1.5 Rapid tranquillisation [61]

During an acute illness, some service users can become behaviourally disturbed and may need help to calm down; for the majority of service users, though, rapid tranquillisation is not necessary and should not be resorted to routinely. It is important to ensure that the environment is properly adapted for the needs of the acutely ill and that communication between staff and service users is clear and therapeutic in order to minimise frustration and misunderstandings. Staff on psychiatric inpatient units should be trained in how to assess and manage potential and actual violence using de-escalation techniques, restraint, seclusion and rapid tranquillisation. Staff should also be trained to undertake cardiopulmonary resuscitation. If drugs are needed to calm an individual, an oral preparation should be offered first. If intramuscular injection proves necessary, lorazepam, haloperidol or olanzapine are the preferred drugs. If two drugs are needed, consider lorazepam and haloperidol. If haloperidol is used, anticholinergics should be administered. Vital signs and side effects should be regularly monitored and full physical and mental health assessment undertaken at the earliest opportunity. Rapid tranquillisation may be traumatic – patients will need debriefing with full explanation, discussion and support.

1.5.1.1 Health professionals should identify and take steps to minimise the environmental and social factors that might increase the likelihood of violence and aggression during an episode, particularly during periods of hospitalisation.

Factors to be routinely identified, monitored and corrected include: overcrowding; lack of privacy; lack of activities; long waiting times to see staff; poor communication between patients and staff; and weak clinical leadership.

1.5.2 Aims of rapid tranquillisation

The aim of drug treatment in such circumstances is to calm the person, and reduce the risk of violence and harm, rather than treat the underlying psychiatric condition. An optimal response would be a reduction in agitation or aggression without sedation, allowing the service user to participate in further assessment and treatment. Ideally, the drug should have a rapid onset of action and a low level of side effects.

1.5.2.1 Staff who use rapid tranquillisation should be trained in the assessment and management of service users specifically in this context: this should include assessing and managing the risks of drugs (benzodiazepines and antipsychotics), using and maintaining the techniques and equipment needed for cardiopulmonary resuscitation, prescribing within therapeutic limits and using flumazenil (benzodiazepine antagonist).

1.5.3 Training for behavioural control/rapid tranquillisation

1.5.3.1 Staff need to be trained to anticipate possible violence and to de-escalate the situation at the earliest opportunity, and physical means of restraint or seclusion should be resorted to ‘only after the failure of attempts to promote full participation in self-care’.

1.5.3.2 Training in the use and the dangers of rapid tranquillisation is as essential as training in de-escalation and restraint. Health professionals should be as familiar with the properties of benzodiazepines as they are with those of antipsychotics.

1.5.3.3 Specifically, health professionals should:

• be able to assess the risks associated with rapid tranquillisation, particularly when the service user is highly aroused and may have been misusing drugs or alcohol, be dehydrated or possibly be physically ill
• understand the cardio-respiratory effects of the acute administration of these drugs and the need to titrate dosage to effect
• recognise the importance of nursing, in the recovery position, people who have received these drugs and also of monitoring pulse, blood pressure and respiration
• be familiar with, and trained in, the use of resuscitation equipment; this is essential as an anaesthetist or experienced 'crash team' may not be available
• undertake annual retraining in resuscitation techniques
• understand the importance of maintaining an unobstructed airway.

1.5.4 Principles of rapid tranquillisation

1.5.4.1 The psychiatrist and the multidisciplinary team should, at the earliest opportunity, undertake a full assessment, including consideration of the medical and psychiatric differential diagnoses.

1.5.4.2 Drugs for rapid tranquillisation, particularly in the context of restraint, should be used with caution because of the following risks:

• loss of consciousness instead of sedation
• over-sedation with loss of alertness
• possible damage to the therapeutic partnership between service user and clinician
• specific issues in relation to diagnosis.

1.5.4.3 Resuscitation equipment and drugs, including flumazenil, must be available and easily accessible where rapid tranquillisation is used.

1.5.4.4 Because of the serious risk to life, service users who are heavily sedated or using illicit drugs or alcohol should not be secluded.

1.5.4.5 If a service user is secluded, the potential complications of rapid tranquillisation should be taken particularly seriously.

1.5.4.6 Violent behaviour can be managed without the prescription of unusually high doses or 'drug cocktails'. The minimum effective dose should be used. The BNF recommendations for the maximum doses (BNF – section 4.2) should be adhered to unless exceptional circumstances arise.

1.5.4.7 With growing awareness that involuntary procedures produce traumatic reactions in service users, following the use of rapid tranquillisation, service users should be offered the opportunity to discuss their experiences and should be provided with a clear explanation of the decision to use urgent sedation. This should be documented in their notes.

1.5.4.8 Service users should also be given the opportunity to write their account of their experience of rapid tranquillisation in the notes.

1.5.5 Route of drug administration

1.5.5.1 Oral medication should be offered before parenteral medication.

1.5.5.2 If parenteral treatment proves necessary, the intramuscular route is preferred over the intravenous one from a safety point of view. Intravenous administration should only be used in exceptional circumstances.

1.5.5.3 Vital signs must be monitored after parenteral treatment is administered. Blood pressure, pulse, temperature and respiratory rate should be recorded at regular intervals, agreed by the multidisciplinary team, until the service user becomes active again. If the service user appears to be or is asleep, more intensive monitoring is required.

1.5.6 Pharmacological agents used in rapid tranquillisation

1.5.6.1 The intramuscular (IM) preparations recommended for use in rapid tranquillisation are lorazepam, haloperidol and olanzapine. Wherever possible, a single agent is preferred to a combination.

1.5.6.2 When rapid tranquillisation is urgently needed, a combination of IM haloperidol and IM lorazepam should be considered.

1.5.6.3 IM diazepam is not recommended for the pharmacological control of behavioural disturbances in people with schizophrenia.

1.5.6.4 IM chlorpromazine is not recommended for the pharmacological control of behavioural disturbances in people with schizophrenia.

1.5.6.5 When using IM haloperidol (or any other IM conventional antipsychotic) as a means of behavioural control, an anticholinergic agent should be given to reduce the risk of dystonia and other extrapyramidal side effects.