Rapid Tranquillisation Policy

Transcription

1 Rapid Tranquillisation Policy

2 Rapid Tranquillisation Policy Document Type Clinical Policy Unique Identifier CL-033 Document Purpose To provide advice, support and consistency for staff dealing with psychiatric emergencies to be able to respond quickly and appropriately to a patient s distress so as to maintain safety of the patients and others. Document Author Alan Pollard Target Audience Clinical and medical staff who are directly involved in the management of acutely disturbed patients and the administration of rapid tranquilisation. Responsible Group The Trust Medicines Management and Safety Committee Date Ratified March 2012 Expiry Date March 2015 Date Equality Impact Assessment Completed 23 rd February 2012 This validity of this policy is only assured when viewed via the Worcestershire Health and Care NHS Trust website (hacw.nhs.uk.). If this document is printed into hard copy or saved to another location, its validity must be checked against the unique identifier number on the internet version. The internet version is the definitive version. If you would like this document in other languages or formats (i.e. large print), please contact the Communications Team on or communications@hacw.nhs.uk. Rapid Tranquillisation Policy Version 2 Page 1 of 20

3 Version History Version Circulation Date Job Title of Person/Name of Group circulated to Brief Summary of Change July 2011 Alan Pollard Update of CP0058 for NHSLA Compliance. Sep 2011 MMSSC Approved by committee for content V1 19 th Jan 12 Clinical Policy Administrator Applying Trust Template and added in Section on midazolam. V2 1 st Mar 12 Alan Pollard Minor Amendments to Appendices Accessibility Worcestershire Health and Care NHS Trust has a contract with Applied Language Solutions to handle all interpreting and translation needs. This service is available to all staff in the trust via a free-phone number ( ). Interpreters and translators are available for over 150 languages. From this number staff can arrange: Face to face interpreting; Instant telephone interpreting; Document translation; and British Sign Language interpreting. Training and Development Worcestershire Health and Care NHS Trust recognises the importance of ensuring that its workforce has every opportunity to access relevant training. The Trust is committed to the provision of training and development opportunities that are in support of service needs and meet responsibilities for the provision of mandatory and statutory training. All staff employed by the Trust are required to attend the mandatory and statutory training that is relevant to their role and to ensure they meet their own continuous professional development. Rapid Tranquillisation Policy Version 2 Page 2 of 20

4 Contents Page 1. Introduction 4 2. Purpose of document 4 3. Definitions 4 4. Scope 4 5. Training/Competencies 4 6. Responsibilities & Duties 5 7. Rapid Tranquilisation 6 8. Monitoring implementation References Associated Documentation 15 Appendices Rapid Tranquillisation Recording Form 16 Observation Sheet and Patient At Risk Score 18 The Rapid Tranquillisation of Acutely Disturbed Patients 20 Rapid Tranquillisation Policy Version 2 Page 3 of 20

5 1. Introduction a. Rapid Tranquillisation (RT) is the use of medication to calm/lightly sedate the patient, reduce the risk to self and/or others and achieve an optimal reduction in agitation and aggression, thereby allowing a thorough psychiatric evaluation to take place and allowing comprehension and response to spoken messages throughout the intervention. Although not the overt intention, it is recognised that in attempting to calm/lightly sedate the patient, rapid tranquillisation may lead to deep sedation/anaesthesia. [NICE Clinical Guidance no 25; 2005] b. RT should be considered as a last resort, when other attempts to maintain safety have failed or where other risk factors are present (i.e. where the absence of RT is likely to lead to prolonged physical intervention). 2. Purpose of document a. These guidelines have been written with the following aims: To provide advice, support and consistency for staff dealing with psychiatric emergencies; For nursing and medical staff to be able to respond quickly and appropriately to a patient s distress; and To maintain safety of the patients and others. 3. Definitions a. Please refer to the Trust Medicines Policy for relevant definitions. 4. Scope a. This policy is aimed at all clinical and medical staff who are directly involved in the management of acutely disturbed patients and the administration of rapid tranquilisation. 5. Training/Competencies a. Worcestershire Health and Care NHS Trust is committed to ensuring its workforce is confident, competent and capable. The Training and Development Unit develop and publish a yearly training prospectus which describes the courses on offer, to whom they are aimed, how often they need to be updated and how to make a booking. Any training offered in support of this policy will be advertised in the prospectus and can be accessed via the intranet. Rapid Tranquillisation Policy Version 2 Page 4 of 20

6 6. Responsibilities and Duties a. Trust Board is responsible for: Setting policy for the organisation through powers delegated to relevant committees; Ensuring policy is implemented through agreed management arrangements; and Ensuring they are alerted to relevant issues arising that may affect policy. b. Chief Executive is responsible for: Ensuring that arrangements are in place so that employees are fully aware of their statutory, organisational and professional responsibilities and that they are fulfilled; Ensuring that the arrangements in support of policy are fully implemented through inclusion in Business Unit Performance Reviews; and In order for this responsibility to be effectively discharged, Executive Directors and senior colleagues will have specific delegated responsibility to support the Chief Executive in this process. Directors must ensure: strategic development and implementation of policy, corporately and within their areas of control; the appropriate assessment and management of risks; effective delegation of responsibilities within their areas of control; effective support for managers decisions and recommendations in terms of the provision of appropriate resources; a framework is in place to ensure that staff are adequately skilled and experienced to safely undertake their work; necessary reporting procedures are in place; and a framework is in place to monitor compliance with policy. c. Service Delivery Unit Leads and Corporate Heads of Service should: Ensure staff attend appropriate training; and Receive 6 monthly monitoring reports from ward managers. d. Ward Managers should: Ensure that the NICE guidelines Rapid Tranquillisation algorithm is displayed in all clinical in-patient areas; Ensure that suitable training and emergency equipment is available in areas where the use of RT may be required; Ensure that all staff involved in administrating and post administration observation are trained in Immediate Life Support (ILS). Within WHAC Trust unqualified staff (trained to BLS level) will be supervised by qualified staff (trained to ILS level); and Rapid Tranquillisation Policy Version 2 Page 5 of 20

7 Ensure that a crash bag (including a defibrillator, valve mask, fluids, suction, oxygen and first line resuscitation medication) is available WITHIN 3 MINUTES. e. Individual members of staff should: Ensure that Advance Statements are considered and documented in CPA and Early Warning Signs care plans. They are preferred treatment choices expressed by the patient when well and are likely to be documented in care records; Use de-escalation skills and to promote the well being and dignity of the patient at all times; Keep up to date with all required training and NICE guidance in relation to rapid tranquillisation; Ensure that During restraint and prior to the administration of RT medication a set of base line observations are recorded; Complete a Rapid Tranquillisation Recording form (See Appendix 1); Complete a PARS RT chart (See Appendix 2); Ensure that a doctor is called to attend; After rapid tranquillisation, support the patient to reintegrate into the ward; and Ensure that a full medical and psychiatric review is carried out and documented. f. Medical Staff Make provision for a doctor to be able to attend as quickly as possible (ideally within 30 min of alert). 7. Rapid Tranquilisation 7.1 Principles for rapid tranquillisation of acutely disturbed patients a. In selecting medication for patients known to the service due regard to any advance statements and knowledge of previous response should be taken into account. b. In consideration of the environment only oral therapy within BNF limits may be administered in a community setting supported by a valid individualised prescription. c. If you are unfamiliar with any of the drugs mentioned in these guidelines consult the latest BNF and/or SmPC (Summary of Product Characteristics) for further information. d. The NICE guidelines Rapid Tranquillisation algorithm should be displayed in all clinical in-patient areas. Laminated copies are available from the MH Pharmacy Team. 7.2 Clinical History and Risk Assessment a. Patients who have received some professional intervention prior to admission or on the unit may have already been given a dose of a sedative or antipsychotic. b. Such medication needs to be taken into account when applying this policy. Rapid Tranquillisation Policy Version 2 Page 6 of 20

8 c. If there is no prior knowledge of the patient assume neuroleptic naivety. RT may be considered to avoid prolonged use of physical intervention or seclusion d. Base line physical observations can be compared to physical observations taken during an emergency situation 7.3 Physical Risk Management Procedures when using Parenteral RT a. Giving RT should be viewed as a medical emergency due to the associated risks. b. The physical safety of patient and others must be considered at all times. c. Suitable training and emergency equipment must be available to areas where the use of RT may be required. d. NICE Clinical Guideline 25 states that all staff involved in administrating and post administration observation should be trained in Immediate Life Support (ILS). Within WHAC unqualified staff (trained to BLS level) will be supervised by qualified staff (trained to ILS level). e. NICE clinical guidance states that a crash bag (including a defibrillator, valve mask, fluids, suction, oxygen and first line resuscitation medication) should be available WITHIN 3 MINUTES f. A doctor should be able to attend as quickly as possible (ideally within 30 min of alert) g. Where physical intervention is also being used, there must be someone available to look after the patient s head. This person should assume the key role with regard to observing for physical distress. In an urgent situation where this is not possible this responsibility should be clearly delegated. The lack of a person looking after the head is reported as a near miss via the incident reporting system. h. No pressure should be applied to the neck, thorax, abdomen, back or pelvic area. i. RT should be avoided during or immediately following a struggle (staff should wait for the patient to calm as much as possible first). The risks of giving RT during a struggle include: Sudden collapse of patient; Needle stick injury / needle breakage; and Inaccurate siting of injection. j. Risks are increased if the patient has taken alcohol / illicit substances or if the patient has a physical condition which may affect cardiopulmonary function. 7.4 Physical Observations when using Parenteral a. During restraint and prior to the administration of RT medication a set of base line observations as listed below must be recorded. b. Physical observations must be continued on a regular basis until the person becomes fully conscious and active again. Rapid Tranquillisation Policy Version 2 Page 7 of 20

9 c. These physical observations must be documented and must include: Temperature; Pulse; Blood pressure; Respiration rate; and Hydration levels (fluid balance chart) then at regular intervals until the patient is active. Changes in physical observation require the following to be considered: Temperature - if this is raised any further antipsychotic should be withheld, due to risk of Neuroleptic Malignant Syndrome. Pulse Irregular or slow pulse (below 60 per minute), refer to specialist medical care immediately. Blood Pressure if below 80mmHg systolic, lie patient flat, tilt bed head down and refer to specialist medical care immediately. Respiratory Rate if falls below 10 per minute give flumazenil.: BNF states 200 micrograms over 15 seconds, then 100 micrograms at 60-second intervals if required to a max of 1mg by IV injection Pulse Oximetery if oxygen saturation falls below 95%, give high flow oxygen using a non-rebreathe mask. When unconscious the airway must be protected. If the patient is asleep, a more frequent and intensive monitoring by appropriately trained staff is required and should be 7.5 Pharmacological recorded in the appropriate Treatments documentation. Particular attention should be paid to the patient s respiratory effort, airway and level of consciousness. d. The safety and efficacy of pharmacological treatments has not been evaluated in people who are intoxicated with drugs (including prescribed medication) or alcohol. Caution should be exercised with special attention to physical monitoring Advance Statements e. Advance statements should be considered. They are preferred treatment choices expressed by the patient when well and are likely to be documented in CPA and Early Warning Signs care plans Oral Therapy a. Choice depends on current treatment and whether you are treating either an emotional or behavioural crisis. NICE guidance suggests we should also consider the presence or absence of psychosis. If the patient is established on antipsychotics, dose adjustment and/ or use of lorazepam should be considered. If the patient uses street drugs or is already receiving benzodiazepines regularly an antipsychotic may be used alone. For the majority of patients, the best response may require a combination of an antipsychotic and lorazepam. For neuroleptic naïve patients haloperidol should not be used. It has limited use in emotional as opposed to behavioural tranquillisation. Note that doses for lorazepam are deliberately above BNF maximum of 4mg in 24 hours. Rapid Tranquillisation Policy Version 2 Page 8 of 20

10 7.5.2 Intramuscular Therapy a. See above for risk management and physical observations. b. IM olanzapine and IM lorazepam must not be given together and 1 hour allowed after administration before the other drug can be given. Lorazepam is the preferred benzodiazepine for IM administrations. Lorazepam injection is a fridge item and requires 1:1 dilution with water for injection. Have flumazenil available to reverse the effects of lorazepam. (Monitor respiratory rate give flumazenil if rate falls below 10/min.) Note that doses for lorazepam are deliberately above BNF maximum of 4mg in 24 hours Olanzapine IM requires reconstitution with water for injection. IM administration results in maximum plasma concentration 5x higher than the same oral dose. Aripiprazole IM has a licence for the rapid control of agitated and disturbed behaviour in patients with schizophrenia or mania. It was not included in the NICE 2005 guidelines as this preparation was not available. No reconstitution is required. IM aripiprazole can be co-administered with IM lorazepam but requires separate injections. 12mg haloperidol IM is equivalent to 20mg orally. Ensure that parenteral anticholinergics are available. Procyclidine 5-10mg IM may be required to reverse acute dystonic reactions. Neuroleptic naïve patients have an increased risk of dystonic reactions and haloperidol should be avoided if possible, and prophylactic IM procyclidine should always be considered Intravenous Therapy NOTE: BEFORE COMMENCING IV THERAPY FULL RESUSCITATION EQUIPMENT MUST BE AVAILABLE IN THE TREATMENT AREA a. If using IV diazepam administer over 2-3 minutes. Use only the Diazemuls preparation of diazepam. There is a higher risk of adverse events with the IV route and vital signs, particularly respiration, should be carefully monitored throughout. Oxygen and an airway must be available. Flumazenil can be used to reverse any problematic over sedation and should be at hand Special Circumstances: Clopixol Acuphase NOTE: NICE DOES NOT REGARD CLOPIXOL ACUPHASE AS AN INTEGRAL PART OF RAPID TRANQUILLISATION a. Acuphase Not to be used in neuroleptic naïve patients: must only be used when there is a need for a consistent level of tranquillisation for what is assumed is going to be an extended period of challenging behaviour associated with psychosis. Usually Rapid Tranquillisation Policy Version 2 Page 9 of 20

11 given in conjunction with IM lorazepam for more acute effect and invariably supplemented by regular oral antipsychotic drugs unless refusing. b. Caution when administering to an actively struggling patient. Using Acuphase does not mean that a patient will have to be maintained on zuclopenthixol decanoate (Clopixol depot). Choice Issues for Intramuscular therapy Emotionally Dominated Crises IM aripiprazole in combination with IM lorazepam allows simultaneous use of parenteral atypical antipsychotic with a parenteral benzodiazepine. Note that the use of IM olanzapine requires a one hour gap before IM lorazepam may be used and vice versa. Behaviourally Dominated Crises IM olanzapine if antipsychotic alone is deemed sufficient. Alternatively IM aripiprazole with IM lorazepam, repeat in 2hrs and then if needed consider IM haloperidol if deteriorating picture. If partial but reasonable response to first injection consider oral lorazepam to supplement. Extreme and Potentially Dangerous Crises. - IM haloperidol with IM lorazepam (prophylactic 10mg IM procyclidine in neuroleptic naive patients is strongly recommended when IM haloperidol is used) Proceed to IV diazepam (Diazemuls) after consulting senior colleague. 7.6 After Rapid Tranquilisation Full medical/psychiatric review within 24hrs.If flumazenil or oxygen was needed a separate physician review should be included. If the patient experienced raised temperature investigations to exclude NMS are needed and an ECG should be performed if there have been significant changes to BP or pulse. Support the patient to reintegrate into the ward environment. Offer the patient the opportunity to discuss their experience of RT and document in the notes. Complete appropriate recording forms. Appendix 1 and 2 Review management plans/care plans; this may help inform future advance statements and provide an opportunity to review overall management of the patient Rapid Tranquillisation Policy Version 2 Page 10 of 20

12 7.7 Locations where Monitoring Equipment is accessible to support Parenteral RT Kidderminster Site Harvington Witley Redditch Site Hill Crest Newtown Site ECT Grafton Treatment centre Berkeley Athelon Hadley Unit Clifton/Abberley Remember there is no provision for Parenteral Rapid Tranquillisation within a community or home setting. 7.8 Legal issues a. If a patient refuses or lacks the capacity to give valid consent to treatment for mental disorders they may be given treatment, using reasonable force if necessary, in an emergency situation or where the treatment is deemed to be in their best interests. This applies to both informal or detained patients. b. Patients detained under provisions of the Mental Health Act 1983 and subject to Part 4 of the Act may be treated against their will without regard to their ability to give consent. c. Section 57 applies to treatment where a second opinion and the patient s consent is required. This does not apply to rapid tranquillisation. d. Section 58 outlines treatment where either the patient s consent or a second opinion is required. This includes treatment with medication if the patient has been subject to detention for 3 months or more. e. If the patient is subject to Section 58 and either has not consented to treatment or the treatment has not been authorised by the Second Opinion Approved Doctor, it may be given if required urgently under Section 62. f. Section 62 applies to any treatment which is: Immediately necessary to save the patient s life; OR Immediately necessary to prevent a serious deterioration of his/her condition (provided the treatment is not irreversible); OR Immediately necessary to alleviate serious suffering by the patient (provided the treatment is not irreversible or hazardous); OR Rapid Tranquillisation Policy Version 2 Page 11 of 20

13 Immediately necessary and represents the minimum interference necessary to prevent the patient from behaving violently or being a danger to himself/herself or others (provided the treatment is not irreversible or hazardous). Section 62 should only be applied with the consent of the RC It only applies to urgent situations where treatment is immediately necessary. Urgent treatment cannot be continued beyond the point at which the crisis has been brought to an end. The Trust has a form the RC must complete for Section 62. However, all patients are covered by Common Law provisions and so treatment may exceptionally be justified by these provisions. Summary of Legal issues Patients deemed to lack capacity may be treated within the provisions of the Mental Capacity Act (2005). Patients who have capacity who are detained under the Mental Health Act 1983 for treatment may be treated in emergency situations under Section 62. All patients are subject to the provisions of Common Law. Rapid Tranquillisation Policy Version 2 Page 12 of 20

14 7.9 Administration of IM Midazolam in case of a shortage of IM Lorazepam supply a. When Lorazepam IM is unavailable, then IM Midazolam is the Second Drug of Choice. b. The Table below sets out the comparison between Midazolam and Lorazepam. Indications Properties of Midazolam Properties of Lorazepam Absorption after IM injection is IM injection is readily and completely rapid and complete. 2 absorbed. 2 Maximum plasma concentrations in 30 minutes. 2 Absolute bioavailability is 90%. 2 Maximum plasma concentrations in minutes. 2 To be used in Rapid Tranquilisation when IM Lorazepam is unavailable. IV Flumazenil should always be available for use when administering IM Benzodiazepines Metabolism is almost entirely by biotransformation, fraction extracted by liver is 30-60%. 2 Hydroxylated by CYP4503A4. 2 Active metabolites exist. Elimination half life hours. Excreted mainly renally. Dose 7.5mg. Repeated at 2 hourly intervals if required up to a maximum of 30mg/24 hours. 3.4 How to administer: 2,3 No Dilution Required. Glass ampoule contains Midazolam 10mg/2mL. Draw and administer deep IM. Metabolised by one-step glucorinidation. 2 No active metabolites exist. Elimination half life hours. Dose 1-2mg. Repeated at 30minute intervals if required up to maximum of 6mg/24hours. 5 How to administer: 2 Dilute 1:1 with water for injection or sodium chloride 0.9% and give IM. c. When IM Benzodiazepine use is being considered in the absence of IM Lorazepam, use IM Midazolam. Olanzapine IM should likewise not be given within 1 hour of either parenteral benzodiazepine. d. Administer 7.5mg by deep IM repeated at 2 hourly intervals. No dilution is required. e. No dilution is required, draw 7.5mg (1.5mL) from 10mg/2mL ampoule. f. References: 1. British National Formulary 49., March British Medical Association. Pharmaceutical Press. 2. Electronic Medicines Compendium. Summary of Product Characteristics for Lorazepam and Midazolam. Via 3. TREC Collaborative group. Rapid Tranquillisation for agitated patients in emergency psychiatric rooms: a randomised controlled trial of Midazolam vs promethazine. BMJ 2003; 327: D Taylor, C Paton and R Kerwin. Taylor and Francis Group. The South London and Maudsley NHS Trust Oxleas NHS Trust 2007 Prescribing Guidelines 9 th Edition. 5. Rapid Tranquillisation Policy Worcestershire Mental Health Partnership NHS Trust: Sept Rapid Tranquillisation Policy Version 2 Page 13 of 20

15 8. Monitoring implementation NHSLA Criteria Lead Monitoring Frequency Committee The sections below will contain Who takes How do we monitor that How often is this Which working all the requirements of the the lead this is done done groups etc. are NHSLA risk management responsibility involved and which standards in relation to this committee oversee policy. The organisation has an approved, documented process for managing the risks associate with rapid tranquilisation. As a minimum the document should include a description of : a) Duties Medical Director b) Prescribing guidelines with Chief Responsive to change 3 year automatic Medicines regards to rapid tranquillisation Pharmacist legislation and other review in line with Management and with the relevant drivers expiry Safety support of Medicines Management and Safety Committee members c) Arrangements for monitoring Ward PARS monitoring sheet Forms monitored Medicines service users having received Manager and Rapid monthly by ward Management and rapid tranquillisation Tranquillisation manager. Six- Safety recording form monthly reports to completed for all Business Unit patients Leads d) Organisations expectations in Practise Training Prospectus Reports to Service Training and relation to staff training as identified in the training needs analysis Development and Service Improvement manager Training records data base included in MAPA 3 Delivery Unit managers Development e) Process for monitoring compliance with the above As above As above As above As above Rapid Tranquillisation Policy Version 2 Page 14 of 20

16 9. References British National Formulary (BNF) (Latest edition). Jones R. (2003) Mental Health Act Manual, 8th edition. Maden & Ashead (2006) Good Practice Guide for the management of Violence Royal College of Psychiatrists. Mental Health Act (1983) Code of Practice ISBN (1999). NICE Clinical Guideline 25 (February 2005). The short-term management of disturbed/violent behaviours, in psychiatric in-patient settings and emergency setting and emergency departments. NICE Clinical Guideline 01 (2002) Schizophrenia: core interventions in the treatment and management of schizophrenia in primary and secondary care. NICE Clinical Guideline 38 (July 2006) Bipolar Disorder. The management of bipolar disorder in adults, children and adolescents in primary and secondary care. Shoumitro, D. Clarke, D. Unwin, G. (2006) Using medication to manage behaviour problems among adults with a learning disability Quick Reference Guide. Royal College of Psychiatrists and Birmingham University Associated documentation a. The follow Trust Policies should be read in conjunction with this Policy. Medicines Policy. Seclusion Policy. Policy for the Management of Actual or Potential Aggression. Resuscitation Policy. Observation Policy. Rapid Tranquillisation Policy Version 2 Page 15 of 20

17 Rapid Tranquillisation Recording Form To be used when service users have had medication in the form of an injection(s) usually under a restraint situation. Retain in service user s notes. Copy sent to ward manager. Name Date Time Consultant MHA Status Ethnic Group Ward Medication Dose Time Route Notes All medication administration recorded on inpatient treatment card Mental Health Act provision Where the service user is detained under the Mental Health Act, medication is covered by patient consent to treatment or section 62, paperwork is in place Monitoring A PARS Chart has been completed in line with Trust policy and the following have all been recorded Conscious Level ( using AVPU) Respiratory rate Pulse Sp 02 Additional Risk factors and concerns Blood pressure Temperature Parameter Has the patient received high doses parenteral antipsychotics If yes, has a 12 lead ECG been undertaken Any concerns regarding patient In all cases document action or hydration status justification in notes Signs of residual EPS Yes No Debrief undertaken within 72 hours yes no Rapid Tranquillisation Policy Version 2 Page 16 of 20

18 Additional comments Rapid Tranquillisation Policy Version 2 Page 17 of 20

19 1. Every 5 10 minutes for 1 hour 2. Then every 30 minutes until the service user is ambulatory 3. Then continue to monitor alertness, mental state and behaviour. Rapid Tranquillisation Policy Version 2 Page 18 of 20

20 Rapid Tranquillisation Policy Version 2 Page 19 of 20

21 THE RAPID TRANQUILLISATION OF ACUTELY DISTURBED PATIENTS MONITOR VITAL SIGNS AS PER GUIDELINES For older adult and frail patients halve all doses initially and titrate according to response Initial Considerations 1. DE-ESCALATION - Talking down, time out, distraction, privacy and quiet (refer to MAPA policy) 2. MEDICATIONS - Note any Psychotropic medication received in last few hours 3. ADVANCE DIRECTIVES Patient preferred treatment choices A: Offer oral therapy: OLANZAPINE 5-10mg (Max 20mg/24hrs) peaks 5-8 hours (NB velotabs are NOT absorbed any quicker) Can be combined with LORAZEPAM 2-4mg (Max 6mg/24hrs) Sedation in minutes, peaks 2 hours, lasts 4-6 hours If emotional disturbance without psychotic symptoms use lorazepam alone Oral risperidone 1-2mg (peak 1 2 hours) or quetiapine (50-100mg) may also be considered if previous response or intolerant to other drugs; doses to remain within BNF prescribing limits. Haloperidol 5-10mg (max 30mg/24hrs 4 hourly intervals between doses) peaks 2-6 hours. The use of haloperidol must be balance with its poor side effect profile and not used in neuroleptic naïve patients Allow sufficient time between doses; see peak times/intervals above B: If unsuccessful or refused: INTRAMUSCULAR THERAPY LORAZEPAM 1-2mg IM (Max 6mg/24hrs) (Sedation in minutes, peaks at minutes, lasts 4-6 hours) NB do not administer lorazepam or olanzapine injections within 1 hour of each other OLANZAPINE 5-10mg IM (Max 20mg/24hrs 2hr interval between injections) peaks minutes OR ARIPIPRAZOLE 9.75mg IM (Max 3xIM doses/24hrs or 30mg total oral+im/24hrs 2hr interval between injections) onset minutes, peaks 1-3 hrs OR HALOPERIDOL 5mg IM (Max 18mg/24hrs) peaks minutes. Try to avoid in neuroleptic naïve patients. Baseline ECG recommended for all patients before use DO NOT MIX INJECTIONS IN ONE SYRINGE Review half hourly and repeat as necessary up to maximum dose. To monitor respiratory rate and give flumazenil if rate falls below 10 per minute. Remember to include oral medication in assessment of doses received IF NO IMPROVEMENT CONSULT SENIOR COLLEAGUE C: Consider DIAZEPAM EMULSION 10mg IV (Diazemuls) Ensure Flumazenil available. Review vital signs particularly respiration throughout. Oxygen and airway must be available Special Circumstances Only CLOPIXOL ACUPHASE IM mg (Sedation in 1-2 hours, peaks in 36 hours, lasts 72 hours) ONLY IF Patient is detained under Mental Health Act and is not antipsychotic naïve Review mental and physical state and identify IDENTIFY LONG TERM TREATMENT AIMS Rapid Tranquillisation Policy Version 2 Page 20 of 20