–22 throughout ● D
Continue to use de-escalation techniques throughout D
• Prescribe oral and i/m doses separately ●
• Don’t use o/i/m abbreviation ●D
• Don’t use two drugs of same class for RT ●D
• Don’t mix medications in same syringe D(GPP)
Potential risks • Over-sedation causing loss of consciousness
• Over-sedation causing loss of alertness
• Loss of airway
• Cardiovascular and respiratory collapse • Prescribers and those who administer medicines should be familiar with:
• Interaction with medication (prescribed or – the properties of benzodiazepines; flumazenil; antipsychotics; antimuscarinics and antihistamines
illicit) – risks (including cardio-respiratory effects, particularly if with high arousal, possible drug misuse,
• Damage to the therapeutic relationship dehydration or physical illness)
• Underlying coincidental physical – the need to titrate doses to effect ●D
disorders D • Prescriber and medication administrator should pay attention to:
– the total dose prescribed
NICE Guideline: quick reference guide – Violence
– arrangements for review
– consent, British National Formulary (BNF) and SPC requirements, physical and mental status ● D
Caution Take extra care in presence of:
• congenital prolonged QTc syndromes
• medications that lengthen QTc intervals
directly or indirectly
There are specific risks with different classes of medication. Risks may be compounded if used in combination.
• hypo/hyperthermia, stress/extreme
emotions, extreme physical exertion D
Benzodiazepines: loss of consciousness; respiratory depression or arrest; cardiovascular collapse when
receiving both clozapine and benzodiazepines
Antipsychotics: loss of consciousness, cardiovascular/respiratory complications and collapse; seizures; akathisia;
dystonia; dyskinesia; neuroleptic malignant syndrome; excessive sedation
Antihistamines: excessive sedation; painful injection; additional antimuscarinic effects D(GPP)
Consult Advance directives if available D
Preferred method 1 Oral Non-psychotic Consider oral lorazepam B Consider all
of drug context medication as part
administration Allow sufficient of RT (including
(1 = preferred D ) time for clinical pro re nata from
response between agreed RT protocol
doses B Psychotic Consider oral lorazepam + oral or advance
context antipsychotic D directive) D
2 Intramuscular (i/m) Oral therapy is:
Non-psychotic • refused or has failed Consider i/m lorazepam
context • not indicated by previous clinical response (if oral route inappropriate) B
Allow sufficient time
for clinical response • not a proportionate response
between doses B
• Transfer to oral
route at earliest
opportunity D Oral therapy is: Consider i/m lorazepam + i/m haloperidol B • When using haloperidol:
• refused or has – procyclidine or
failed May also consider i/m olanzapine* for benzatropine should be
• not indicated moderate disturbance B immediately available
by previous to reduce risk of
Psychotic clinical ! Don’t give i/m lorazepam within dystonia or other
context response 1 hour of i/m olanzapine. Use oral lorazepam extrapyramidal
• not a with caution B side-effects D
proportionate • Give procyclidine or
response * benzatropine i/m or i/v
The manufacturer has issued a warning that use
outside of the details contained within the SPC may as manufacturer’s
increase the risk of fatality instruction D
3 Intravenous (i/v) Immediate Consider i/v • Be aware of symptoms of:
• Decision to
tranquillisation benzodiazepines use not to be – respiratory depression
(Exceptional essential or haloperidol – dystonia
made by
circumstances D junior staff in – cardiovascular compromise ●D
only)
isolation D • Crash bag must be available within 3 mins ●D
• Specify and • Staff must be trained to Immediate Life Support
record D
(ILS) ●
circumstances
D
• Never leave service user unattended ●
for use D
After RT • Monitor vital signs ●D • Intensive and frequent monitoring by If verbal Post-incident
• Record blood pressure, pulse, trained staff required if: responsiveness is lost: review within
temperature, respiratory rate and – service user is/appears sedated/asleep • use level of care 72 hours D(GPP)
hydration at intervals agreed by – i/v administration used as for general
multidisciplinary team until service user – BNF limit or SPC exceeded anaesthesia D
active again ●D – in high-risk situations
• Pulse oximeters should be available ● D – illicit substances/alcohol ingested
– presence of relevant medical
disorder/taking prescribed medication
• Pay particular attention to respiratory
effort, airway and level of consciousness
• Record in care plan D
Drugs NOT recommended for RT Zuclopenthixol acetate** • When transferring a service user between units,
the following should also be sent:
• C
Oral or i/m chlorpromazine ● • Not recommended for RT due to long onset and duration of action, but – a full medication history (including the service
• i/m diazepam ● C may be considered as an option when: user’s response to medications) and any
• C
Thioridizine ● – service user will be disturbed/violent over extended time period adverse effects
• D
i/m depot antipsychotics ● – past history of good/timely response – an advance directive
• Olanzapine (dementia-related disturbance) ●C – past history of repeated parenteral administration – the service user’s account of their experience
• C
Risperidone (dementia-related disturbance) ● – cited in an advance directive (where possible)
• Never administer to those without previous antipsychotic exposure • On discharge, file all such information in
• Consult BNF and manufacturer’s SPC regarding its use B their healthcare record to be reviewed
regularly. D(GPP)
** Zuclopenthixol acetate is commonly known as ‘acuphase’ by staff and service users
NICE Guideline: quick reference guide – Violence
13
Interventions for the management of disturbed/violent behaviour