Psychiatry - Rapid Tranquillisation

Question 1

Rapid Tranquillisation?

Answer 1

NICE definition: ​

• The use of medication to calm/lightly sedate the service user, 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

Always consider other factors that may have exacerbated situations:

• Poor communication
• Lack of privacy
• Overcrowding
• Boredom
• Long waiting times or lack of information

Use other methods first before RT e.g. verbal de-escalation

Question 2

Rapid Tranquillisation?

Legal Issues?

Answer 2

• RT should be humane, ethical, legal and clinically effective
• Any advance care planning?
• Common law can be utilised without recourse to the Mental Capacity Act (MCA) – to avert serious risk and to also make decisions in good faith
• All treatment should be reasonable and proportionate
• Where possible, treatment without consent should be under one of the treatment sections of the Mental Capacity Act (usually section 3)

Question 3

Rapid Tranquillisation?

Assess Risk?

Answer 3

Increased risk in children, frail elderly, pregnancy, Lewy body dementia, or by concurrent medical illness

These risks are:

• Loss of consciousness
• Airway obstruction
• Respiratory depression ± arrest
• Hypotension or cardiovascular collapse
• Cardiac arrest
• Seizure
• Extrapyramidal side-effects (EPSEs) or neuroleptic malignant syndrome
• Exclude medical contra-indications to RT (e.g. cardiac disease or respiratory disorders) and ensure facilities for basic CPR and flumazenil are available

Question 4

Rapid Tranquillisation?

Regimens?

Answer 4

• Oral preferred: Lorazepam, olanzapine, haloperidol
• First-line: lorazepam - non-psychotic behavioural
• Lorazepam + antipsychotic - behavioural disturbance in the context of psychosis
• Olanzapine (and risperidone) should be avoided in patients with dementia, due to an increased risk of stroke and death
• IM sometimes IV
• Ideally give an antimuscarinic drug (e.g. procyclidine) if haloperidol is given

Question 5

Rapid Tranquillisation?

Monitoring and Documentation?

Answer 5

Monitoring:

• Blood pressure/pulse/respiratory rate every 5 minutes,
• temperature every 30 minutes and look for evidence of dystonia

Documentation - ensure at least the following minimum is recorded:
Reasons for using RT:

• Legal situation
• Physical assessment - any medical hazards recognised
• Patient’s diagnosis.
• Drugs given - in what sequence and dosage
• Outcome
• Monitoring chart and ongoing plan

Debrief:

• Discuss, as a significant event, whether the need for RT could have been anticipated and prevented.
• Discuss the patient’s account if available