Agitation and rapid-tranquilisation Flashcards
What are some warning signs that a patient may become violent?
Verbal warnings
- Direct threats: take these seriously
- Abuse: swearing or insults
- Tone: angry, sarcastic, threatening, or rude
- Volume: shouting or prolonged silence
Physical warnings:
- Prolonged staring/narrowed eyes/angry frown/dilated pupils
- Fast breathing/sweating/facial reddening or blanching
- Gritting teeth/clenching fists/trembling/agitation
- Leaning over you
- Pacing (don’t let people walk behind you)
- Violent gestures, e.g. pounding the table.
What are some de-escalation strategies that can be used if a patient becomes aggressive? What should not be done?
De-escalation and escape - while exiting or resolving mild hostility..
DO
- Keep your tone and body language calm—no sudden movements.
- Give your patient space.
- Apologize if you’ve upset them.
- Empathize and feed back their feelings, e.g. ‘It’s frustrating for you’.
- Tell them that they are frightening you.
- Back out. Never turn your back on someone who threatens you.
- Tell staff immediately.
DON’T
- Say, ‘Calm down’. This implies that you think they are unreasonably angry; it is inflammatory.
- Touch them.
- Make jokes.
- Stand to ‘match’ a patient who stands; stay seated or back out. If currently standing, don’t stand face to face
- or put your hands on your hips. Standing to their side, shoulder-on, is less confrontational and makes you a
- smaller target.
List the causes of agitation in hospital patients.
What are some risk factors for violence in an inpatient setting regarding the patient?
- Being young
- History of violence
- Being compulsorily admitted
- Co-morbid substance misuse
- Being in the acute phase of the illness
What are some risk factors for violence in an inpatient setting in relation to the environment?
- Lack of structured activity
- High use of temporary staff
- Low levels of staff-patient interaction
- Poor staffing levels
- Poorly defined staffing roles
- Unpredictable ward programmes
- Lack of privacy
- Overcrowding
- Poor physical facilities
- Availability of weapons
Define rapid tranquilisation.
Use of medication by the parenteral route (usually IM) if oral medication is not possible or appropriate and urgent sedation with medication is needed.
Define de-escalation.
The use of techniques (including verbal and non-verbal communication skills) aimed at defusing anger and averting aggression
PRN medication can be used as part of a de-escalation strategy but PRN medication used alone is not de-escalation.
What patient risk factors must be considered before administering RT?
- Total dose of daily medication prescribed/administered
- PMH
- Pregnancy
- Cardiac problems, prolonged QTc
Summarise the protocol for rapid tranquilisation.
If there is no response to lorazepam after 1 hour, what combination of drugs can be tried for RT?
Consider another dose lorazepam 1mg
Then consider: IM promethazine 25mg to 50mg + haloperidol IM 2 to 5 mg
Then if no response: senior help (pharmacist and consultant)
What should be done before haloperidol is used as RT?
Baseline ECG should be done before giving IM haloperidol
What should be monitored during RT and how often?
Response should be monitored within 1 hour.
Also monitor:
- HR
- BP
- RR
- consciousness
- temperature
- level of hydration
Intervals determined by senior doctors. If there are preexisting health problems of if maximum dose has been reached then monitor often e.g. every 15 min. This should be documented on NEWS2 chart. If monitoring of sats not possible then do ABCDE assessments.
What is the treatment of a patient whose RR drops below 10breaths/min after rapid tranquilisation?
If the patient’s respiratory rate drops below 10/min due to benzodiazepine administration staff should call an ambulance immediately and unless contra indicated Flumazenil IV needs to be administered.
What is the maxmimum lorazepam IM dose in 24 hours?
1-2mg given per dose and can be repeated after 1 hour
Up to 4mg in 24 hours
What is the maximum dose of IM haloperidol that can be given over 24 hours?
2-5mg per dose
Dose can be repeated after 2 hours
Max dose 12mg in 24 hours