[ See also separate articles Mania and Hypomania and Bipolar Disorder.
The National Institute for Health and Clinical Excellence (NICE) defines rapid tranquilisation (RT) as 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. The aim should be to maintain the service user in as calm a state as possible whilst being able to maintain communication with them. It is recognised that RT may lead to deep sedation/anaesthesia, although this is not the overt intention.
Always consider any antecedents to the the acute situation: has the situation been exacerbated by poor communication, lack of privacy, overcrowding, boredom, long waiting times or lack of information; will skilled interviewing techniques (and other interventions, eg de-escalation) negate the need for RT?
NICE recommends that after an RT episode, the patient should be invited to record their own experience of the incident.
This should ideally include:
- Full history - from as many sources as possible.
- Legal status - is the patient already under the Mental Capacity Act (MCA)?
- If the patient is already on a psychiatric ward (informally or under section 5(2)), rapid tranquilisation (RT) treatment can be given under common law.
- Mental state examination.
- Previous psychiatric history.
- Full medication history - including alcohol and substance abuse.
- Physical examination (if safe to do so).
- Recent drug screen (if available).
- Add notes to any clinical page and create a reflective diary
- Automatically track and log every page you have viewed
- Print and export a summary to use in your appraisal
- Rapid tranquilisation (RT) should be humane, ethical, legal and clinically effective.
- Consider the presence of any advance directives.
- A primary concern in violent situations should be for the safety of all. Decisions made in good faith by medical staff in the acute situation, taken to avert serious risk, can be sanctioned by common law without recourse to the Mental Capacity Act (MCA). All treatment should be reasonable and proportionate. Where possible, treatment without consent should be under one of the treatment sections of the MCA (usually section 3).
Risks are increased 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.
- Extrapyramidal side-effects (EPSEs) or neuroleptic malignant syndrome.
Exclude medical contra-indications to rapid tranquilisation (RT), eg cardiac disease or respiratory disorders, and ensure facilities for basic CPR and flumazenil are available.
- Oral medication is preferred to parenteral drugs whenever possible.
- NICE suggests lorazepam, olanzapine or haloperidol (if using haloperidol, consider anticholinergic).
- Do not use 'drug cocktails' and keep to within a manufacturer's recommended doses (use the minimum effective dose) whenever possible. NICE accepts that there may be rare occasions when the dosage range recommended by the manufacturer may need to be exceeded. In this situation, a risk-benefit analysis should be made and recorded. More intensive monitoring will then be required than if the dosage had been within the recommended range.
- Lorazepam should be considered first for non-psychotic behavioural disturbance - oral if possible but intramuscular if necessary.
- Behavioural disturbance in the context of psychosis should be treated with lorazepam combined with an antipsychotic.
- Olanzapine (and risperidone) should be avoided in patients with dementia, due to an increased risk of stroke and death.
- The risks and benefits of the intramuscular versus the intravenous route will have to be weighed up for individual patients, ie difficulties of siting the cannula versus speed of onset of action.
- Oral therapy should be commenced as soon as feasible.
- Never mix lorazepam with other drugs in the same syringe. Using olanzapine with lorazepam concurrently is not recommended. Ideally give an antimuscarinic drug (eg procyclidine) if haloperidol is given.
- Midazolam is used in preference to lorazepam in Australia due to its faster onset of action.
Chart for rapid tranquilisation
|Medication||Time to max plasma concentration||Approximate half-life|
|15-60 min||10-36 h|
|2-6 h||10-36 h|
|2-6 h||10-36 h|
|60-90 min||12-16 h|
|2 h||12 h|
|5-8 h||32-50 h|
|15-45 min||32-50 h|
|1-2 h||24 h|
|1-2 h||24 h|
|1-2 h||24 h|
- BP/pulse/respiratory rate every 5 minutes, temperature every 30 minutes and look for evidence of dystonia.
- Transfer (accompanied by staff) only when the patient has been stable for at least 30 minutes (calm and cardiovascular and respiratory observations stable).
Ensure at least the following minimum is recorded:
Reasons for using rapid tranquilisation (RT)
- Legal situation (ie which part of the Mental Health Act used).
- Physical assessment - any medical hazards recognised.
- Patient's diagnosis.
- Drugs given - in what sequence and dosage.
- Monitoring chart and ongoing plan.
Discuss as a significant event - could the need for rapid tranquilisation (RT) have been anticipated and prevented? Discuss the patient's account if available.
Further reading & references
- The Management of bipolar disorder in adults, children and adolescents, in primary and secondary care; NICE (2006)
- Violence: The short-term management of disturbed or violent behaviour in in-patient psychiatric settings and emergency departments, NICE Clinical Guideline (2005)
- Schizophrenia - core interventions in the treatment and management of schizophrenia in primary and secondary care, NICE Clinical Guideline (March 2009)
- Dubin WR; Rapid tranquilization: antipsychotics or benzodiazepines?; J Clin Psychiatry. 1988 Dec;49 Suppl:5-12.
- Nobay F, Simon BC, Levitt MA, et al; A prospective, double-blind, randomized trial of midazolam versus haloperidol Acad Emerg Med. 2004 Jul;11(7):744-9.
|Original Author: Dr Huw Thomas||Current Version: Dr Laurence Knott||Peer Reviewer: Dr Adrian Bonsall|
|Last Checked: 20/02/2012||Document ID: 405 Version: 6||© EMIS|
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