Name of policy: Effective from - NHS Gateshead€¦ · Name of policy: Policy for the Rapid Tranquilisation (RT) of Adult Patients Displaying Acutely Disturbed or Violent Behaviour

RM80 Policy for the Rapid Tranquillisation (RT) of Adult Patients

Displaying Acutely Disturbed or Violent Behaviour v2

Policy No: RM80

Version: 2.0

Name of policy: Policy for the Rapid Tranquilisation (RT) of

Adult Patients Displaying Acutely Disturbed or

Violent Behaviour

Effective from: 21/12/2016

Date ratified 02/12/2016

Ratified Safeguarding Committee

Review date 01/12/2018

Sponsor Director of Nursing, Midwifery & Quality

Expiry date 01/12/2019

Withdrawn date

Unless this copy has been taken directly from the Trust intranet site (Pandora) there is no

assurance that this is the most up to date version

This policy supersedes all previous issues



2

Version control

Version

Release

Author/Reviewer

Ratified

by/Authorised

by

Date

Changes

(Please

identify page

no.)

1.0

15/05/2014 Dr C Kirkley, Old

Age Psychiatry

SafeCare

Council

09/04/2014

2.0 21/12/2016 Joanne Coleman

Strategic

Safeguarding Lead

Safeguarding

Committee

02/12/2016



3

Contents Page No.

1. Introduction ...................................................................................................................... 4

2. Policy scope ....................................................................................................................... 4

3. Aim of policy...................................................................................................................... 4

4. Duties - roles and responsibilities ..................................................................................... 4

5. Definition of terms ............................................................................................................ 5

6. Rapid tranquilisation (RT) of Adult patients displaying acutely disturbed or violent

behaviour .......................................................................................................................... 6

6.1 What is RT? .............................................................................................................. 6

6.2 What is not RT? ....................................................................................................... 6

6.3 Key priorities ........................................................................................................... 6

Algorithm 1 (overview)............................................................................................ 9

6.4 Prediction ................................................................................................................ 10

6.5 Medication .............................................................................................................. 10

6.6 Mental Health Act ................................................................................................... 11

6.7 Patient monitoring .................................................................................................. 11

6.8 Medical Specific Risks .............................................................................................. 12

Algorithm 2 (RT in under 65s) ............................................................................... 13

Algorithm 3 (RT in over 65s) ................................................................................. 14

6.9 Consultant advice .................................................................................................... 17

6.10 Standard doses ........................................................................................................ 17

6.11 Further (specialist) Treatments ............................................................................... 17

6.12 Intravenous Therapy ............................................................................................... 17

7. Training ............................................................................................................................. 18

8. Diversity and inclusion ...................................................................................................... 18

9. Monitoring compliance with the policy ............................................................................ 18

10. Consultation and review of this policy .............................................................................. 19

11. Implementation of this policy ........................................................................................... 19

12. References......................................................................................................................... 19

13. Associated documentation ............................................................................................... 19

Appendix 1 Physical health monitoring and remedial measures ..................................... 20

Appendix 2 Guidelines for use of Flumazenil .................................................................... 21

Appendix 3 Shortage of Lorazepam injection – alternative agents and

management options ........................................................................................................ 22

Appendix 4 Rapid tranquilisation in pregnant women ..................................................... 23



4

Policy for the Rapid Tranquilisation (RT) of Adult Patients

Displaying Acutely Disturbed or Violent Behaviour

1. Introduction

The Trust recognises the importance of good practice in preventing and managing

aggressive, violent and potentially violent incidents. Potential behaviour problems should

be identified, planned for and defused.

However, severe behavioural disturbances will sometimes happen despite all attempts to

prevent them. It may become necessary to use pharmacological interventions alongside

physical restraint to maintain the safety and physical health of an individual.

The administration of medicines under restraint to maintain safety is Rapid Tranquillisation

(RT)

2. Policy scope

This policy covers all healthcare staff working within inpatient and outpatient settings

where RT may be utilised.

3. Aim of policy

The aim of this policy is to minimise risk related to the use of RT, ensuring a standard

approach to care, based on the best available evidence. The guidance is developed to

comply with relevant local and national standards.

4. Duties, roles and responsibilities

Trust Board

The Trust Board has responsibility for ensuring that a safe and effective policy is in place for

RT and that training and facilities are available to support the implementation of the policy.

Chief Executive

Has responsibility for ensuring the trust has robust and effective policies relating to rapid

tranquilisation.

Mental Health Committee

The Mental Health Committee will be responsible for monitoring the appropriate use and

patient monitoring following RT.

Safeguarding Lead

The Safeguarding lead will be responsible for the regular audit of incidents of RT.

Pharmacy Services

Provide drug information and advice as required to both staff and patients. Ensure

medication to treat disturbed behaviour is available.



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Associate Directors /Service Line Managers

Ensure within their area of responsibility the application of the rapid tranquillisation policy

is adhered to and where necessary take action to ensure compliance.

Medical Staff

Ensure they are familiar with the policy and adhere to the protocols and procedures.

Ensure that an assessment of the patient’s physical health is carried out before prescribing

and administrating any medication. Complete all relevant RT documentation, update the

current medication chart and ensure nurse in charge is fully aware of any decisions

regarding medication.

The Ward/Department Sister/Charge Nurse

Will be fully aware of the contents of this policy and will ensure that all staff in their

ward/department are aware of this policy and other policies and guidance which relate to

this policy. Ensure that de-escalation methods are tried first and that any incident of RT is

fully documented and reported accordingly.

Registered Nurses

Will ensure they are aware of the policy and adhere to the protocols and procedures and

will ensure they attend all relevant training.

Security Staff

Security staff will support nursing and medical teams in the management of violent/

aggressive behaviour.

5. Definition of terms

Rapid Tranquilisation is a reactive management strategy and typically involves physical

intervention. It is the administration of medication to calm or sedate an agitated, violent

or aggressive patient as quickly as is safely possible: not to treat the individual’s underlying

condition.

Parenteral medication involves administration of medication either via Intramuscular (IM)

or Intravenous (IV) routes.

IM (intramuscular) is the injection of drugs directly into the muscle.

IV (intravenous) is administration of a drug or substance directly into the vein.

Advance Decision is an advance refusal of specific medical treatment to be taken into

account and adhered to when a person loses the capacity to make the refusal

contemporaneously as defined by the Mental Capacity Act 2005. An Advanced Decision

relating to medical treatment for mental health disorder may be overruled by Part IV of the

Mental Health Act 1983.

Neuroleptic malignant syndrome (NMS) is caused almost exclusively by the use of

antipsychotic medication. Rapid and large increases in dosage, such as rapid

tranquillisation, can also trigger the development of NMS. Signs and symptoms include



6

muscular rigidity, pyrexia and confusion; sometimes muscle tremors and a sore throat. If

NMS occurs it should be treated as a medical emergency.

6. Rapid tranquilisation (RT) of adult patients displaying acutely disturbed or violent

behaviours

6.1 What is RT?

• RT is a reactive management strategy and typically involves physical

intervention

• Clinical judgement may be required to distinguish between what is RT and

what is administration of as required medical (PRN) within the following

definitions

• RT is the administration of medication to calm or sedate an agitated, violent

or aggressive patient as quickly as is safely possible; not to treat the

individuals underlying condition

• The highly aroused condition of the patient during RT may intensify the

effect of medicine used. Patients’ physical health must be monitored after

administration (see para 6.7)

6.2 What is not RT?

If medication is used proactively as an intervention to prevent a violent or

aggressive incident this is not RT.

Some patients may have a care plan which required a prescribed medication

(usually on an as required (PRN) basis) to be given to prevent them from becoming

violent or aggressive – this is not RT

6.3 Key Priorities

6.3.1 Drugs for rapid tranquillisation, particularly in the context of restraint,

should be used with caution because of the following risks:-

• Loss of airway

• Loss of consciousness instead of sedation

• Respiratory depression or cardiac arrest

• Over sedation with loss of alertness

• Cardiovascular collapse

• Seizures

• Adverse effects, for example, neuroleptic malignant syndrome

• Interactions with medication (prescribed or illicit)

• Underlying coincidental physical disorders

6.3.2 If parenteral (IM or IV) proves necessary then the IM route is preferred over

IV from a safety point of view. The service user should be transferred to oral

routes of administration at the safest opportunity.



7

6.3.3 Sufficient time should be allowed for clinical response between IM doses of

medications.

6.3.4 The use of two drugs of the same class for the purpose of RT is not

recommended.

6.3.5 Medications should never be mixed in the same syringe.

6.3.6 When using IM Haloperidol as a means of managing disturbed/violent

behaviour, an antimuscarinic agent such as Procyclidine should be

immediately available to reduce the risk of dystonia and other

extrapyramidal side effects. This should be given as per manufacturers

recommendations.

6.3.7 IV administration of Diazepam should not be used (due to the high risk of

respiratory depression) except in exceptional circumstances, which should

be specified and recorded.

6.3.8 Rapid tranquilisation should only be considered once de-escalation and

other strategies have failed to calm the patient. The intervention (along with

physical intervention) should be considered a management strategy and not

be regarded as a primary treatment technique. When determining which

intervention to employ, clinical need, the safety of service users and others

and, where possible, any advance decisions should be taken into account.

The intervention selected must be a reasonable and proportionate response

to the risk posed by the patient at that particular time; this follows guidance

given under the Mental Capacity Act 2005.

6.3.9 The reasons for using Rapid Tranquilisation (and any other intervention)

must be explained to the patient at the earliest opportunity.

6.3.10 Resuscitation

• In the event of a need for resuscitation in Cragside or Sunniside - dial

999 for attendance by the ambulance service

• For all other areas within the trust where rapid tranquilisation might

be used a crash trolley must be available. Equipment available must

include an automatic external defibrillator, a bag valve mask, oxygen

and suction equipment. All equipment must be properly maintained

and checked as discussed in the Trust Resuscitation policy RM27a.

6.3.11 All prescribers and staff involved in rapid tranquilisation must be familiar

with and have access to the Trust Resuscitation Policy RM27a.

6.3.12 Any incident requiring rapid tranquilisation (or physical intervention or

seclusion) must be contemporaneously recorded. All appropriate staff

should be trained to ensure that they are aware of how to correctly record

any incident using the appropriate documentation.



8

6.3.13 All events of rapid tranquilisation must be reported as an incident on the

Datix Incident Reporting system

6.3.14 A post-incident review should take place as soon as possible and at least

within 72 hours of an incident ending. Wherever possible, a person not

directly involved in the incident should lead the review. The review should

address the following factors:

• What happened during the incident?

• Trigger factors.

• Each person’s role in the incident.

• Their feelings at the time of the incident, at the review and how they

may feel in the near future.

• What can be done to address their concerns?

6.3.15 Patients should be given the opportunity to document their own account of

the intervention in their medical notes.

6.3.16 Legal considerations: When considering RT it is essential that the clinician is

clear under what legal authority the treatment will be administered. Legal

authority could come from either the capable/ competent patient’s valid

consent (common law) or the Mental Health Act (see section 6.6).

Alternatively, the Mental Capacity Act, if there is reasonable belief that the

patient lacks capacity and that there is reasonable evidence that the

treatment is in the patient’s best interests then the Mental Capacity Act can

be used. Any restraint required should be proportionate and necessary to

prevent harm to the patient. The entry made into the patient’s notes should

make it clear which authority was used at the time of RT.

6.3.17 If a patient has underlying alcohol dependency & has alcohol withdrawal

symptoms please refer to the Alcohol pathway policy & detoxification

guideline 2011



9

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Algorithm 1

Overview algorithm for the short-term management of

disturbed/violent behaviour

PREDICTION

Risk assessment Searching

PREVENTION De-escalation techniques

Observation

INTERVENTIONS FOR CONTINUED MANAGEMENT Consider, in addition to above, one or more of the following

Rapid

Tranquilisation

Seclusion

Physical Intervention

Use to avoid prolonged physical

intervention

Medication is required to calm a

psychotic or non-psychotic

behaviourally disturbed service

user

Used to avoid prolonged

physical intervention Better if service user

responds quickly

Can be used to enable

rapid tranquillisation to

take effect

CONTRA-INDICATED AS

AN INTERVENTION

When service user has taken

previous medication

Should be terminated

when rapid

tranquillisation, if given,

has taken effect

When other interventions

not yet explored

Prolonged physical

intervention

POST-INCIDENT REVIEW

Reference: The short-term management of disturbed/violent behaviour in psychiatric in-patient settings and emergency departments. (National Institute for Clinical Excellence – February 2005)

Protocol/Policy for the Rapid Tranquillisation (RT) of Patients Displaying Acutely Disturbed or Violent Behaviour version 1

6.4 Prediction

Certain factors can indicate an increased risk of aggressive or physically violent

behaviour. A comprehensive clinical risk assessment must be completed including

demographic or personal history, clinical and situational variable. A risk

management plan must be developed on admission if it is felt there may be the

need for RT. This management plan, where possible, should be agreed with the

patient and their carer’s, friends and/or relative.

Employing RT should only be considered once de-escalation and other strategies

have failed in line with the Physical Control and Restraint Policy (RM73)

6.5 Medication

6.5.1 Treatment Aims

• To reduce suffering for the patient: psychological or physical (through

self-harm or accidents).

• To reduce risk of harm to others by maintaining a safe environment.

• To do no harm (by prescribing safe regimes and monitoring physical

health).

6.5.2 Doses

It is recognised that clinicians may decide that the use of medication outside

of the Summary of Product Characteristics (SPC) is occasionally justified,

bearing in mind the overall risks. However, where the regulatory authorities

or manufacturer issues specific warning that this may result in an increased

risk of fatality, the medication should only be used strictly in accordance

with the current marketing authorisation.

In certain circumstances, current British National Formulary (BNF) uses and

limits, and the manufacturers SPC, may be knowingly exceeded e.g.

Lorazepam. This decision should not be taken lightly or the risks

underestimated, and a risk-benefit analysis should be recorded in the case

notes and a rationale in the care plan. Where the risk-benefit is unclear,

consideration should be given to seeking advice from clinicians who are not

directly involved in the care of the patient.

If current BNF doses or SPC are exceeded it is particularly important to

undertake frequent and intensive monitoring of a calmed patient. Particular

attention must be given to regular checks of the airway, level of

consciousness, pulse, blood pressure, respiratory effort, temperature and

hydration.

Doses of medication should be individualised for each patient. This will be

dependent on several factors including the patient’s age (older patients will

generally require lower doses), concomitant physical disorders (e.g. renal,



11

hepatic, cardiovascular, neurological), and concomitant medication.

Particular attention must be given to any psychotropic medication

administered to the patient in the past 24 hours and how rapid

tranquilisation treatment might need to be adjusted as a result.

6.5.2 Discontinuation

Rapid tranquilisation should be discontinued at the point of

response. Thereafter, the patient must continue to be closely

monitored, and future medication (both regular and as required)

should be reviewed.

6.6 Mental Health Act

Patients detained under the Mental Health Act are subject to consent to Treatment

(MHA part 4). If they have been detained for more than 3 months, they will require

consent under Section 58 (3) with a current T2 or T3 form, or be treated under

Section 62 – urgent treatment to prevent harm to self or others.

All information relevant to MHA status must be fully documented in the medical

notes.

The patients legal status should be reviewed whenever parenteral medication is

considered. The enforced administration of medication by injection in an informal

patient may necessitate use of the Mental Health Act

6.7 Patient Monitoring

Where possible, baseline measurements of the following should be recorded before

any parenteral drug administration:

- Temperature

- Pulse

- Respiratory Rate

- Blood Pressure

The measurements above must also be recorded every 5 – 10 minutes for 1 hour

following the parenteral administration of any drug. Thereafter, they should be

recorded at the half hourly intervals until the patient is fully ambulatory. In

addition, staff should closely monitor for signs of extra-pyramidal side effects in

response to the administration of antipsychotic medication.

The patient must be monitored by “within eyesight” observation.

Where the patient is unconscious or asleep, the same monitoring should take place

so far as is possible, and pulse-oximetry should also be used.

Where possible, and where facilities exist, ECG and haematological monitoring are

also strongly recommended when parenteral anti-psychotics are administered,



12

especially where high doses have been used. High stress levels, agitation, and

hypokalemia all place the patient at high risk of developing cardiac arrhythmias.

The observations must be recorded on the EWS chart.

6.8 Medication Specific Risks

There are specific risks with different classes of medication and these risks may be

compounded when medication is used in combination. Close monitoring of the

patient is essential.

Benzodiazepines Loss of Consciousness, Respiratory Depression or Cardiac Arrest,

Cardiovascular Collapse (particularly in Clozapine patients).

Antipsychotics Loss of Consciousness, Cardiovascular / respiratory complications

and collapse, seizures, akathisia, Dystonia, Dyskinesia, neuroleptics malignant

syndrome, excessive sedation.



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Algorithm 2

Rapid Tranquilisation of the Acutely Disturbed / Violent Patient Under 65s

[a, b]

and/or

[c, d]

AND and /or [b]

Step 1 NON-PHARMACOLOGICAL MEASURES

De-escalation, distraction, seclusion etc

Consult any Advance

Directives

Step 2

Oral

Treatment

Lorazepam 1 – 2mg

1st

line, non psychotic context or

if already prescribed regular

antipsychotics

• ALLOW AT LEAST 45 MINUTES FOR ORAL MEDICATION TO WORK

• IF INEFFECTIVE, REPEAT ORAL MEDICATION AT SAME DOSES

• ALLOW AT LEAST 45 MINUTES FOR REPEATED ORAL MEDICATION TO WORK

• IF ORAL MEDICATION IS REFUSED CONSIDER COVERT ADMINISTRATION

• Prior to proceeding to step 3 (i/m treatment) consider using Buccal Midazolam 10 – 20mg

(Unlicensed)

Step 3

I/M

Treatment

Ensure baseline measurements are recorded on the EWS chart: TEMPERATURE,

PULSE, BP, RESPIRATORY RATE before IM administration, and repeat every 5-10

minutes for 1 hour, then half-hourly until patient is ambulatory. Use pulse oximetry if

patient asleep or unconscious.

MONITOR

PATIENT

CLOSELY! Lorazepam 1-2mg I/M [d] [e]

1st

line non psychotic context

• ALLOW AT LEAST 30 MINUTES FOR I/M HALOPERIDOL and/or I/M LORAZEPAM TO

WORK. IF INEFFECTIVE, REPEAT AT SAME DOSES AND

ALLOW A FURTHER 30 MINUTES FOR EFFECT.

DO NOT PROCEED FURTHER

WITHOUT ADVICE FROM

CONSULTANT

(see Section 6.9)

IF INEFFECTIVE,

SEEK SPECIALIST ADVICE FROM CONSULTANT

Olanzapine 10mg

Or

Haloperidol 5mg

If psychotic context

Haloperidol 5mg I/M [f]



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Notes for Algorithm 2

a. Choice depends on current treatment. It patient is established on antipsychotics,

Lorazepam may be used alone. If the patient uses “street drugs” or already receives regular

benzodiazepines, an antipsychotic may be used alone. For the majority of patients, best

response will be with combination therapy.

b. Ensure Procyclidine injection is available. Antipsychotic may cause acute dystonic reaction.

c. As in (a), either antipsychotic or benzodiazepine may be used alone, but best results are

likely with combination therapy.

d. Ensure Flumazenil injection is available to reverse effects of Lorazepam injection.

e. Lorazepam should be mixed 1:1 with water before injecting. Shortage of Lorazepam

injection see Appendix 3.

f. Haloperidol (5mg) can also be used but should be the last drug considered because of the

relatively high incidence of acute Dystonia and the recommendation that patients should

have a pre-treatment ECG & IM Procyclidine available.



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Algorithm 3

Rapid Tranquilisation of the Acutely Disturbed / Violent Patient - Patient Aged Over 65 Years -

[a,b]

AND/OR

[c,d]

AND/ AND/ OR

Step 1 NON-PHARMACOLOGICAL MEASURES

De-escalation, distraction, seclusion etc Consult any

advance directives

Step 2

Oral

Treatment

Lorazepam 0.5-1mg

1st

line, non psychotic

context or if already

prescribed regular

antipsychotics

Olanzapine 2.5 - 5mg

Haloperidol 0.5 - 2.5mg

(Unless previously tolerated

higher doses )

In patients with Parkinson’s disease or dementia,

especially those with a history of vascular disease or

Lewey body dementia, antipsychotics should be used

with caution or not at all. [b, f]

• ALLOW AT LEAST 45 MINUTES FOR ORAL MEDICATION TO WORK

• IF INEFFECTIVE, REPEAT ORAL MEDICATION AT SAME DOSES

• ALLOW AT LEAST 45 MINUTES FOR REPEATED ORAL MEDICATION TO WORK

• IF ORAL MEDICATION IS REFUSED CONSIDER COVERT ADMINISTRATION

• Prior to proceeding to step 3 (i/m treatment) consider using Buccal Midazolam 10 – 20mg

(Unlicensed)

Ensure baseline measurements are recorded on the EWS chart: TEMPERATURE,

PULSE, BP, RESPIRATORY RATE before IM administration, and repeat every 5-10

minutes for 1 hour, then half-hourly until patient is ambulatory. Use pulse

oximetry if patient asleep or unconscious.

Step 3

I/M

Treatment

MONITOR

PATIENT

CLOSELY!

Lorazepam 1-2mg I/M [d] [e]

1st

line non psychotic context

Haloperidol 1 – 2.5mg I/M [f]

• ALLOW AT LEAST 45 MINUTES FOR I/M HALOPERIDOL and/or I/M

LORAZEPAM TO WORK. IF INEFFECTIVE, REPEAT AT SAME DOSES AND

ALLOW A FURTHER 45 MINUTES FOR EFFECT.

DO NOT PROCEED

FURTHER WITHOUT

ADVICE FROM

CONSULTANT

(see Section 6.9)

IF INEFFECTIVE,

SEEK SPECIALIST ADVICE FROM CONSULTANT



16

Notes for Algorithm 3:

a. Choice depends on current treatment. If patient is established on antipsychotics,

Lorazepam may be used alone. If the patient uses “street drugs” or already receives regular

benzodiazepines, an antipsychotic may be used alone. For the majority of patients, best

response will be with combination therapy.

b. Ensure Procyclidine injection is available. Antipsychotic may cause acute dystonic reaction.

c. As in (a), either antipsychotic or benzodiazepine may be used alone, but best results are

likely with combination therapy.

d. Ensure Flumazenil injection is available to reverse effects of Lorazepam injection.

e. Lorazepam should be mixed 1:1 with water before injecting. Shortage of Lorazepam

injection see below.

f. Haloperidol (5mg) can also be used but should be the last drug considered because of the

relatively high incidence of acute Dystonia and the recommendation that patients should

have a pre-treatment ECG & IM Procyclidine available.



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6.9 Consultant Advice

Advice must be sought from the Consultant, (or Consultant on-call), at any stage of

rapid tranquilisation if any doubt exists regarding how best to proceed.

6.10 Standard Doses (BNF)

Standard doses of medication used in rapid tranquilisation are listed below.

Whenever possible doses prescribed should be within these limits. However,

prescribing outside recommended standard doses may occasionally be justified.

(See section 6.5.2)

6.10.1 Haloperidol: oral = 30mg / 24 hours, I/M = 18mg / 24 hours (i.e. 3mg

haloperidol I/M is approximately equivalent to 5mg oral)

6.10.2 Lorazepam: oral = 4mg / 24 hours, I/M = 30mcg / kg / 6 hours (i.e. I/M

maximum is approximately 6-8mg / 24 hours)

6.10.3 Olanzapine: oral = 20 mg/24 hours, this dose should not be exceeded

without obtaining specialist advice

6.11 Further (specialist) Treatments

The following treatments are rarely used, have a minimal evidence base and are

unlicensed. They may only be prescribed by or under guidance of a senior clinician

or consultant who has previous experience of their use. Any decision to use these

treatments must only be taken when more conventional treatments have failed and

must be fully documented in the patient’s notes.

6.11.1 Midazolam I/M Flumazenil must be available

6.11.2 Promethazine I/M Can be used in patients who are

benzodiazepine tolerant. Slow onset of

action but highly sedating.

6.11.3 Diazepam I/V (Diazemuls) Flumazenil must be available.

Produces very rapid response.

6.11.4 Haloperidol I/V Dose as per I/M route.

(see section 6.12)

6.12 Intravenous Therapy

6.12.1 The intravenous administration of benzodiazepines or haloperidol should

not normally be used except in very exceptional circumstances, which

should be specified and recorded. This decision should only be taken by a

consultant or senior clinician who has had previous experience of its use.



18

6.12.2 If immediate tranquilisation is essential then intravenous administration may

be considered necessary. If so, it is essential that attending staff have been

appropriately trained to recognise symptoms of respiratory depression,

acute dystonia and cardiovascular compromise.

6.12.3 If intravenous medication is used, the patient must never be left

unattended. Intravenous administration must not take place without full

access to support and resuscitation services.

7 Training

7.1 All staff involved in administering or prescribing rapid tranquilisation, or monitoring

patients to whom parenteral rapid tranquilisation has been administered, must

receive ongoing competency training to a Trust recognised standard which includes

maintenance of airway, cardio-pulmonary resuscitation (CPR), the use of

defibrillators, and the use of pulse oximeters. This must include training to ensure

that they are aware of how to correctly record any incident using the appropriate

documentation.

7.2 All prescribers, and those staff who administer medicines for rapid tranquilisation,

should be familiar with and have received training which includes the following

• The properties of benzodiazepines, the benzodiazepine antagonist

flumazenil, antipsychotics, antimuscarinics and antihistamines.

• Associated risks, including cardio-respiratory effects of the acute

administration of the drugs, particularly when the patient is highly aroused

and may have been misusing drugs, is dehydrated, or is possibly physically ill.

• The need to titrate doses to effect.

8 Diversity and Inclusion

The Trust is committed to ensuring that, as far as is reasonably practicable, the way we

provide services to the public and the way we treat staff reflects their individual needs and

does not unlawfully discriminate against individuals or groups on the grounds of any

protected characteristic (Equality Act 2010). This policy aims to uphold the right of all staff

to be treated fairly and consistently and adopts a human rights approach. This policy has

been appropriately assessed.

9 Monitoring compliance with the policy

Standard/process/issue Monitoring and audit

Method By Committee Frequency

Audit of incidents of RT

against case notes to

ensure appropriate use

and monitoring following

RT

Audit of

all

incidents

reported

on Datix

Safeguarding

lead

Mental

Health

Committee

and

SafeCare

6 monthly



19

10 Consultation and review

There has been significant consultation on the policy including the Associate and Divisional

Directors, Service Line Managers, Modern Matrons, Medical & Nursing staff within Old Age

Psychiatry and Accident & Emergency, CMH Nursing staff, relevant Ward sisters, pharmacy

and operational staff.

11 Implementation of policy (including raising awareness)

The policy will be implemented in line with OP27 Policy on the Development,

implementation and management of policies and through departmental meetings and

brought to the attention of relevant staff through team meetings.

12 References

12.1 Violence – the short term management of disturbed / violent behaviour in

psychiatric in-patient settings and emergency departments. National Institute for clinical

Excellence, February 2005.

12.2 The South London and Maudsley NHS Trust and Oxleas NHS Trust Prescribing

Guidelines (1oth edition)

12.3 Antenatal and Postnatal mental health. National Institute for Clinical Excellence,

February 2007.

12.4 Mental Health Act 1983 Code of Practice

12.5 Mental Capacity Act 2005 Code of Practice

12.6 NICE Clinical Guideline 25 February 2005

13. Associated documentation

RM73 Restrictive Interventions Policy

RM27a Resuscitation Policy

RM04 Incident reporting policy

Medicines Management Policy

RM32 Policy and Procedure for the Care of Individuals who are Violent or Abusive



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Appendix 1

Physical health monitoring and remedial measures

Rapid Tranquilisation – monitoring After any parenteral drug administration, monitor the following:

Temperature

Pulse

Blood Pressure

Respiratory Rate

Every 5 – 10 minutes, for one hour, then half-hourly until patient is ambulatory.

If the patient is asleep or unconscious, the use of pulse oximetry to continuously measure oxygen

saturation is desirable. A nurse should remain with the patient until they are ambulatory again and

observation should be re-assessed at this stage.

ECG and haematological monitoring are also strongly recommended when parenteral

antipsychotics are given, especially when higher doses are used. Hypokalaemia, stress, and

agitation place the patient at risk of cardiac arrhythmias.

Remedial measures in rapid tranquilisation Problem Remedial measures Acute dystonia Give Procyclidine 5 – 10mg IM (Including oculogyric crises) Reduced respiratory rate Give oxygen; raise legs; ensure patient is not lying face down. (<10/min) or oxygen saturation Give flumazenil if benzodiazepine-induced respiratory depression (<90%) suspected (see Appendix 2). If induced by any other sedative agent, ventilate mechanically. Irregular or slow (<50/min) pulse Refer to specialist medical care immediately. Fall in blood pressure Lie patient flat, tilt bed towards head. Monitor closely (>30mmHg orthostatic drop or <50mmHg diastolic) Increased temperature Withhold antipsychotics (risk of NMS and perhaps arrhythmias). Check creatinine kinase urgently.



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Appendix 2

Guidelines for use of Flumazenil

Guidelines for use of flumazenil

Indication for use If respiratory rate falls below 10/minute after the administration

of Lorazepam, Midazolam or diazepam.

Contra-indications Patients with epilepsy who have been receiving long-term

benzodiazepines.

Caution Dose should be carefully titrated in hepatic impairment.

Dose and route of Initial 200mcg intravenously over 15 seconds – if required level

administration of consciousness not achieved after 60 seconds the,

Subsequent dose: 100mcg over 10 seconds

Time before dose 60 seconds

can be repeated

Maximum dose 1mg in 24 hours (one initial dose and eight subsequent

doses).

Side effects Patients may become agitated, anxious or fearful on

awakening. Seizures may occur in regular benzodiazepine

users.

Management Side effects usually subside.

Monitoring

• What to monitor? Respiratory rate

• How often? Continuously until respiratory rate returns to baseline level.

Flumazenil has a short half life. Respiratory function may

recover then deteriorate again.

Note: If respiratory rate does not return to normal or patient is not alert after initial doses

assume sedation due to some other cause.



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Appendix 3

Shortage of Lorazepam injection – Alternative agents and management options.

• Buccal Midazolam (10-20mg) may be considered initially (although unlicensed) to avoid the

need to move on to an intramuscular injection.

• If oral / buccal treatment is not appropriate, or if two doses fail (with 45-60 minute gap

between doses), consider if antipsychotic therapy is appropriate

Haloperidol Adults under 65, 5mg I/M. Adults over 65, 1 – 2.5mg I/M

• If a benzodiazepine is indicated Diazepam, (can be painful if given by the intramuscular

route). Adults under 65, 10mg I/M, Adults under 65, 5mg I/M.

• Alternatively Midazolam i.m. can be used. Flumazenil must be available.

Adults under 65, 70 – 100mcg / Kg, maximum dose 5mg.

Adults over 65, 25 – 50mcg / Kg usual dose range 1 – 2.5mg max dose 5mg.

• Promethazine 25 – 50mg can be prescribed by or under guidance of a senior clinician or

consultant who has had previous experience of its use see section 6.12.2



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Appendix 4

Rapid Tranquilisation in Pregnant Women

A pregnant woman requiring rapid tranquillisation should be treated using the Protocol/Policy for

the Rapid Tranquilisation (RT) of Adult Patients Displaying Acutely Disturbed or Violent Behaviour

except

• Do not seclude the woman following rapid tranquillisation.

• Adapt restraint procedures to avoid possible harm to the foetus.

• When choosing an agent for rapid tranquillisation, consider an anti psychotic (e.g.

haloperidol) or benzodiazepine (e.g. lorazepam) with a shorter half life. If an antipsychotic is used

it should be at the minimum effective dose to minimise the risk of neonatal extrapyramidal

symptoms. If a benzodiazepine is used the risks of floppy baby syndrome should be taken into

account.

• Manage the woman’s care during the perinatal period in close collaboration with a

paediatrician and an anaesthetist.

Adapted from:

NICE clinical guideline 45

Antenatal and postnatal mental health

Published: February 2007

Documents

Name of policy: Effective from - NHS Gateshead€¦ · Name of policy: Policy for the Rapid Tranquilisation (RT) of Adult Patients Displaying Acutely Disturbed or Violent Behaviour