Frmulary and Prescribing Guidelines SECTION 8: MANAGEMENT OF ACUTELY DISTURBED BEHAVIOUR
8. Rapid Tranquillisatin 8.1 Management f acutely disturbed ADULTS Befre cnsidering pharmaclgical measures: (see CLG52 fr mre infrmatin) Cnsider de-escalatin, using nn drug appraches: seclusin/mving t a lw stimulus area, talking dwn, time ut, distractin If pssible, d a mental state examinatin and physical state examinatin, take a histry including drug/alchl status, drug sensitivities, cncurrent medicatin Check fr intercurrent illness and recent illicit substance use Establish a wrking diagnsis Check fr any advance directive in relatin t medicines NON-PHARMACOLOGICAL MEASURES UNSUCCESSFUL INAPPROPRIATE L E V E L 1 Disturbed BUT accepting ral medicatin L E V E L 2 Disturbed AND refusing ral medicatin nurse in a quiet area Review all medicatin prescribed within last nging verbal de-escalatin 24hurs (BNF limits, side effects etc) fd and fluid t be prvided Cnsultant pinin may have t be sught review current medicatin decide whether additinal medicatin required PARENTERAL interventins (IM) AL interventins (PO) Lrazepam (1-2mg; max 4mg/24H) Can be repeated after 1 hur Dse shuld be reduced by 50% in patients taking sdium valprate Halperidl (5-10mg; max 20mg/24H) Can be repeated after 1 hur Ensure cardiac status f patient is knwn, preferably with previus ECG Chlrprmazine 50-100mg (Max 300mg/24H Can be repeated after 1 Hur Risperidne (2mg) Ordispersible tablets may be cnsidered if the patient is likely t spit ut the tablets Can be repeated after 2 hurs Olanzapine (10mg) Ordispersible tablets may be cnsidered if the patient is likely t spit ut the tablet Can be repeated after 2 hurs Lrazepam IM (1-2mg; max 4mg/24H) Sedatin in 30-45 mins; peaks 1-3 hurs; Lasts 4-6 hurs, dse shuld be reduced by 50% in patients taking sdium valprate Prmethazine IM (50mg; 100 mg/24h) Can be repeated in 1-2 hurs, may be used in benzdiazepine-tlerant patients Prmethazine is the first line alternative during shrtages f lrazepam AND/ Halperidl IM (5mg; max 12mg/24H) Use alne r in cmbinatin with lrazepam, sedatin in 10 mins, peaks in 15-60 mins, half life 10-36 hurs, Ensure cardiac status f patient is knwn, preferably with previus ECG Olanzapine IM as mntherapy (5-10mg; max 20mg/24H) Peaks in 15-45 mins D nt repeat within 2 hurs D nt use lrazepam within ne hur f administering lanzapine IM Cnsultant s direct invlvement mandatry Cnsult n-call pharmacist Secnd pinin f anther cnsultant Avid Diazepam if ECT is being cnsidered L E V E L 3 Prmethazine 50mg IM Diazepam 10mg IV ver at least 5 minutes. Can be repeated up t 3 times if insufficient effect. 2 Apprved by Medicines Management Grup Octber 2016
8. Rapid Tranquillisatin 8.2 Management f acutely disturbed OLDER ADULTS Befre cnsidering pharmaclgical measures: (see CLG52 fr mre infrmatin) Cnsider de-escalatin, using nn drug appraches: seclusin/mving t a lw stimulus area, talking dwn, time ut, distractin If pssible, d a mental state examinatin and physical state examinatin, taking int accunt frailty, drug/alchl status, drug sensitivities, cncurrent medicatin, dementia Check fr intercurrent illness and recent illicit substance use Establish a wrking diagnsis Check fr any advance directive in relatin t medicines NON-PHARMACOLOGICAL MEASURES UNSUCCESSFUL INAPPROPRIATE L E V E L 1 Disturbed BUT accepting ral medicatin L E V E L 2 Disturbed AND refusing ral medicatin nurse in a quiet area Review all medicatin prescribed within last nging verbal de-escalatin 24hurs (BNF limits, side effects etc) fd and fluid t be prvided Cnsultant pinin may have t be sught review current medicatin decide whether additinal medicatin required PARENTERAL interventins (IM) AL interventins (PO) Lrazepam (0.5-1mg; max 2mg/24H) Can be repeated after 1 hur Dse shuld be reduced by 50% in patients taking sdium valprate. Wrsens cnfusin in BPSD Halperidl (1-3mg; max 10mg/24H) Can be repeated after 1 hur Ensure cardiac status f patient is knwn, preferably with previus ECG Risperidne (0.5-1mg) Ordispersible tablets may be cnsidered if the patient is likely t spit ut the tablets Can be repeated after 2 hurs Preferred ptin in BPSD Olanzapine (2.5-5mg) Ordispersible tablets may be cnsidered if the patient is likely t spit ut the tablet Can be repeated after 2 hurs Lrazepam IM (0.5-1mg; max 2mg/24H) Sedatin in 30-45 mins; peaks 1-3 hurs; Lasts 4-6 hurs, dse shuld be reduced by 50% in patients taking sdium valprate D nt use lrazepam within ne hur f administering lanzapine IM Prmethazine IM (25mg; 50mg/24H) Can be repeated in 1-2 hurs, may be used in benzdiazepine-tlerant patients Prmethazine is the first line alternative during shrtages f lrazepam AND/ Halperidl IM (1-2mg; max 10mg/24H) Use alne r in cmbinatin with lrazepam, sedatin in 10 mins, peaks in 15-60 mins, half life 10-36 hurs, Ensure cardiac status f patient is knwn (ECG) Olanzapine IM as mntherapy (5-10mg; max 20mg/24H) Peaks in 15-45 mins D nt repeat within 2 hurs L E V E L 3 Refer t cnsultant Refer t cnsultant 3 Apprved by Medicines Management Grup Octber 2016
8. Rapid Tranquillisatin 8.3 Management f acutely disturbed CHILDREN & ADOLESCENTS Befre cnsidering pharmaclgical measures: (see CLG52 fr mre infrmatin) Cnsider de-escalatin, using nn drug appraches: seclusin/mving t a lw stimulus area, talking dwn, time ut, distractin If pssible, d a mental state examinatin and physical state examinatin, take a histry including drug/alchl status, drug sensitivities, cncurrent medicatin Check fr intercurrent illness and recent illicit substance use Establish a wrking diagnsis Check fr any advance directive in relatin t medicines NON-PHARMACOLOGICAL MEASURES UNSUCCESSFUL INAPPROPRIATE L E V E L 1 Disturbed BUT accepting ral medicatin nurse in a quiet area nging verbal de-escalatin fd and fluid t be prvided review current medicatin decide whether additinal medicatin required If patient is unknwn t services initially treat with Lrazepam and avid antipsychtics if pssible AL interventins (PO) Lrazepam ( 12 yrs 1-2mg, max 4mg/24H; <12 yrs 0.5-1mg, max 2mg/24H) Can be repeated after 1 hur Reduce dse by 50% in patients taking sdium valprate Prmethazine ( 12 yrs 25-50mg; <12 yrs 10-25mg) Can be repeated after 1 hur Halperidl ( 12 yrs 1-5mg, max 10mg/24H; <12 yrs 0.5-3mg, max 5mg/24H) Can be repeated after 1 hur Ensure cardiac status f patient is knwn, preferably with previus ECG Risperidne ( 12 yrs 1-2mg; <12 yrs 0.5-1mg) Ordispersible tablets may be cnsidered if the patient is likely t spit ut the tablets Can be repeated after 2 hurs Olanzapine ( 12 yrs 10mg) Ordispersible tablets may be cnsidered if the patient is likely t spit ut the tablet Can be repeated after 2 hurs L E V E L 2 Disturbed AND refusing ral medicatin Review all medicatin prescribed within last 24hurs (BNF limits, side effects etc) Cnsultant pinin may have t be sught PARENTERAL interventins (IM) Lrazepam IM ( 12 yrs 1-2mg, max 4mg/24H; <12 yrs 0.5-1mg, max 2mg/24H) Sedatin in 30-45 mins; peaks 1-3 hurs; lasts 4-6 hurs Dse shuld be reduced by 50% in patients taking sdium valprate Prmethazine IM ( 12 yrs 25-50mg; <12 yrs 10-25mg) Prmethazine is the first line alternative during shrtages f lrazepam Halperidl IM ( 12 yrs 1-5mg, max 10mg/24H; <12 yrs 0.5-3mg, max 5mg/24H) Sedatin in 10 mins; peaks in 15-60 mins; halflife 10-36 hurs Use alne r in cmbinatin with Lrazepam Ensure cardiac status f patient is knwn, preferably with previus ECG Olanzapine IM as mntherapy ( 12 yrs 5-10mg, max 3 injectins/24h) Peaks in 15-45 mins D nt repeat within 2 hurs D nt use lrazepam within ne hur f administering lanzapine IM Quetiapine ( 12 yrs 25-50mg; <12 yrs 12.5-25mg) Can be repeated after 2 hurs 4 Apprved by Medicines Management Grup Octber 2016
8. Rapid Tranquillisatin 8.4 Drugs apprved fr management f acute disturbed behaviur See latest BNF fr licensed indicatins. Drug and frm Time t max. plasma Cnc. Half life Halperidl IM injectin 15-60 mins 10-36 hurs Halperidl slutin 3-6 hurs 10-36 hurs Halperidl tab 3-6 hurs 10-36 hurs Cmments Lrazepam IM injectin 60-90 mins 12-16 hurs The FDA has warned f a serius risk f death when benzdiazepines are Lrazepam tabs 2 hurs 12 hurs used in cmbinatin with Opiid analgesic r cugh preparatins. 6 Olanzapine dispersible tab. 5-8 hurs 32-50 hurs Olanzapine injectin 15-45 mins 32-50 hurs Olanzapine tab 5-8 hurs 32-50 hurs Prmethazine IM injectin 2-3 hurs 5-14 hurs Risperidne dispersible tab. 1-2 hurs 24 hurs Risperidne liquid 1-2 hurs 24 hurs Risperidne tab 1-2 hurs 24 hurs IM lanzapine may prduce a 5-fld increase in plasma cnc. vs. the same dse given rally 8.5 Guidelines fr the use f Flumazenil Indicatins fr use Cntra-indicatins Cautins Dse & rute f administratin (in adults) Time befre the dse can be repeated Maximum dse: Side effects Respiratry rate < 10/minute after administratin f benzdiazepines Patients with epilepsy wh have been receiving lng-term benzdiazepines Dse shuld be carefully titrated in hepatic impairment Initially: 200 mcg intravenusly ver 15 secnds 60 secnds Subsequent dse: 100 mcg ver 10 secnds as required (up t 8 dses) 1 mg in 24 hurs (ne initial dse and eight subsequent dses) Patients may becme agitated, anxius, r fearful n awakening. Seizures may ccur in regular benzdiazepine users Respiratry rate shuld be mnitred cntinuusly until respiratry rate returns t baseline level. Flumazenil has a shrt half-life (much shrter than diazepam) and respiratry functin may recver then deterirate again. Nte: If respiratry rate des nt return t nrmal r patient is nt alert after initial dses give, then assume sedatin is due t sme ther cause. 5 Apprved by Medicines Management Grup Octber 2016
8. Rapid Tranquillisatin 8.6 Acute Disturbed Behaviur Mnitring Errr! Reference surce nt fund. After any parenteral drug administratin, mnitr and recrd n the MEWS chart the fllwing: 1. Temperature 2. Pulse 3. Bld pressure 4. Respiratin rate Every 5-10 minutes fr ne hur and then half hurly until patient is ambulatry. If the patient is asleep r uncnscius, the cntinuus use f pulse ximetry t measure xygen saturatin is desirable. A nurse shuld remain with the patient until ambulatry. ECG and haematlgical mnitring are als necessary when parenteral antipsychtics are administered, especially when higher dses are used. Hypkalaemia, stress and agitatin place the patient at risk f cardiac arrhythmias. A crash bag shuld be available within 3 minutes 8.7 Remedial Measures in ADULTS 1 Prblem Acute Dystnia (including culgyric crisis) Reduced respiratry rate (<10 per minute) Or xygen saturatin (<90%) Irregular r slw pulse (<50/min) Fall in Bld pressure (>30 mmhg rthstatic drp r <50 mmhg diastlic) Increased Temperature Remedial Measures Give prcyclidine 5-10mg IM Give xygen raise legs; Ensure that patient is nt lying face dwn. Give flumazenil if benzdiazepine-induced respiratry depressin suspected. If induced by any ther sedative agent and Dr is nt immediately available: TRANSFER TO A MEDICAL BED AND VENTILATE MECHANICALLY Refer t specialist medical care immediately Lie patient flat, tilt bed twards head. Mnitr clsely. Withhld antipsychtics: (risk f NMS and perhaps arrhythmias). Check Creatinine kinase 8.8 Guidelines fr the Use f Clpixl Acuphase (zuclpenthixl acetate) Acuphase shuld nly be used after an acutely psychtic patient has required repeated injectins f shrt-acting antipsychtic drugs such as halperidl r lanzapine r sedative drugs such as lrazepam. Acuphase shuld nly be given when enugh time has elapsed t assess the full respnse t previusly injected drugs therefre allw 15 minutes after IV injectins r 60 minutes after IM administratin. Acuphase shuld never be administered: In an attempt t hasten the antipsychtic effect f any ther antipsychtic therapy Fr rapid tranquillisatin At the same time as ther parenteral antipsychtics r benzdiazepines At the same time as dept medicatin 6 Apprved by Medicines Management Grup Octber 2016
8. Rapid Tranquillisatin As a test dse fr zuclpenthixl decanate dept T a patient wh is physically resistive (risk f intravasatin and il emblus). T patients wh accept ral medicatin T patients wh are antipsychtic-naïve T patients wh are less than 12 years ld. T patients wh are sensitive t EPSE T patients wh are uncnscius T patients wh are pregnant T patients with hepatic r renal impairment T patients with cardiac disease 8.8.1 Dse Onset and duratin f actin Acuphase shuld be given in a dse f 50-150mg, up t a maximum f 400mg ver a tw week perid. This maximum duratin ensures that a treatment plan is put in place. It des nt indicate that there are knwn harmful effects frm mre prlnged administratin, althugh such use shuld be very exceptinal. There is n such thing as a curse f Acuphase. The patient shuld be assessed befre each administratin. Injectins shuld be spaced at least 24 hurs apart. Nte, Zuclpenthixl acetate is widely misused as a srt f chemical straightjacket. In reality, it is a ptentially txic preparatin with very little published infrmatin t supprt its use. It is perhaps best reserved fr thse few patients wh have a prir histry f gd respnse t Acuphase that is, thse patients wh have an advance directive recmmending the use f Acuphase during psychtic episdes. Sedative effects usually begin t be seen 2 hurs after injectin and peak after 12 hurs. The effects may last fr up t 72 hurs. Nte: Acuphase has n place in rapid tranquillisatin: its actin is nt rapid. 8.9 NICE Clinical Guidelines NICE NG10, May 2015, Vilence and Aggressin: Shrt term management in mental health, health and cmmunity settings. NICE defines Rapid Tranquillisatin as the use f medicatin by the parenteral rute (usually intramuscular r exceptinally, intravenus) if ral medicatin is nt pssible r apprpriate and urgent sedatin with medicatin is needed. All staff that prescribe and administer the abve medicatins shuld be: Aware f the risks assciated with pharmaclgical management f acutely disturbed patients, such as: damage t the therapeutic relatinship between service user and Health Care Prfessinal (NICE endrses requesting service users accunts f their experiences upn discharge t anther unit) 7 Apprved by Medicines Management Grup Octber 2016
8. Rapid Tranquillisatin ver-sedatin leading t lss f alertness and lss f cnsciusness (NICE guidelines mandate that the service user must be able t respnd t cmmunicatin thrughut and if verbal cmmunicatin is lst, then the same level f care as fr general anaesthesia must be used). cardivascular and respiratry cllapse [see mnitring after administratin which cnsists f: temperature (risk f neurleptic malignant syndrme), respiratin rate, xygen saturatin, BP, HR (pulse), level f cnsciusness and any evidence f EPSE. The physical and mental status f the service user shuld be taken int accunt in deciding the initial dse and subsequent dse increments. interactin f the medicines used in management with medicines already taken by the patient (whether prescribed by his/her GP, r illicit) Familiar with the medicines used in management, their crrect prescriptin, and that ral (PO) and intramuscular (IM) dses must be prescribed separately that tw drugs f the same class shuld nt be written tgether (fr example, d nt write up diazepam and lrazepam, and/r halperidl * and lanzapine n the prn side f the drug chart) that medicatins shuld nt be mixed in the same syringe (that is, lrazepam shuld be given by separate injectin and site, frm a cncurrent halperidl injectin if cmbined antipsychtic/ benzdiazepine is clinically required) the NEED F CONSENT, r else ensure that the apprpriate Mental Health Sectin(s) is in place the prperties f drugs used that is BNF and SPC requirements, including need fr baseline ECG and the ptential f individual drugs t lengthen (directly r indirectly) the QTc interval. Additinally they must knw the ttal daily dses allwed and the need t titrate dse t effect. the risks assciated with particular classes f medicines: Benzdiazepines: lss f cnsciusness; respiratry depressin r arrest; cardivascular cllapse when receiving bth clzapine and benzdiazepines Antipsychtics: excessive sedatin; lss f cnsciusness; cardivascular/respiratry cmplicatins and cllapse; seizures; akathisia; dystnia; dyskinesia; neurleptic malignant syndrme Antihistamines: excessive sedatin; painful injectin; additinal antimuscarinic effects the medicines NOT recmmended, namely: 8 Apprved by Medicines Management Grup Octber 2016
8. Rapid Tranquillisatin PO/IM chlrprmazine IM diazepam Thiridazine (n lnger marketed in the UK) IM dept antipsychtics Olanzapine (fr dementia-related disturbance) Zuclpenthixl acetate due t lng nset and duratin f actin. Hwever, it may be cnsidered as an ptin where there is a past histry f gd and timely respnse, r where there is an advance directive and when the service user has a histry f disturbed behaviur ver an extended time perid. Aware that there are preferred levels f administratin (the preferred methd f drug administratin being PO, then intramuscular IM and then, and nly if immediate tranquillisatin is essential, IV) and that: if patient will accept ral and is nt psychtic, NICE recmmends ral lrazepam. Alternatively, if psychtic and taking ral, cnsider an antipsychtic (e.g. halperidl r lanzapine) in additin t ral lrazepam. if patient will nt accept ral (r, frm previus experience, this is cnsidered ineffective) cnsider IM lrazepam fr nn-psychtic patients. Alternatively, if psychtic and nt accepting ral, cnsider use f IM lrazepam in additin t IM antipsychtic (e.g. halperidl r lanzapine). IM Lrazepam and IM Olanzapine can nly be given cncurrently if a minimum f ne hur has elapsed between the tw agents (When using antipsychtics parenterally, ensure ready availability f parenteral prcyclidine. NICE als recmmends parenteral benztrpine, but this prduct has, since, been discntinued in the UK.) Familiar with pst management prcedures, such as: Regular mnitring and recrding f BP, HR (pulse), RR, O2 saturatins, level f cnsciusness, EPSE and temperature; the frequency f which must be increased if IM/IV administratin has been used BNF/SPC dsages have been exceeded High-risk situatins such as knwn/suspected illicit drug use Patient has a significant medical histry/is n prescribed medicatin If verbal respnsiveness is lst use same level f mnitring as fr general anaesthesia Upn transfer t anther unit, ensure that full dcumentatin is cmplete with: Full medicatin histry (that is, which medicines were/were nt effective and any adverse drug interactins); Frmulatin f advance directive(s); Service user s accunt f their experience (if feasible). Apprved by Medicines Management Grup Octber 2016 9
8. Rapid Tranquillisatin References 1. The Suth Lndn and Maudsley NHS Fundatin Trust and Oxleas NHS Fundatin Trust 2015 Prescribing Guidelines. 12 th Editin. Wiley Blackwell 2. NICE CG 25, Feb 2005 Vilence: The shrt-term management f disturbed/vilent behaviur in psychiatric in-patient settings and emergency departments http://guidance.nice.rg.uk/cg25 (Accessed Dec 2015) 3. British Natinal Frmulary (70 th Editin, September 2015) 4. Summary f Prduct Characteristics[accessed Dec 2015] http://www.medicines.rg.uk/emc/ 5. NICE NG 10 May 2015. Vilence and Aggressin: Shrt term management in mental health, health and cmmunity settings. http://www.nice.rg.uk/guidance/ng10 6. http://www.fda.gv/drugs/drugsafety/default.htm Accessed September 2016 Apprved by Medicines Management Grup Octber 2016 10