Rapid Tranquilisation (RT)

This is the parenteral administration of tranquilising drugs with the aim of obtaining a state of calm as soon as possible in a acutely disturbed or violent patient. It is used when the patient or others are at serious risk. It should be the last resort, after physical and environmental approaches, and only after oral (liquid or soluble) formats have been tried or considered inappropriate.¹

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 e.g. de-escalation) negate the need for RT?

This should ideally include:

• Full history - from as many sources as possible
• Legal status - is patient already under the Mental Capacity Act (MCA)?
• If patient is already on a psychiatric ward (informally or under section 5(2)), 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)

Always think of organic causes (particularly if fluctuating levels of consciousness, disorientation, visual hallucinations) - or any previous head injury?

RT should be humane, ethical, legal and clinically effective. Consider the presence of any advance directives.
Primary concern in violent situations should be for the safety of all. Decisions made by medical staff made in good faith 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
• Seizure
• Extrapyramidal side effects (EPSE) or neuroleptic malignant syndrome

Exclude medical contraindications to RT (e.g. cardiac disease or respiratory disorders) and ensure facilities for basic CPR and flumazenil are available.

NICE suggests² lorazepam, olanzapine or haloperidol (if using haloperidol, consider anticholinergic). Do not use "drug cocktails" and keep to within manufacturers recommended doses (use minimum effective dose).

Never mix lorazepam with other drugs in the same syringe. Using olanzapine with lorazepam concurrently is not recommended. Ideally give antimuscarinic drug (e.g. procyclidine) if haloperidol is given.³

• BP/pulse/respiratory rate every 5 minutes, temperature every 30 minutes, and look for evidence of dystonia.
• Transfer (accompanied by staff) only when patient has been stable for at least 30 minutes (calm, and cardiovascular and respiratory observations stable).

Ensure at least the following minimum is recorded:^2,4

Reasons for using RT

• Legal situation (ie which part of MHA used)
• Physical assessment - any medical hazards recognised
• Patient's diagnosis
• Drugs given - in what sequence and dosage
• Outcome
• Monitoring chart and ongoing plan

Consider allowing patient to write his/her account in notes afterwards.²

Discuss as a significant event - could need for RT have been anticipated and prevented? Discuss patients account if available.