Rapid Tranquillisation

Rapid Tranquillisation
Target Audience
Who Should Read This Policy
All Inpatient Staff    
Version 2 June 2018

Rapid Tranquillisation Policy
Ref. Contents Page
Explanation of terms used in this policy 4

1.0 Introduction 5
1.1 Rapid Tranquillisation Definition 5
2.0 Purpose 5
3.0 Objectives 6
4.0 Principle and Practise of Rapid Tranquillisation 6
4.1 De-escalation Techniques 6
4.2 Choice of Intervention 6
4.3 Use of oral p.r.n medication 7
4.4 Rapid Tranquillisation and Physical Intervention 7
4.5 Rapid Tranquillisation and Seclusion 8
4.6 Care Planning/Reviews 8
4.7 Risk Assessment 9
4.8 Advance Statements 9
4.9 Legal Issues and the Mental Health Act (MHA) 9
4.10 Physical monitoring/review of history Before Rapid Tranquillisation 9
5.0 Rapid Tranquillisation 10
5.1 Medical Staff Availability 10
5.2 Medical Equipment 10
5.3 Rapid Tranquillisation treatment aims 10
5.4 Rapid Tranquillisation Prescribing 11
5.5 Choice of Medication in Rapid Tranquillisation 12
Algorithm 1: BCPFT Algorithm for Rapid Tranquillisation / oral p.r.n 13
5.6
prescribing for Working Age Adults/Older Adults
Table 1: Rapid Tranquillisation / oral p.r.n notes for Working Age 14
5.7
Adults
5.8 Table 2: Rapid Tranquillisation / oral p.r.n notes for Older Adults 16
5.9 General Prescribing Notes 18
Table 3: Drug information for oral p.r.n and IM Rapid Tranquillisation 19
5.10
medication to be used with guideline
5.11 Prescribing in complex cases 20
Guidelines for the use of Zuclopenthixol Acetate injection 21
5.12
(Clopixol Acuphase®)
Zuclopenthixol Acetate (Clopixol Acuphase®) Post-Administration 23
5.13
Physical Observations Record Chart
Version 2.0 January 2019 2

6.0 Risks and Complications associated with Rapid Tranquillisation 24

6.1 Circumstances for special care 24
6.2 Observations 24
6.3 Remedial Measures 25
6.4 Table 3: Managing the Complications and Side Effects of Medication 26
Algorithm 2: Rapid Tranquillisation of the Acutely Disturbed / Violent 27
7.0
Patient - Adolescents Aged > 12 Years
Notes for prescribing Rapid Tranquillisation / oral p.r.n for 28
7.1
adolescents
8.0 Documentation 28
9.0 Post Incident Support and Debrief 29
10.0 Procedures connected to this policy 29
11.0 Links to Relevant Legislation 29
11.1 Links to Relevant National Standards 30
11.2 Links to other Key Policies 30
Best Practice - Dissemination, Implementation and Monitoring of 31
12.0
NICE Quality Standards and Guidance
13.0 References 31
14.0 Roles and Responsibilities for this policy 32
15.0 Training 33
16.0 Equality Impact Assessment 34
17.0 Data Protection Act and Freedom of Information Act 34
18.0 Monitoring policy’s effectiveness 35
Appendix
NEWS Observation Chart 37
Medical Emergency Flowchart 41

Explanation of terms used in this policy
Rapid Tranquillisation (RT) - NICE defines Rapid Tranquilisation (RT) as ‘use of medication by
the parenteral route (usually intramuscular) if oral medication is not possible or appropriate
and urgent sedation with medication is needed’. The aim of treatment is to use medication to calm
or lightly sedate the patient and reduce the risk to themselves and/or others. The desired outcome is to
achieve an optimal reduction in agitation and aggression, thereby allowing a thorough psychiatric
evaluation to take place.
Violence - any incident where staff, patients or others are abused, threatened or assaulted in
circumstances related to their work, involving an explicit or implicit challenge to their safety, wellbeing or
health
Aggression - this may be of a verbal nature or a physical act, whereby intentional behaviour leads to
harm to the individual, to another person or to the damage of property
Seclusion - supervised confinement of a patient in a room, which may be locked. Its sole aim is to
contain severely disturbed behaviour that is likely to cause harm to others
Calming - reduction of anxiety
Advance Statements - preferred treatment choices expressed by the patient when well and are likely to
be documented in care records. An advance statement is not legally binding
Light Sedation - state of rest and reduction of psychological activity, but verbal contact is maintained
QTc prolongation - QTc is a measurement obtained from an ECG. If this is above normal limits (440ms
for men and 470ms for women) it may predict a risk factor for the ventricular arrhythmia Torsade de
Pointes, which is occasionally fatal (sudden cardiac death). Psychotropic agents such as haloperidol have
been associated with QTc prolongation. Above 500ms there is strong evidence for increased risk of
arrhythmias. QTc prolongation may occur more frequently with higher doses, combinations of
psychotropic medication, intravenous administration and in predisposed patients. Check Maudsley
guidelines for risk of QTc prolongation.
Parenteral - administration of medicine usually via intramuscular route or, exceptionally, intravenous
National Early Warning Scoring (NEWS) - single standardised early warning system which has been
developed by the Royal College of Physicians and has been adopted nationally by the NHS to enable
consistency across both acute and community hospital settings
p.r.n (pro re nata) - when required. In this guideline, p.r.n. refers to the use of oral medication as part
of a strategy to de-escalate or prevent situations that may lead to violence or aggression; it does not refer
to p.r.n. medication used on its own for Rapid Tranquillisation during an episode of violence or aggression

1.0 Introduction
Black Country Partnership NHS Foundation Trust recognises that it is sometimes

necessary to use pharmacological intervention to maintain the safety and physical health of
some patients who are acutely unwell.
It is accepted that certain situations may arise in psychiatric in-patient environments or

S136 suite that can lead to potential or actual harm of the patient or those around them as
a result of their extremely disturbed or challenging behaviour. This could arise due to
psychotic or non-psychotic illness and may need to be brought rapidly under control with
the appropriate use of medication in order to avoid prolonged use of physical interventions.
Rapid tranquillisation is not a first line therapy for managing violence and aggression. The
underlying condition does not necessarily predict response to rapid tranquillisation nor
preclude rapid tranquillisation. Other approaches to manage imminent violence include de-
escalation techniques, consideration of placement, physical interventions and seclusion but
when used, management strategies to reduce the level of risk should be recorded in care
plans.
The aim of treatment is to use medication to calm or lightly sedate the patient and reduce
the risk to themselves and/or others. The desired outcome is to achieve an optimal
reduction in agitation and aggression, thereby allowing a thorough psychiatric evaluation to
take place.
This policy should be read in conjunction with the Prevention and Management of Violence
and Aggression including NHS Sanctions Policy.
1.1 Rapid Tranquillisation Definition
CQC guidance BG0401 and NICE guidance NG10 defines Rapid Tranquillisation (RT)
as ‘use of medication by the parenteral route (usually intramuscular) if oral medication is
not possible or appropriate and urgent sedation with medication is needed’. RT includes all
medication administered whilst the patient is restrained to control behaviour.
Administration of oral medication is not considered to be RT, however due to the potential
agitated state, it is good practice to closely monitor the patient following administration of
combinations of oral medication and repeated doses of oral medication given within the
same episode to control behaviour.
2.0 Purpose
The purpose of this policy is to provide staff with clear direction in regard to the use of
Rapid Tranquillisation (RT) when faced with incidents of acutely disturbed behaviour and
extreme aggression.

3.0 Objectives
 To define and explain the use of Rapid Tranquillisation in inpatient settings or the
S136 Suite.
 To provide a standardised approach to physical monitoring and nursing care before,
during and following Rapid Tranquillisation.
 To provide a framework for ensuring:
 The decision to use Rapid Tranquillisation is made with due consideration.
 Rapid tranquillisation is used safely and effectively.
 The use of Rapid Tranquillisation (RT) is reflected upon and care plans
reviewed appropriately.
4.0 Principles and Practice of Rapid Tranquillisation (RT)
In certain situations within psychiatric in-patient environments or the S136 suite, potential
or actual harm of a patient or those around them can arise as a result of their extremely
disturbed or challenging behaviour. Initial approaches to manage imminent violence can
include de-escalation techniques, oral p.r.n medication, consideration of placement,
physical interventions and seclusion.
4.1 De-escalation Techniques
 Maintain adequate distance.

 Ensure environment is conducive to calmness (e.g. low stimulation levels, noise and
other patients).
 Move to a safe place. Use a designated area or room to reduce emotional arousal or
agitation and support the service user to become calm practised. Do not routinely use
the seclusion room (if available) for this purpose because the service user may
perceive this as threatening (NICE NG10 8.3.2.9).
 Explain intentions and be calm and self-assured.
 Use non-threatening non-verbal communication.
 Converse and try to develop therapeutic relationship throughout.
 Use of sensory resources i.e. weighted blanket, games consoles.
4.2 Choice of Intervention
Where de-escalation techniques have failed to calm a patient, it may be necessary to make
use of additional interventions, such as oral p.r.n medication, physical intervention, Rapid
Tranquillisation (RT) and seclusion to manage the incident. All such interventions should
only be considered once de-escalation techniques have been tried and have not
succeeded in calming the patient. The choice of intervention(s) will depend on a number of
factors, but should be guided primarily by:
 Patient preference (if known).
 The clinical needs of, and risks to, the patient.
 Obligations to other patients affected by the disturbed/ violent behaviour.
 The protection of staff, patients and visitors.
 The facilities available within the particular setting.

4.3 Use of oral p.r.n medication
When prescribing oral p.r.n. medication as part of a strategy to de-escalate or prevent

situations that may lead to violence and aggression, consider the following;
 p.r.n should be offered first line.
 do not prescribe p.r.n. medication routinely or automatically on admission
 tailor p.r.n. medication to individual need and include discussion with the service
user if possible
 ensure there is clarity about the rationale and circumstances in which p.r.n.
medication may be used and that these are included in the care plan
 ensure that the maximum daily dose is specified and does not inadvertently exceed
the maximum daily dose stated in the British national formulary (BNF) when
combined with the person’s standard dose or their dose for RT
 only exceed the BNF maximum daily dose (including p.r.n dose, the standard dose
and dose for rapid tranquillisation) if this is planned to achieve an agreed therapeutic
goal, documented, and carried out under the direction of a senior doctor
 ensure that the interval between p.r.n doses is specified.
 The multidisciplinary team should review oral p.r.n medication at least once a week
and, if p.r.n medication is to be continued, the rationale for its continuation should be
included in the review. If p.r.n medication has not been used since the last review,
consider stopping it.
 If more than one medication is prescribed, the care plan should include the preferred
order of administration of medicines and time interval between the medicines.
 If two medications are intended to be given at the same time this should be clearly
stated.
 It should be noted that a single p.r.n antipsychotic dose does not have an
antipsychotic action, as onset of its antipsychotic effect will require regular dosing
over days and weeks.
 When deciding which medication to use take into account any contra-indications,
special warnings or precautions required. Also consider;
 the service user's preferences or advance statements and decisions
 pre-existing physical health problems or pregnancy
 possible intoxication (alcohol or psychoactive drugs)
 previous response to these medications, including adverse effects
 potential for interactions with other medications
 total daily dose of medications prescribed and administered.
 For full details of contra-indications, special warnings and precautions for all
medicines can be found on http://www.medicines.org.uk/emc
4.4 Rapid Tranquillisation and Physical Intervention
In certain situations, the multidisciplinary team may agree use of medication as the most
appropriate method of managing extreme behaviour. Where this is likely to require the use
of physical intervention in order to safely administer the medication - the force used to
administer medication must be reasonable.
Current physical intervention skills do not allow for the complete immobilisation of a patient.
Movement will be generated by an agitated patient thus making it difficult to safely

administer RT. In order to reduce the injection risks staff should wait until movement is at a
minimum and/or the patient is ready to cooperate with the injection. Consider RT or
seclusion as alternatives to prolonged manual restraint (longer than 10 minutes) [NICE
NG10 8.4.5.8].
4.5 Rapid Tranquillisation and Seclusion
The combined use of seclusion and RT should be avoided wherever possible, however, if
seclusion is judged necessary to manage the serious risk of violence the following should
be considered and the potential complications of RT should be taken seriously;
 Continuous observation through the observation window by a delegated nurse
 Terminating seclusion once RT has taken effect
 The patient’s respiration and where possible all other vital signs should be monitored
 Once seclusion is instigated refer to Seclusion Policy for further guidance
4.6 Care Planning/Reviews
Ensure that patients who might be subject to RT have an individual care plan. The
multidisciplinary team should develop and document an individualised pharmacological
strategy for using routine and p.r.n. medication to calm, relax, tranquillise or sedate service
users who are at risk of violence and aggression as soon as possible after admission to the
ward or S136 suite.
Where possible care plans for the management of individual service users should be made
in advance of the episode of acutely disturbed behaviour. These care plans should
indicate:
 At what stage medicines should be used
 If more than one medicine is prescribed in what order they should be administered
 At what stage medical involvement is required.
 clarification of target symptoms
 the likely timescale for response to medication
The plans should be developed on the basis of past experience of the response of the
service user to the medicines used and should include any advance statements agreed
with the service user.
The multidisciplinary team should review the pharmacological strategy and the use of
medication at least once a week and more frequently if events are escalating and
restrictive interventions are being planned or used. The review should be recorded and
include:
 the total daily dose of medication, prescribed and administered, including p.r.n
medication
 the number of and reason for any missed doses
 therapeutic response
 the emergence of unwanted effects.
If RT is being used, a senior doctor should review all medication at least once a day.

4.7 Risk Assessment
The decision to use RT should be made after clinical assessment of need and risk to the
patient and/or others. All patients should have a regular and comprehensive risk
assessment to ensure the safety of the patient and the clinical environment. Risk
assessments should be ongoing as risks may change according to circumstances.
The risks associated with RT are to be explored by the team prior to the administration of
medication to determine safety and appropriateness. RT is potentially hazardous and the
risk of adverse effects is higher if the patient has taken illicit drugs or alcohol.
4.8 Advance Statements

Patients identified to be at risk of disturbed or violent behaviour should be given the
opportunity to have their needs and wishes recorded in the form of an advance directive
and within a care plan.
4.9 Legal Issues and the Mental Health Act (MHA)
If a patient refuses or lacks capacity to give valid consent to treatment, ensure there is
appropriate legal authority in place prior for prescribing/administering RT e.g. if detained
over 3 months, a section 62 or T3 is in place to cover prescribed medication.
The enforced administration of medication by injection to an informal patient may

necessitate use of the Mental Health Act. If treatment is to continue against the patient’s
wishes then a MHA assessment must be undertaken to ensure continued administration is
lawful.
4.10 Physical monitoring/review of history Before Rapid Tranquillisation (RT)
In anticipation of the likelihood of prescribing medication for RT, the prescribing doctor
should:
 Ensure baseline measurements are taken and recorded i.e. blood pressure,
temperature, pulse, respiration, weight
 Review the patient’s clinical record with regard to his/her general medical history
and consider the possibility of a physical examination
 Previous response to RT or other methods of managing imminent violence
 Be aware of any previous drug sensitivity / allergies and communicate this
information to all members of the MDT through normal communication channels
Check for recent ECG, blood and urine drug screen results, a previous history of
severe extrapyramidal side effects
 Review current prescribed medication (including regular and p.r.n) and any recently
administered depots/LAI’s. Also take note of recent administration of p.r.n
medication

5.0 Rapid Tranquillisation
Rapid tranquillisation (RT) is used in situations requiring the rapid control of agitation,
aggression or excitement when other less coercive techniques of calming a patient, such
as verbal de-escalation or intensive nursing techniques have failed and the patient is
refusing oral p.r.n medication. RT involves the administration of parenteral medication in
order to produce a state of calm/light sedation. The medications used for RT should ideally
have a low level of side effects and rapid onset of action.
For the purpose of this policy, RT describes the use of parenteral medication to control
severe mental and behavioural disturbance, including:
 Aggression associated with the mental illness of schizophrenia, mania and other
psychiatric conditions
 Organic disorders, including dementia from a variety of causes
5.1 Medical Staff Availability
A doctor should be quickly available at all times to attend to an alert by ward staff or S136
suite staff when RT is implemented. NICE Clinical Guideline on Violence and Aggression
(NG10) recommends that a doctor should aim to be at the scene within 30 minutes.
Medical support must be available in case of adverse reactions, over sedation or the need
to administer IV Flumazenil (to reverse sedation, drowsiness). If RT is to be considered out
of hours the duty doctor should be contacted and requested to attend.
5.2 Medical Equipment
The blue emergency ILS bag should be available within 3 minutes in inpatient settings
where RT might be used. The bag should be maintained and checked routinely.
5.3 Rapid Tranquillisation 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).

5.4 Rapid Tranquillisation Prescribing
RT as parenteral injection (usually IM) should only be considered when de-escalation

techniques and oral p.r.n have been less effective or refused. The use of IM medication for
RT must be reported externally and for this reason the use of IM medication must be
reported via the Physical Intervention Monitoring Form and a Datix incident report
completed.
5.4.1 The reason for prescribing should be documented in the clinical record, including the
care plan.
5.4.2 Do not prescribe RT medication routinely or automatically on admission on the when

required section of the drug chart. NICE guidance states that RT should initially only be
prescribed as a single dose. Additional doses of RT should not be administered for the
service user until the full effect of the first dose has been assessed and found to be
physically tolerated. In exceptional circumstances, for example when the service user has
a known relapse presentation requiring repeated episodes of RT, it may be prescribed with
a specified number of doses for administration. Prescriptions for multiple doses of RT
should be agreed by the multidisciplinary team or authorised by a Consultant Psychiatrist.
5.4.3 Only when RT continues to be required should it be prescribed on the ‘as required
medicines’ section of the chart including indication, maximum dose, interval and maximum
daily dose. This should be reviewed at least once weekly.
5.4.4 If more than one medication is prescribed, the care plan should include the
preferred order of administration of medicines and time interval between the
medicines.
5.4.5 When deciding which medication to use take into account any contra-indications,
warning or precautions required.
 the service user's preferences or advance statements and decisions

 pre-existing physical health problems or pregnancy
 possible intoxication (alcohol or psychoactive drugs) or delirium
 previous response to these medications, including adverse effects
 potential for interactions with other medications
 the total daily dose of medications prescribed and administered.
Full details of contra-indications, special warnings and precautions for all medicines can be
found on http://www.medicines.org.uk/emc
5.4.6 Care must be taken when giving IM injections particularly to highly aroused and/or
violent individuals. The provision of adequate staff trained in approved care and techniques
should always be on standby even when patients agree to IM treatment, as there are the
inadvertent risks of intra-arterial injection, bolus dosing, nerve damage, bruising, needle
breakage in patients who may struggle or are resistive, and also a higher than expected
absorption rate due to the increased blood flow to the muscles in a highly aroused
individual.

5.5 Choice of Medication in Rapid Tranquillisation
NICE NG10 states the following;
 Use either IM lorazepam on its own or IM haloperidol combined with intramuscular

promethazine (due to its antimuscarinic properties) for RT in adults.
 If there is insufficient information to guide the choice of medication for RT, or the
service user has not taken antipsychotic medication before, use IM lorazepam.
 If there is evidence of cardiovascular disease, including a prolonged QTc, or no
ECG has been carried out, avoid intramuscular haloperidol combined with IM
promethazine and use IM lorazepam instead.
 If there is a partial response to intramuscular lorazepam, consider a further dose.
 If there is no response to intramuscular lorazepam, consider IM haloperidol
combined with IM promethazine.
 If there is a partial response to IM haloperidol combined with IM promethazine,
consider a further dose.
If there is no response to intramuscular haloperidol combined with intramuscular
promethazine, consider intramuscular lorazepam if this hasn't been used already
during this episode.
 If intramuscular lorazepam has already been used, arrange an urgent team meeting
to carry out a review and seek a second opinion if needed.
Alternatives which may be considered are;
 Aripiprazole IM (alone or in combination with Lorazepam IM). Although not

considered by NICE NG10 due to insufficient evidence, it is may be prescribed on
inpatient wards if it is considered to be the safest and most appropriate treatment
option for the service user.
 Olanzapine IM alone. Not considered by NICE NG10 because the manufacturer of

IM olanzapine has withdrawn the product from the UK market. As a result they were
unable to make recommendations regarding its use. However, it remains a licensed
product in the European Union (EU) and may be prescribed, if following a
multidisciplinary review it is considered to be the most appropriate treatment option
for a service user. IM olanzapine MUST NOT be co-administered with IM
lorazepam, hypnotics (e.g. promethazine) or other antipsychotics. These medicines
must not be given within 60 minutes of IM olanzapine (pre or post dose). This is due
to the increased risk of respiratory depression, hypotension and bradycardia; on rare
occasions fatalities have occurred.
The use of two medicines of the same class for the purpose of RT or p.r.n should not
occur.

5.6 Algorithm 1: BCPFT Algorithm for Rapid Tranquillisation / oral p.r.n prescribing for Working Age Adults/Older Adults
- Have access to procyclidine injection for acute dystonic

reactions and flumazenil for benzodiazepine induced
Consider starting/increasing regular oral
Consider de-escalation techniques respiratory depression.
medication
e.g. talking down, distractions, time out - Have access to emergency resuscitation facilities
No response
WORKING AGE ADULTS OLDER ADULTS

Drug (oral) Drug (oral)
Consider pharmacological management Lorazepam 1 to 2mg Lorazepam 500microgams to 1 mg
Seek advice re: MHA status. or Optimise regular psychotropic
Is a section 62 required? Promethazine 25 to 50mg And/or another from the list below
Response
medication
(Where the use of benzodiazepines is inappropriate) Risperidone 0.25mg to 1mg
Quetiapine 25mg
And/or another from the list below Olanzapine 2.5 to 5mg
Olanzapine 5 to 10mg or
Quetiapine 25 to 50mg *Haloperidol 1 to 2.5mg and
or Promethazine 12.5-25mg
Try Oral Therapy ( p.r.n ) *Haloperidol 2 to 5mg and
Promethazine 25-50mg Use formulation most appropriate to patient Restart or start oral medication
*Note ECG requirements
Use formulation most appropriate to patient
Patient refusing oral /

Rapid response required /
No response to oral WORKING AGE ADULTS OLDER ADULTS
Drug (IM) Drug (IM)
Lorazepam 1-2 mg Lorazepam 500 micrograms to 1mg
Review appropriateness of
or or Response
continuing intramuscular
Promethazine 25-50mg Aripiprazole 5.25-9.75mg
therapy
(Where the use of benzodiazepines is or
inappropriate) *Haloperidol 0.5 to 2.5mg and
or Promethazine 12.5-25mg
*Haloperidol 2 to 5mg and (if known to tolerate typical antipsychotics)
Try intramuscular injection ( RT ) Promethazine 25-50mg
(if known to tolerate typical antipsychotics) *Note ECG requirements
Monitor Patient
Never mix two drugs in the same syringe.
Always dilute lorazepam injection before use
No response within 30 minutes
Review
Consider repeating IM Lorazepam (Adult Max 4 mg in 24 hours) and Haloperidol 5mg injections
(caution – maximum adult Haloperidol dose is 20mg IM in 24 hours, avoid repeating Haloperidol in the elderly
Complex case – refer to consultant / above a total of 5mg IM without Consultant advice)
seek advice from pharmacy or any of the following
1) Aripiprazole usually 9.75mg IM [either alone or with IM Lorazepam](max dose 30mg in 24hrs by
any route, however only IM used in RT,)
or
2) Olanzapine 5 to 10mg IM ALONE [not within 60 mins of IM Lorazepam](max dose 20mg in 24
hours by any route)

5.7 Table 1: Rapid Tranquillisation / oral p.r.n notes for Working Age Adults
1  Review the use of non-pharmacological strategies for managing an imminent risk of violence
 Review the patient’s consent to treatment. Is it necessary to use section 62?
 Review the patient’s clinical record for previous medical history and recent investigations
 Note total medication in last 24 hours and response
 Consider physical examination
 Consult with a more senior doctor at any stage if unsure
 Flumazenil must be available in case of Benzodiazepine-induced respiratory depression
2 ORAL p.r.n medication.
LORAZEPAM oral 1-2mg

(May repeat after 45-60 minutes)
If the patient is prescribed a regular oral or depot antipsychotic or has
[Max. 4mg/24 hours] cardiovascular disease, consider using Lorazepam alone.
PROMETHAZINE oral 25-50mg Consider using promethazine if the patient is benzodiazepine tolerant.
(May repeat after 1-2 hours)
[Max. 100mg/24 hours] If not already taking a regular oral or depot/LAI antipsychotic, has respiratory
disease or a doctor is not present out of hours, consider using an antipsychotic
alone.
OLANZAPINE oral 10mg
(May repeat after 4 hours.)
Avoid using Haloperidol in antipsychotic naïve patients or those with prolonged
[Max. 20mg/24 hours) QTc. The SPC for Haloperidol recommends avoiding concomitant antipsychotics
and having a pre-treatment ECG.
HALOPERIDOL oral 5mg
(with Promethazine) Haloperidol should be combined with promethazine to minimise EPSE as per
NICE NG10.
(May repeat after 4 hours.)
[Max. 20mg/24 hours]
Ensure Procyclidine is available for extra pyramidal side-effects (EPSE).
QUETIAPINE oral 25-50MG

Allow sufficient time for clinical response between doses.
(may repeat after 4 hrs.)
[Max. 750-800mg/24hrs]

3 No response or patient refuses oral consider using INTRAMUSCULAR medication. The options for RT include:
LORAZEPAM IM 1-2 mg
(May repeat after 30-60 minutes.) If the patient is prescribed a regular oral or depot Antipsychotic or has
cardiovascular disease, consider using Lorazepam alone.
[Max. 4mg/24 hours]
Promethazine may be used as an alternative and is a useful option in a

PROMETHAZINE IM 25-50mg
Benzodiazepine-tolerant patient.
(May repeat after 1-2 hours.)
If the patient is not already taking a regular oral or depot Antipsychotic, is
Benzodiazepine tolerant, has respiratory disease or a doctor is not present out of
ARIPIPRAZOLE IM 5.25–9.75mg hours, consider using an Antipsychotic alone.
Usual dose 9.75mg.

(May repeat after 2 hours.) Allow sufficient time for clinical response between doses. Transfer to oral route at
earliest opportunity.
Avoid using Haloperidol in Antipsychotic naïve patients. Maudsley suggests that

HALOPERIDOL IM 2-5mg Haloperidol should be the last drug considered. The SPC recommends a pre-
(May repeat after 4-8 hours) treatment ECG. The incidence of acute dystonia is high – combine with IM
Promethazine and ensure oral/IM Procyclidine is available.
[Max.20mg/24 hours]
Allow sufficient time for clinical response between doses. Transfer to oral route at
OLANZAPINE IM 5-10mg earliest opportunity.
(may repeat after 2 hours)
[Max. 20mg/24 hours] IM olanzapine MUST NOT be co-administered with IM lorazepam, Promethazine
or other antipsychotics.
4 If unsuccessful seek advice from consultant psychiatrist on duty. Consider alternatives.

5.8 Table 2: Rapid Tranquillisation / oral p.r.n notes for Older Adults
1  Review the use of non-pharmacological strategies for managing an imminent risk of violence
 Review the patient’s consent to treatment. Is it necessary to use section 62?
 Review the patient’s clinical record for previous medical history and recent investigations
 Note total medication in last 24 hours and response
 Consider physical examination
 Consult with a more senior doctor at any stage if unsure
 Flumazenil must be available in case of benzodiazepine-induced respiratory depression
2 ORAL p.r.n medication should be first choice where possible
2.1 Patient with known diagnosis of schizophrenia, mania or Have longer times between doses.
other functional disease Consider half adult doses. Caution: renal or hepatic
impairment, cardiovascular disease. Monitor B.P.
2.2 Dementia with Lewy Bodies (DLB) present or cannot be Consider oral Lorazepam 0.5mg-1mg every 4 hours
excluded [Max. 2mg/24 hours].
Avoid Antipsychotic medication as it can cause sudden
deterioration, side effects and even death.
2.3 Dementia other than DLB Consider oral Lorazepam 0.5mg-1mg every 4 hours [Max.
If the patient is established on a regular Antipsychotic or has 2mg/24 hours].
cardiovascular disease, consider using Lorazepam alone. Consider oral Haloperidol 1-2.5mg [Max.5mg/24 hours]
If the patient is benzodiazepine tolerant or has respiratory or Quetiapine 25mg or Risperidone 0.25mg.
disease or a doctor is not present out of hours, consider using (Avoid using haloperidol in Antipsychotic naïve patients. The
an antipsychotic alone.
SPC recommends avoiding concomitant Antipsychotics and
Caution – antipsychotic drugs are associated with an having a pre-treatment ECG. Ensure Procyclidine is available
increased risk of mortality, stroke and transient ischaemic for EPSEs).
attack.
Promethazine in the elderly - caution should be exercised in

patients with a diagnosis of dementia.
Olanzapine – do not use in dementia.
Monitor status and continue oral. If no response or patient refuses oral medication seek advice from duty consultant
3 psychiatrist. In cases of emergency consider using INTRAMUSCULAR medication.

3.1 Dementia with Lewy Bodies (DLB) present or cannot be Consider IM Lorazepam 0.5mg-1mg only [Max. 2mg/24
excluded hours.
3.2 Consider IM Lorazepam 0.5mg-1mg only (Max. 2mg/24

hours).
Consider IM Haloperidol 0.5-2.5mg (Max. 5mg in 24 hours).
Dementia other than DLB
(Avoid using Haloperidol in Antipsychotic naïve patients.
If the patient is established on a regular antipsychotic or has
cardiovascular disease, consider using Lorazepam alone. SPC recommends pre-treatment ECG. Ensure Procyclidine is
available for side-effects).
If the patient is benzodiazepine tolerant or has respiratory
Consider IM Aripiprazole 5.25-9.75mg [max 30mg in
disease or a doctor is not present out of hours, consider using
an antipsychotic alone. 24hrs]. May be used in combination with IM Lorazepam.
Caution – antipsychotic drugs are associated with an

increased risk of mortality, stroke and transient ischaemic Promethazine in the elderly - caution should be exercised in
attack. patients with a diagnosis of dementia.
Olanzapine – do not use in dementia.
4 If unsuccessful seek advice from consultant psychiatrist on duty. Consider alternatives.

5.9 General Prescribing Notes
1. Previous medication taken by the patient must be considered.

2. Care must be taken to ensure that High dose prescribing does not inadvertently occur through the
use of p.r.n medication given in combination with regular medication.
3. Two drugs of the same class should not be used for RT.
4. The BNF maximum doses include both oral and IM formulations.
5. Oral and intramuscular medications should be prescribed separately on the treatment chart.
6. Drugs should never be mixed in the same syringe prior to administration.
7. A baseline ECG is recommended prior to treatment in all patients prescribed Haloperidol. If it has
been refused or not taken for any other reason, this should be documented in the patient’s notes
clearly with the reasons why stated.
8. Despite the need for rapid and effective treatment, the use of two or more antipsychotics
(antipsychotic polypharmacy) should be avoided on the basis of risk associated with QTc
prolongation. Other drugs may also affect the QT interval e.g. Citalopram, Escitalopram,
Macrolide and Fluoroquinolone antibiotics, Amiodarone, Hydroxyzine. Contact pharmacy for
further information.
9. Elderly: in patients with dementia, antipsychotic drugs are associated with a small increased risk
of mortality, stroke and transient ischaemic attack. Risperidone should only be used for the short-
term treatment (up to 6 weeks) of persistent aggression in patients with moderate to severe
Alzheimer's dementia unresponsive to non-pharmacological approaches and when there is a risk
of harm to self or others.
10. Ensure Procyclidine is available to manage acute dystonic reactions or other extrapyramidal side-
effects of antipsychotic medication especially Haloperidol.
11. Risperidone and Olanzapine are available as oro-dispersible tablets.
12. Benzodiazepines side effects: loss of consciousness, respiratory depression or arrest, risk
cardiovascular collapse when receiving both Clozapine and benzodiazepines.
13. Antipsychotics side effects: loss of consciousness, cardiovascular/respiratory complications and
collapse, seizures, akathisia, dystonia, dyskinesia, neuroleptic malignant syndrome, excessive
sedation.
14. Antihistamines side effects: excessive sedation, painful injection, additional anti-muscarinic
effects.
15. Simultaneous administration of injectable antipsychotics and parenteral Benzodiazepines may be
associated with excessive sedation and cardio-respiratory depression. Patients should be
monitored for excessive sedation and orthostatic hypotension.
16. A resuscitation bag should be available within 3 minutes in healthcare settings where rapid
tranquillisation might be used. The equipment should include an automatic external defibrillator, a
bag valve mask, oxygen, cannulas, fluids, and suction and first-line resuscitation medications.
17. It is recognised that clinicians may decide that the use of medication outside the Summary of
Product Characteristics (SPCs) is occasionally justified, bearing in mind the overall risks.
However, where the regulatory authorities or manufacturer issues a specific warning that this may
result in an increased risk of mortality, the medication should only be used strictly in accordance
with the current marketing authorisation.

5.10 Table 3: Drug information for oral p.r.n and IM Rapid Tranquillisation medication to be used with guideline
BNF
Time to Reach
Drug Onset of Maximum Other e.g. monitoring, licensing, QT c
Route Maximum Conc /
Action Dose in 24 administration rating
Half life
hours
Peak 1-3 hrs. May be repeated after 2 hrs. Half-life extends

Aripiprazole IM NR 30mg Low
t1/2 75 hrs to 146 hrs in poor metabolisers of CYP2D6
ECG requirement – QTc prolongation

Peak 4 hrs.
Haloperidol Oral 1-2 hrs. 20mg Note the change in maximum dose of IM High
t1/2 20 hrs
haloperidol, as result of harmonisation by the
Peak 60-90 mins.
Haloperidol IM 20 mins 20mg European Medicines Agency. See BNF. High
t1/2 20 hrs
20-30 Peak 2hrs Oral has similar onset of action to IM
Lorazepam Oral 4mg NR
mins. t1/2 12 hrs Risk of paradoxical disinhibition
<20-30 Peak 60-90 mins.
Lorazepam IM 4mg IV Flumazenil must be available NR
mins. t1/2 12 hrs
20-60 Peak 1-4 hrs Caution: high relative maximum BNF dose.
Clonazepam PO 8mg NR
mins t1/2 20-60 hrs Risk of accumulation, due to long half-life.
Peak 5-8 hrs. Do not use Olanzapine in Dementia
Olanzapine Oral 1 hr. 20mg Low
t1/2 31-52 hrs Time to peak is longer.
15-30 Peak 15-45 mins Do not use within 1 hr of IM Lorazepam
Olanzapine IM 20mg Low
mins t1/2 31-52 hrs IM results in peak 5x higher than oral dose.
Peak 2-3 hrs.
Promethazine Oral 20 mins 100mg Suitable for benzodiazepine tolerant pts. NR
t1/2 7-15 hrs
Peak 2-3 hrs Can be combined with Haloperidol due to its
Promethazine IM 20 mins 100mg NR
t1/2 7-15 hrs anti-cholinergic properties.
Peak 1.5-1.8 hrs.
Quetiapine IR Oral NR 750/800mg Limited clinical experience Moderate
t1/2 hrs 7-12 hrs
Peak 1-2 hrs.
Risperidone Oral NR 16mg Limited clinical experience or trial data Low
Peak 12-36 hrs.
Zuclopenthixol
IM 2-8 hrs. Duration of action 150mg See separate guidelines NR
ACETATE
48-72 hours
NR=Not Recorded

5.11 Prescribing in complex cases
After discussion with consultant only: not for routine use in Rapid Tranquillisation.
If a patient is on maximum dose of oral antipsychotic, consider using above BNF

maximum doses or alternative antipsychotic short-term only. In certain circumstance,
current BNF limits and the manufacturer’s SPC may be knowingly exceeded. This
decision should not be taken lightly or the risks underestimated. Record a risk-benefit
analysis in the case notes and a rationale in the care plan. Undertake frequent and
intensive monitoring of a calmed service user.
Zuclopenthixol acetate injection (Clopixol Acuphase®)

[See 5.12 on following page for further guidance]
Caution in elderly. It is not recommended for RT due to its significantly delayed onset
and relatively long duration of action.
Benzodiazepines
Consider Lorazepam: High dose. Use with caution and document in patients clinical
notes reason for prescribing high dose. Undertake frequent and intensive monitoring. A
doctor must be present to administer Flumazenil if needed.

5.12 Guidelines for the use of Zuclopenthixol Acetate injection

(Clopixol Acuphase®)
N.B. For use following approval from consultant only
BNF Short-term management of acute psychosis, mania or exacerbations of

Indication chronic psychoses.
Dosage 50-150mg (1-3ml). Elderly: 50-100mg
If necessary repeat after 2-3 days. One additional dose may be given 1-2
days after the first injection. Maximum cumulative dose 400mg over 14
Frequency
days. Maximum duration of treatment of 2 weeks. Not for long-term
treatment.
Deep intramuscular injection into the upper outer buttock or lateral thigh.
Route
Injection volumes greater than 2ml should be distributed between 2 sites.
Onset,
Sedative effects usually begin to be seen between 2-8 hours after injection
duration
and peak between 12-36 hours. The effects can last for up to 72 hours.
of action
If resisting injection i.e. struggling, use appropriate MAPA techniques to
decrease risk of injection into vein.
Other If maintenance treatment is necessary change to an oral Antipsychotic 2-3
days after last injection or to a longer acting Antipsychotic depot injection
given concomitantly with last injection of Zuclopenthixol Acetate.
Clopixol Acuphase® injection should be considered only;

 following consultant approval.
 after an acutely psychotic patient has required repeated injections of short-acting
Antipsychotic drugs such as Haloperidol, or sedative drugs such as Lorazepam.
 for patients known to respond to it.
 in physically violent patients for who repeated attempts at injection would be
dangerous for all parties.
 be given only when enough time has elapsed to assess the full response to
previously injected drugs. Allow at least 60 minutes after IM injection.
 if cited in an advance directive.
Clopixol Acuphase® injection should never be administered;

 in an attempt to ‘hasten’ the antipsychotic effect of other Antipsychotic Therapy
 for Rapid Tranquillisation (onset of effect is too slow)
 at the same time as other parenteral antipsychotics or benzodiazepines (may
lead to over sedation which is difficult to reverse)
 as a ‘test dose’ for Zuclopenthixol Decanoate depot injection
 to a patient who is physically resistant (risk of intravasation and oil embolus)

Clopixol Acuphase® injection should never be used for, or in, the following:
 Patients who accept oral medication
 Patients who are antipsychotic naïve
 Patients who are sensitive to extrapyramidal side effects (dystonia, laryngeal
spasm, oculogyric crisis or previous neuroleptic malignant syndrome)
 Patients who are unconscious
 Patients who are pregnant
 Patients with convulsive disorders or Parkinson’s disease
 Those with hepatic or renal impairment
 Those with cardiac disease
 Those with a depressed level of consciousness due to any cause (e.g. intoxication
with alcohol, illicit drugs, barbiturates or opiates), coma
 Those resisting injection i.e. struggling. Use appropriate physical intervention
techniques to decrease risk of injection into vein
 Patients that are not detained under the Mental Health Act
Caution should be exercised in patients who have recently received a dose of depot/LAI
antipsychotic which has not yet reached peak levels.
ECG monitoring is strongly recommended. Prolonged QTc related to antipsychotic

treatment may also be exacerbated by the co- administration of other drugs known to
significantly prolong QTc.
NICE suggests that Clopixol Acuphase® injection may be considered an option when:
 service user will be disturbed/violent over an extended time period
 past history of good/timely response
 past history of repeated parenteral administration
 cited in an advance directive
Never administer to those without previous antipsychotic exposure.
There is no such thing as ‘a course of Acuphase’. Once a first dose has been prescribed
the treatment plan should clearly document the circumstances when further doses may
be administered. Subsequent doses should not be written up on the drug chart
until patient has been reassessed by the doctor.
Physical Monitoring
Use Chart 1 overleaf to record physical monitoring following administration of

zuclopenthixol acetate (Clopixol Acuphase®)

5.13 Zuclopenthixol Acetate (Clopixol Acuphase®)

Post-Administration Physical Observations Record Chart
Name: Ward:
Date and time administered: Dose:
Time since Time Level of Respiratory BP Pulse NEWS Signs of Hydrated Sign
administration 24hr Alertness Rate Score EPSEs (Yes/No)
(AVPU) (Yes/No)
Baseline
2 hours
4 hours
6 hours
8 hours
12 hours
16 hours
20 hours
24 hours
28 hours
32 hours
36 hours
40 hours
44 hours
48 hours
Codes: - Level of Alertness (AVPU)
A Alert: Eyes open with normal verbal response.

V Voice: Eyes closed but will open eyes on command, and with normal verbal response.
P Pain: Eyes closed, responds to painful stimuli (nail bed depression – finger or toe nail).
U Unresponsive: Does not respond to ANY of the above. Completely unconscious

6.0 Risks and Complications associated with Rapid Tranquillisation

There are specific risks associated with the different classes of medications that are
used in RT. The specific properties of the individual drugs should be taken into
consideration. When combinations are used, risks may be compounded. Staffs need to
be aware of the following:
For benzodiazepines:
 Loss of consciousness
 Respiratory depression or arrest
 Cardiovascular collapse (in patients receiving both Clozapine and
Benzodiazepines)
For antipsychotics:
 Loss of consciousness
 Cardiovascular and respiratory complications and collapse
 Seizures
 Subjective experience of restlessness (akathisia)
 Acute muscular rigidity (dystonia)
 Involuntary movements (dyskinesia)
 Neuroleptic malignant syndrome (NMS)
 Excessive sedation
6.1 Circumstances for special care

Extra care should be taken when implementing RT in the following circumstances:
 The presence of congenital prolonged QTc syndromes
 The concurrent prescription or use of other medication that lengthens QTc intervals
both directly and indirectly
 The presence of certain disorders affecting metabolism, such as hypo-and
hyperthermia, stress and extreme emotions and extreme physical exertion
6.2 Observations
After RT is administered, the following should be monitored:
 Results of vital signs must be recorded on the NEWS Observation Chart (see
appendix 1), nursing and medical notes
 Scheduled observation and engagement levels should be assessed by a doctor,
with nursing staff, and the frequency of observations following RT recorded in case
notes. However it is recommended that;
 Side effects, blood pressure, pulse, temperature, respiratory rate, level of
hydration and level of consciousness should be monitored every 15 minutes for 1
hour after IM injections
 After the first hour continue to monitor every 30 minutes until the patient becomes
ambulatory and there are no further concerns.
 If the patient is asleep the use of pulse oximetry to continuously monitor oxygen
saturation is recommended
 If the patient becomes unconscious or if there is an increase in NEWS score,
care should be escalated following the clinical response table in Appendix 1.
Refer to the Medical Emergency Flowchart (Appendix 2)

 Some observations may be difficult if a patient remains agitated or aggressive.

Problems in this regard should be clearly documented and discussed with the
prescriber or the clinical team
 For further information regarding this please see the Management of
Deteriorating Patient Policy
6.3 Remedial Measures

 Monitoring by nursing staff is necessary to ensure complications and side effects
are recognised
 The NEWS observation chart is to be completed following Rapid Tranquillisation
(appendix 1)
 Where possible, baseline measurements should be recorded.
 After any parenteral drug administration, you should monitor: temperature; pulse;
blood pressure, respiratory rate, level of consciousness, level of hydration and side
effects.
 Every 15 minutes for 1 hour and then half hourly until patient is ambulatory. Record
in notes.
 Patients who refuse to have their vital signs monitored or who remain too
behaviourally disturbed to be approached should have respiration and level of
consciousness recorded and refused documented for other vitals. Also be vigilant
for signs/symptoms of pyrexia, hypotension, over sedation and general physical
well-being.
 If the patient is asleep, the continuous use of pulse oximetry to measure oxygen
saturation is desirable. A nurse should remain with the patient until ambulatory
 Seek urgent medical advice if the patient deteriorates or is unconscious.
 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.
ECG monitoring is formally recommended for all patients receiving Haloperidol in
any formulation
 Please refer to table 3 on the following page for more guidance

6.4 Table 3: Managing the Complications and Side Effects of Medication
Complication Symptom Management

Muscle spasms especially in the head and neck
and can result in a forced sideways twisting of the Procyclidine 5-10mgs IM immediately
Acute
neck. Laryngeal spasm, which leads to difficulty in Repeat if necessary after 20 minutes
Dystonia /
swallowing and breathing. Oculogyric crisis is Max 20 mg in 24 hours
EPSE
forced movement of the eyes usually upwards (If not severe oral may be given)
which the patient can’t reverse
(>30 mmHg orthostatic drop or <50 mmHg
Fall in blood Give oxygen, lay patient flat, raise legs, and ensure patient is not lying
diastolic) characterised by light-headedness and
pressure face down monitor blood pressure
dizziness
Irregular or
Slow (<50/minute) or irregular pulse Refer to specialist medical care immediately
slow pulse
Check creatinine kinase urgently
Neuroleptic Malignant Syndrome (NMS) include
Increased Risk of NMS and perhaps arrhythmias – monitor closely, cool patient,
fever, rigidity, confusion, fluctuating consciousness,
temperature and refer to ITU if continued or any other signs of NMS
fluctuating blood pressure, and tachycardia
Withhold antipsychotics and seek urgent medical advice
Seek urgent medical advice
Reduced (< 10/minute)  Give oxygen, raise legs and ensure patient is not lying face down
respiratory or oxygen saturation (< 90%)  Nurses in BCPFT are not IV trained, so Flumazenil will need to be
rate (Respiratory depression) administered by a doctor
 If respiratory rate drops below 10/minute in a patient who has
(Flumazenil – to treat benzodiazepine induced received Benzodiazepines, give Flumazenil (Stock in the
respiratory depression – patients may become emergency cupboard at Penn Hospital and the ‘out of hours’
agitated, anxious or fearful on awakening. Seizures cupboard at Edward Street Hospital, Hallam Street Hospital and
may occur in regular benzodiazepine users) Heath Lane Hospital)
1. 200mcg I.V. over 15 seconds
2. If consciousness not resumed within 60 seconds give 100mcg
over 10 seconds
3. Repeat at 60 second intervals. Maximum dose 1mg/24 hours
 Continue to monitor after respiratory rate returns to normal
 Flumazenil has a short duration of action so further doses may be
required
 Do not use in pts with epilepsy on long term benzodiazepines
 Dose should be carefully titrated in hepatic impairment
 If induced by other agent – mechanical ventilation will be required
 Arrange transfer to ITU at Acute Hospital immediately

7.0 Algorithm 2: Rapid Tranquillisation of the Acutely Disturbed / Violent Patient - Adolescents Aged > 12y Years
Developed in consultation with BCPFT CAMHS Consultants
Consider de-escalation techniques

e.g. talking down, distractions, time out
No response
Oral p.r.n
Consult any Advance Decisions Lorazepam 1 to 2mg
Check Consent has been given or
Promethazine 12.5mg to 25mg
(Where the use of benzodiazepines is inappropriate)
And/or another from the list below

Olanzapine 5mg
Risperidone 0.25mg to 1mg
* Haloperidol 1 to 5mg and Promethazine 12.5-25mg
Try Oral Therapy (oral p.r.n) (if known to tolerate typical antipsychotics)
Use formulation most appropriate to patient

Patient refusing oral /

Rapid response required /
No response to oral Rapid Tranquillisation (IM)
Drug (IM)
Lorazepam 500 micrograms to 1mg
or
Promethazine 25-50mg
(Where the use of benzodiazepines is inappropriate)
/or
* Haloperidol 1 to 5mg and Promethazine 12.5-25mg
(if known to tolerate typical antipsychotics, however avoid if antipsychotics are co-administered)
Try intramuscular injection (RT)
Monitor Patient
Never mix two drugs in the same syringe.
Always dilute lorazepam injection before use
No response within 30 minutes
Review
ALLOW AT LEAST 30 MINUTES FOR I/M LORAZEPAM TO WORK.

If ineffective, repeat at same doses and allow a further 30 mins for effect.
Complex case – seek specialist advice from consultant for further options

7.1 Notes for prescribing Rapid Tranquillisation / oral p.r.n for adolescents
Evidence
 The best evidence for benefit over risk of harm is for IM lorazepam used alone and the
combination of IM haloperidol plus an IM promethazine.
 When IM haloperidol is combined with IM promethazine there is some suggestion that
risk of movement-related side effects may be reduced.
 In contrast, the combination of an IM benzodiazepine plus IM haloperidol does not
appear to be more effective than an IM lorazepam used alone.
 While IM haloperidol used alone is more effective than placebo, it clearly carries greater
risk of extrapyramidal and other side effects when compared with placebo or an IM
lorazepam.
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.
 Ensure procyclidine injection is available. Antipsychotics may cause acute dystonic

reaction/EPSE.
 Ensure flumazenil IV injection is available to reverse effects of lorazepam injection.
 The maximum daily dose of haloperidol is either 10mg orally or 5mg by IM injection.
 In adolescents, older than 12 years of age the recommended dose of promethazine 10-
25mg (max 50mg/day).
 There is a higher incidence of paradoxical disinhibition with benzodiazepines compared to
adults.
 Caution if using haloperidol if young person is unknown to services, or antipsychotic naive
adolescent, as EPSE may be more common than in adults. Baseline ECG is strongly
recommended.
In young people who are not Gillick competent, parents/carers should be informed of the
situation and consent sought for such treatment. It is good practice to inform both the young
person and their parents/carers.
The use of many of these medicines in under 18 years is outside of their UK license and is
therefore ‘off’ label prescribing. As such the prescriber responsibility and potential liability are
increased. The young person and their patient/carer should be informed of the ‘off label’ use of
medicines, and this should be documented in the patient’s notes. Refer to the trusts Unlicensed
Medicines Policy.
8.0 Documentation
Record any incident requiring rapid tranquillisation:
 Documenting all care or treatment given clearly in the patients records and DATIX
 Rapid tranquillisation physical observation chart is to be used to monitor vital signs
 Where an incident has required the use of a physical intervention, a physical
intervention monitoring form should be completed
 Where an incident has required the use of seclusion, a seclusion monitoring form
should be completed

9.0 Post Incident Support and Debrief

Following the use of RT, a debrief should be completed soon afterwards.
Patients should be offered the opportunity to discuss their experiences to reduce the
incidence and severity of trauma. The patient should be provided with a clear explanation
of; the decision to use RT, the medication and its effects and a discussion of their
experiences. The patient’s care plan should acknowledge his/her preferences and wishes
should they become behaviourally disturbed again. The patient should also be offered
the opportunity to write about their experience and be supported to do this. Where the
patient would like the involvement of an independent body the nurse in-charge should
ensure that advocacy services are contacted.
A post-incident staff debrief should take place immediately or as soon as possible and at
least within 72 hours of an episode of RT. A person not directly involved in the incident
(such as staff from a different ward) should ideally lead the debrief, which should include
a minimum of a nurse and a doctor. This meeting should be used to ensure that the
appropriate documentation has been completed and to identify and address physical
harm to patients or staff, ongoing risks and the emotional impact on patients and staff,
including witnesses, with issues relating to the use of RT discussed and lessons
incorporated into practice. Prescriptions for RT should be reviewed by the
multidisciplinary team and, especially if used repeatedly, with appropriate changes made
to regularly prescribed medication.
10.0 Procedures connected to this Policy

There are no procedures connected to this policy.
11.0 Links to Relevant Legislation
Mental Health Act 1983

The Mental Health Act 1983 (which was substantially amended in 2007) is the law in
England and Wales that allows people with a ‘mental disorder’ to be admitted to hospital,
detained and treated without their consent – either for their own health and safety, or for
the protection of other people.
Mental Capacity Act 2005

Mental Capacity Act 2005, covering England and Wales, provides a statutory framework
for people who lack capacity to make decisions for themselves, or who have capacity and
want to make preparations for a time when they may lack capacity in the future. The Act
sets out who can take decisions, in which situations, and how they should go about this.
In addition - in some cases, people lack the capacity to consent to particular treatment or
care that is recognised by others as being in their best interests, or which will protect
them from harm. Where this care might involve depriving adults at risk of their liberty in
either a hospital or a care home, extra safeguards have been introduced in law –
Deprivation of Liberty Safeguards, to protect their rights and ensure that the care or
treatment they receive is in their best interests.
11.1 Links to Relevant National Standards
Nice Guidelines Violence and Aggression NG10 (2015)

This guideline has been developed to advise on the short-term management of violence
and aggression in mental health, health and community settings in adults, children (aged
12 years or under) and young people (aged 13 to 17 years). This guideline updates and
replaces NICE guideline CG25 (published February 2005).

Nice Guidelines Psychosis and Schizophrenia CG178 (2014)

This guideline has been developed to advise on the treatment and management of
psychosis and schizophrenia in adults. The guideline recommendations have been
developed by a multidisciplinary team of healthcare professionals, people with
psychosis and schizophrenia, their carers and guideline methodologists after careful
consideration of the best available evidence. It is intended that the guideline will be
useful to clinicians and service commissioners in providing and planning high quality
care for people with psychosis and schizophrenia while also emphasising the
importance of the experience of care for people with psychosis and schizophrenia
and their carers
Nice Guidelines Bipolar Disorder CG185 (2014)

This guideline, which updates the 2006 National Institute for Health and Care Excellence
(NICE) guideline (NCCMH, 2006; NICE, 2006), has been developed to
advise on the assessment and management of bipolar disorder in adults, children
(aged under 13 years) and young people (aged 13 to 18 years) in primary and
secondary care. It applies to people with bipolar I, bipolar II, mixed affective and
rapid cycling disorders. Non-bipolar affective disorders are not covered because
these are addressed by other guidelines.
11.2 Links to other key policies
Management of the Deteriorating Patient Policy

The purpose of this policy is to ensure that clinical staffs working within the trust have a
standardised approach to recognising changes in the patient’s normal physiology and
responding quickly by alerting experienced help.
Prevention and Management of Violence and Aggression including NHS sanctions

The purpose of this policy is to detail the Trust’s strategy and legislative compliance in
tackling violence and aggression against patients and staff.
Seclusion Policy
The purpose of this policy is to ensure that employees of the Trust have clear
Directions related to the use of seclusion. The policy will also ensure that staffs work
within the Mental Health Act 1983 Code of Practice.
Clinical Observation Policy

The purpose of this policy is to make clear the arrangements in place for the observation
of patients and to provide direction and guidance to clinical staff in order to ensure safe
levels of observation in clinical areas.

12.0 Best Practice - Dissemination, Implementation and Monitoring of NICE Quality Standards and Guidance
The purpose of these guidelines is to provide a clear process for responding effectively to the publication of NICE quality standards and national
guidance, to ensure current practice reflects the best possible evidence and it is both clinically and cost effective.
13.0 References
 Care Quality Commission Brief Guide BG040: Rapid Tranquillisation (by the parenteral route) in Mental Health March 2018
 Patel M, Sethi F et al. Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: De-
escalation and rapid tranquillisation. 2018. Journal of Psychopharmacology,1-40.
 European Medicines Agency. 28th April 2017. Questions and answers on Haldol and associated names (haloperidol, oral solutions and
injectable solution). Outcome of a procedure under Article 30 of Directive 2001/83/EC.
 Mental Health Policy Implementation Guide: Developing Positive Practice to Support the Safe and Therapeutic Management of Aggression
and Violence in Mental Health In-Patient Settings Department of Health (2004)
 Taylor D, Barnes T, Young A. The Maudsley Prescribing Guidelines in Psychiatry. 13th Edition. 2018. Wiley-Blackwell.
 British National Formulary. Accessed via https://www.medicinescomplete.com on 1st Sept 2018.
 Mental Health Act Manual, 8th edition. Jones R. (2003)
 Good Practice Guide for the management of Violence. Royal College of Psychiatrists. Maden & Ashead (2006)
 Mental Health Act (1983) Code of Practice (1999)
 Nice Guidelines Violence and Aggression: Short-Term Management in Mental health, Health and Community Settings NG10 (2015)
 Nice Guidelines Psychosis and Schizophrenia in Adults: Treatment and Management CG178 (2014)
 Nice Guidelines Bipolar Disorder: The Assessment and Management of Bipolar Disorder in Adults, Children and Young People in Primary and
Secondary Care CG185 (2014)
 National Early Warning Score (2012) – Royal College of Physicians
 BSMHFT Rapid Tranquillisation Policy V10 2017
 Sussex Partnership NHS Foundation Trust The Rapid Tranquillization Policy. (including the use of oral PRN medication) 2016

14.0 Roles and Responsibilities for this Policy
Title Role Responsibilities

- Ensure the Trust’s management and use of rapid tranquillisation is discharged appropriately and has lead responsibility for
Executive Director of
the implementation of this policy
Nursing, AHPs and Executive Lead
- Ensure a systematic and consistent approach to the use of rapid tranquillisation within inpatient areas
Governance
- Bring any serious concerns regarding the implementation of this policy to the attention of the Board
- Strategic overview and final responsibility for overseeing the use of rapid tranquillisation within inpatient areas across the
Trust Board Strategic
Trust
- Responsible for ensuring that the use of rapid tranquillisation is managed efficiently and effectively in accordance with the
Executive Committee Accountable
Board’s Assurance Framework and strategic priorities
Quality & Safety - Responsible for overseeing the implementation of a systematic and consistent approach to the use of rapid tranquillisation
Responsible
Steering Group - Provide exception and progress reports to the Executive Committee
- Responsible for the use of rapid tranquillisation within their Group
- Lead discussions on the use of rapid tranquillisation at Group Quality & Safety Steering Group meetings
Clinical Directors Lead
- Oversee the completion of audits and subsequent action plans in respect of rapid tranquillisation
- Provide updates on the use of rapid tranquillisation within their Group to the Quality & Safety Steering Group
- Responsible for monitoring the use of rapid tranquillisation within their Group
- Ensure all incidents of rapid tranquillisation are reported via Datix, the trust’s incident reporting procedure
Group Quality &safety - Monitor use of rapid tranquillisation on a case by case basis within each Group
Implementation
steering groups - Report and discuss all incidents at monthly meetings of each Quality & Safety Steering Group
- Receive results and recommendations of all related clinical audits
- Responsible for monitoring action plans to implement changes to current practice until completion
Medicines Management Scrutiny and - Monitor the frequency and any trends regarding the use of rapid tranquillisation and liaising with Group Quality & Safety
Committee Performance Steering Groups
- Responsible for monitoring the safe and appropriate prescribing of medication

Pharmacy Staff Monitor
- Responsible for ensuring that all managers are aware of the policy and promote good practice
Group Directors and
Operational Lead - Provide support and guidance regarding resources to enable this policy to be implemented
Group Managers
- Ensure nursing staff implement safe systems of work in accordance with the procedures referred to in the policy
- Ensure they are familiar with this policy and be responsible for adhering to the procedures referred to
- Ensure staff attend training applicable to their role and for implementing the guidance across their areas of responsibility
Service Managers and - Ensure aggressive/violent patients have primary and secondary behavioural management plans in place
Operational
Ward Managers - Ensure risk assessments of environmental health and safety factors that can reduce the likelihood of violence/aggression
are carried out and plans are put in place to minimise them
- Ensure all incidents of rapid tranquillisation are reported

Title Role Responsibilities

- Responsible for safe administration of prescribed rapid tranquillisation medication and subsequent observations
Nurses in Charge Operational
- Report incidents associated with the use of rapid tranquillisation
- Ensure they use de-escalation skills and promote the well-being and dignity of the patient at all times
- Ensure they are familiar with the policy and be responsible for adhering to the procedures referred to within the policy
- Ensure Advance Statements are considered and documented in CPA and Early Warning Signs care plans
- Provide support and information to patients and carers regarding the application of guidelines implemented to address
aggressive/violent incidents
Nursing Staff Adherence
- Undertake risk assessments with patients where there is deemed a potential for aggressive/violent behaviour
- Develop primary and secondary behavioural management plans
- Attend training applicable to their role
- Ensure they are aware of signs and symptoms of adverse reaction to medication to ensure patient safety is maintained
- Any delegated observation task remains the responsibility of the delegating nurse
- Adhere to the prescribing requirements identified in the guidelines and the actions to take in the event of an adverse drug
reaction
- Always refer to the most up to date British National Formulary (BNF) to check recommended drugs and dosage
- Consider any advanced directives
- Be available at the time of administration but no longer than 30 minutes after being requested
- Be available to administer Flumazenil if needed
Medical Staff Adherence
- Be part of a multi-disciplinary team (MDT), ensuring risk assessments are conducted with the patient where there is a
potential for aggressive/violent behaviour
- Support the implementation and monitoring of this policy
- Be aware of any previous adverse reactions to medication
- Advise on the levels of scheduled observation and engagement levels required following rapid tranquillisation
Practice Development
- Responsible for collating monthly incidents of the use of rapid tranquillisation and feeding back to service leads
Team

15.0 Training
What aspect(s) Is this training covered in the
Which staff groups Trust’s Mandatory and Risk How often will Who will ensure and
of this policy will If no, how will the Who will deliver the
require this Management Training Needs staff require monitor that staff have
require staff training be delivered? training?
training? Analysis document? training this training?
training?
Rapid All inpatient Yes Learning and Annually Workforce Development
Tranquillisation qualified nurses Development Team Group
and Healthcare
Support Workers in
MH and LD
Observation of Inpatient Nurses Yes Learning and 3 yearly Workforce Development
patients and Development Team Group
Healthcare Support
Workers
Medicines Inpatient Nurses & Yes Learning and 2 yearly Workforce Development
Management Medical Development Team Group
staff
16.0 Equality Impact Assessment The following statement should always be included
Black Country Partnership NHS Foundation Trust is committed to ensuring that the way we provide services and the way we recruit and treat staff
reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group. The Equality Impact
Assessment for this policy has been completed and is readily available on the Intranet. If you require this in a different format e.g. larger print,
Braille, different languages or audio tape, please contact the Equality & Diversity Team on Ext. 8067 or email
bcpft.equalityimpactassessment@nhs.net
17.0 Data Protection and Freedom of Information

Data Protection Act provides controls for the way information is handled and to gives legal rights to individuals in relation to the use of their data. It
sets out strict rules for people who use or store data about individuals and gives rights to those people whose data has been collected. The law
applies to all personal data held including electronic and manual records. The Information Commissioner’s Office has powers to enforce the Data
Protection Act and can do this through the use of compulsory audits, warrants, notices and monetary penalties which can be up to €20million or 4%
of the Trusts annual turnover for serious breaches of the Data Protection Act. In addition to this the Information Commissioner can limit or stop data
processing activities where there has been a serious breach of the Act and there remains a risk to the data.

The Freedom of Information Act provides public access to information held by public authorities. The main principle behind freedom of information
legislation is that people have a right to know about the activities of public authorities; unless there is a good reason for them not to. The Freedom of
Information Act applies to corporate data and personal data generally cannot be released under this Act.
All staffs have a responsibility to ensure that they do not disclose information about the Trust’s activities; this includes information about service
users in its care, staff members and corporate documentation to unauthorised individuals. This responsibility applies whether you are currently
employed or after your employment ends and in certain aspects of your personal life e.g. use of social networking sites etc. The Trust seeks to
ensure a high level of transparency in all its business activities but reserves the right not to disclose information where relevant legislation applies.
The Information Governance Team provides a central point for release of information under Data Protection and Freedom of Information following
formal requests for information; any queries about the disclosure of information can be forwarded to the Information Governance Team.
18.0 Monitoring this policy is working in practice
Group/Committe
What key elements will be Where How will they be Who will Group/Committee
How e to ensure Evidence this
monitored? described in monitored? undertake this that will receive and
Frequently? actions are has happened
(measurable policy objectives) policy? (method + sample size) monitoring? review results
completed
Rapid Tranquillisation is used 4.0 Process New NICE or national Quality & Safety Monthly Group Quality & Group Quality & Reports and
in line with national guidance guidance/legislation, Steering Group Safety Steering Safety Steering minutes of the
and to meet our legal reports of best practice or Groups Groups meetings
obligations recommendations from an
external agency in respect
of rapid tranquillisation will
be identified and
implemented in accordance
with the Trust’s Best
Practice NICE and Dealing
with External
Recommendations policies
Clinical Directors, Group 7.0 Roles and Monitoring of all incidents Quality & Safety Monthly Group Quality & Group Quality & Minutes of
Quality & Safety Steering Responsibiliti of rapid tranquillisation Steering Group Safety Steering Safety Steering meetings and
Groups, nursing and medical es for this Groups Groups monitoring
staff are discharging their Policy templates
responsibilities for rapid
Tranquillisation
Group Annual Audit Quality & Safety Annually Group Quality & Group Quality & Minutes of
Programmes and the Steering Group Safety Steering Safety Steering meetings and
implementation of action Groups Groups monitoring
plans templates

Group/Committe
What key elements will be Where How will they be Who will Group/Committee
How e to ensure Evidence this
monitored? described in monitored? undertake this that will receive and
Frequently? actions are has happened
(measurable policy objectives) policy? (method + sample size) monitoring? review results
completed
Prescribing guidelines for 4.4 All incidents of rapid Group Pharmacist Monthly Medicines Medicines Reports and
rapid Tranquillisation Prescribing tranquillisation must be monitors the Management Management minutes of the
Guidelines reported via Datix, the medication used Committee Committee meetings
trust’s incident reporting for Rapid
procedure Tranquillisation on
a case by case
basis within each
Group
How observations are 4.6 A detailed review of Quality & Safety Monthly Group Quality & Quality & Safety Sign off of
recorded, including Observations practice will be audited Steering Group Safety Steering Steering Group action
timeframes when patients 4.7 Remedial Group and Medicines plans/minutes
have received rapid Measures Management of meetings
Tranquillisation Appendix 1 Committee
NEWS
Observation
Chart
Arrangements for monitoring 4.6 A detailed review of Quality & Safety Monthly Group Quality & Quality & Safety Sign off of
service users who have Observations practice will be audited Steering Group Safety Steering Steering Group action plans/
received rapid 4.7 Remedial Group and Medicines minutes of
tranquillisation Measures Management meetings
Appendix 1 Committee
NEWS
Observation
Chart
How the organisation trains 8.0 Training Report on percentage of Workforce Quarterly Group Management Group Reports and
staff, in line with the training staff trained in all Development Boards for Group Management minutes of the
needs analysis mandatory topics Group compliance and Boards for Group meetings
Workforce compliance and
Development Group Workforce
for Trust compliance Development
Group for Trust
compliance
8.0 Training Reports on identified ward/ Workforce Quarterly Group Management Group Reports and
departmental compliance, Development Boards for Group Management minutes of the
where performance falls Group compliance and Boards meetings
below 95% compliance Workforce
Development Group
for Trust compliance

Appendix 1
Based on the observation chart for the National Early Warning Score (NEWS)
RAPID TRANQUILLISATION PHYSICAL OBSERVATION CHART
Patient name Ward Date of birth
DATE Time monitoring initiated: Time monitoring stopped:
TIME(24 hour)
Observations (minutes) 0 15 30 45 60 90 120 150 180 210 240 270 300 NEWS
c
≥39 2
38.1-39. cc 1
TEMP
TEMP
36.1 - 38 c
35.1 - 36 1
≤35 c 3
≥220 3 3
211-219
201-210
191-200
BLOOD PRESSURE (SYSTOLIC)

BLOOD PRESSURE (SYSTOLIC)
181-190
171-180
161-170
151-160
141-150
131-140
CONTINUE TO MONITOR UNTIL AMBULATORY
121-130
111-120
101-110 1 1
91-100 2 2
81-90 3 3
71-80 3 3
61-70 3 3
51-60 3 3
≤50 3 3
≥131 3
121-130 2
111-120 2
101-110 1
91-100 1
PULSE
PULSE
81-90
71-80
61-70
51-60
41-50 1
≤40 3
≥ 25 3
RESP RATE
RESP 21-24 2
RATE 12-20
9-11 1
≤8 3
≥96
94-95 1
SpO2 92-93 2
≤91 3
Inspired O2 %
Oxygen Saturation Oxygen
Conscious Level = Alert Saturation
Conscious
V/P/U=3 Level
V/P/U=3
Hydrated (Y/N) Hydrated
TOTAL NEW SCORE TOTAL
Escalation plan Y / N / n/a NEWS
Escalation
Sign/Initials plan
Sign/Initials
Note: Where observations are Refused, record as ‘R’

The National Early Warning Score (NEWS) and Triggers
Scores
Clinical Risk
Low
Aggregate 1 – 4
RED score*
(Individual parameter
scoring 3) Medium
Aggregate 5 – 6
Aggregate 7
or more High

Outline Clinical Response to NEWS Triggers
NEWS FREQUENCY OF CLINICAL RESPONSE

SCORE MONITORING
0 Minimum 12 hourly  Continue routine NEWS monitoring with every
set of observations
 Inform registered nurse who must assess the
Total: patient
1-4 Minimum 4-6 hourly
 Registered nurse to decide if increased
frequency of monitoring and / or escalation of
clinical care is required
 Registered nurse to urgently inform the medical
Total: team caring for the patient; (within 1hour)
5 or more Increased frequency
or to a minimum  Urgent assessment by a clinician with core
3 in one of 1 hourly competencies to assess acutely ill patients
parameter
 Clinical care in an environment with monitoring
facilities; Consider transfer to acute hospital
 Registered nurse to immediately inform the

Total: medical team caring for the patient – this
7 Continuous monitoring of should be at least at Specialist Registrar level;
or more vital signs
A HIGH NEWS SCORE OF 7 OR MORE
REQUIRES URGENT TRANSFER TO AN
ACUTE HOSPITAL (9-999)

CLINICAL PRACTICE STANDARDS: Rapid Tranquillisation (RT) Checklist

(Based on POMH audit)
Checklist Questions Yes No Sign Date Comments
Has oral medication been offered before

administering IM medication for behavioural
disturbance?
Has physical monitoring post RT been recorded

adequately on the physical observation chart?
Has a debrief been completed promptly post RT?

This as a minimum should include a nurse and a
doctor and address physical harms to patients or
staff, ongoing risks and the emotional impact on
patients and staff, including witnesses.
Has the patient’s written care plan addressed the

management of future episodes of disturbed
behaviour.
This should be completed within a week.
Has the patient’s care plan acknowledged his/her

preferences and wishes should they become
behaviourally disturbed again?
This should be completed within a week
If Haloperidol has been used as part of RT, has a QTc =______ms

recent ECG been completed. Date of ECG:________

Appendix 2
MEDICAL EMERGENCY
NURSE DISCOVERING EMERGENCY

TO SHOUT FOR HELP/ACTIVATE
ALARM
ASSESS RESPONSE, AIRWAY

AND BREATHING
BREATHING?
YES NO
GIVE 100% OXYGEN VIA NON RE-

START 30 CHEST
BREATHE O₂ MASK. USING
COMPRESSIONS
ABCDE APPROACH RECORD FOLLOWED BY 2
OBSERVATIONS RECORD NEWS RESCUE BREATHS
SCORE
1 MEMBER OF STAFF TO CALL 9-999

CALL 1 MEMBER OF STAFF TO COLLECT
MEDICAL STAFF EMERGENCY BAG AND SUCTION UNIT
IMMEDIATELY
TREATMENT AMBULANCE ILS TRAINED MEMBER OF

GIVEN REQUIRED STAFF TO LEAD TEAM
CALL 9-999
ARRIVAL OF
AMBULANCE
LEAD NURSE TO
HANDOVER TO
AMBULANCE CREW
POST INCIDENT
 CLEAN AREA, REPLENISH EMERGENCY BAG
 COMPLETE DATIX AND MED EMERGENCY FORM
 DEBRIEF STAFF (Resus Officer to attend debrief)
Policy Details
Corporate Governance only
Title of Policy Rapid Tranquillisation Policy
Unique Identifier for this policy BCPFT-CB-POL-09
State if policy is New or Revised Revised
Previous Policy Title where applicable N/A

Policy Category
Challenging Behaviour Policy
Clinical, HR, H&S, Infection Control etc.
Executive Director Executive Director of Nursing, AHPs and
whose portfolio this policy comes under Governance
Policy Lead/Author
Deputy Chief Pharmacist / Chief Pharmacist
Job titles only
Committee/Group responsible for the
Medicines Management Committee
approval of this policy
Month/year consultation process
n/a
completed *
Month/year policy approved January 2019
Month/year policy ratified and issued March 2019
Next review date January 2022
Implementation Plan completed * Yes
Equality Impact Assessment completed * Yes
Previous version(s) archived * Yes
Disclosure status ‘B’ can be disclosed to patients and the public

‘National Early Warning Score’, ‘NEWS’,
‘Lorazepam’, ‘Haloperidol’, ‘Olanzapine’,
Key Words for this policy ‘Promethazine’, ‘Zuclopenthixol Acetate’, ‘Oral’,
‘IM’, ‘advance statement’, ‘seclusion’, ‘light
sedation’
* For more information on the consultation process, implementation plan, equality impact
assessment, or archiving arrangements, please contact Corporate Governance
Review and Amendment History

Version Date Details of Change
Reviewed in light of CQC guidance BG040; Update to physical monitoring
V2.0 Jan 2019
proforma
New policy format and minor amendments- maximum daily doses for
Aug 2015 Haloperidol (oral and IM) amended and National Early warning scoring
V1.1
system added
V1.0 Nov 2012 Alignment of policies following TCS

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Rapid Tranquillisation

Who Should Read This Policy

All Inpatient Staff    

Version 2 June 2018

Ref. Contents Page

Explanation of terms used in this policy 4

Version 2.0 January 2019 2

6.0 Risks and Complications associated with Rapid Tranquillisation 24

Version 2.0 January 2019 3

Explanation of terms used in this policy

Calming - reduction of anxiety

Version 2.0 January 2019 4

Black Country Partnership NHS Foundation Trust recognises that it is sometimes

It is accepted that certain situations may arise in psychiatric in-patient environments or

1.1 Rapid Tranquillisation Definition

Version 2.0 January 2019 5

4.0 Principles and Practice of Rapid Tranquillisation (RT)

4.1 De-escalation Techniques

 Maintain adequate distance.

4.2 Choice of Intervention

Version 2.0 January 2019 6

4.3 Use of oral p.r.n medication

When prescribing oral p.r.n. medication as part of a strategy to de-escalate or prevent

4.4 Rapid Tranquillisation and Physical Intervention

Version 2.0 January 2019 7

4.5 Rapid Tranquillisation and Seclusion

4.6 Care Planning/Reviews

Version 2.0 January 2019 8

4.7 Risk Assessment

4.8 Advance Statements

4.9 Legal Issues and the Mental Health Act (MHA)

The enforced administration of medication by injection to an informal patient may

4.10 Physical monitoring/review of history Before Rapid Tranquillisation (RT)

Version 2.0 January 2019 9

5.0 Rapid Tranquillisation

5.1 Medical Staff Availability

5.2 Medical Equipment

5.3 Rapid Tranquillisation treatment aims

 To reduce suffering for the patient: psychological or physical (through self-harm or

Version 2.0 January 2019 10

5.4 Rapid Tranquillisation Prescribing

RT as parenteral injection (usually IM) should only be considered when de-escalation

5.4.2 Do not prescribe RT medication routinely or automatically on admission on the when

 the service user's preferences or advance statements and decisions

Version 2.0 January 2019 11

5.5 Choice of Medication in Rapid Tranquillisation

NICE NG10 states the following;

 Use either IM lorazepam on its own or IM haloperidol combined with intramuscular

Alternatives which may be considered are;

 Aripiprazole IM (alone or in combination with Lorazepam IM). Although not

 Olanzapine IM alone. Not considered by NICE NG10 because the manufacturer of

Version 2.0 January 2019 12

- Have access to procyclidine injection for acute dystonic

WORKING AGE ADULTS OLDER ADULTS

Patient refusing oral /

*Note ECG requirements

Version 2.0 January 2019 13

2 ORAL p.r.n medication.

LORAZEPAM oral 1-2mg

QUETIAPINE oral 25-50MG

Version 2.0 January 2019 14

Promethazine may be used as an alternative and is a useful option in a

Usual dose 9.75mg.

Avoid using Haloperidol in Antipsychotic naïve patients. Maudsley suggests that