Rapid Tranquillisation

1. Rapid Tranquillisation Best practice with medicines Carol Paton

2. RT is �the use of medication to control acutely disturbed behaviour� Aims To prevent harm to self To prevent harm to others To do no harm NOT to sedate into unconsciousness

3. RT is not first line De-escalation Time out Placement (eg PICU) Restraint Seclusion

4. RT is viewed by patients as: An over-reaction Controlling/coercive Traumatic Degrading Punitive Nurses are always more positive re benefits Haglund et al. J Psych Ment Health Nursing 2003,10;65-72 Greenberg et al. Bull Am Acad Psychiatry Law 1996,24;513-524

5. The evidence base�� �������..�..underpinning RT is poor. Patients are too unwell to consent to participate in RCTs. Data for mildly/moderately disturbed patients may not be directly applicable

6. Antipsychotics Oral antipsychotics effective if patient willing to take (risperidone, quetiapine, olanzapine, haloperidol). Haloperidol IM is proven effective (with promethazine) in severe disturbance (TREC). Olanzapine IM is proven effective (alone) in moderate disturbance. TREC 1 BMJ 2003,327;708. TREC 2 BJPsych 2004,185;63-69

7. NICE Violence Guideline Strength of the evidence base Almost all �D� and �GPP� � very little higher �D� = � directly based on category IV evidence ( expert committee reports or opinions and/or clinical experience of respected authorities) or extrapolated from category I, II or III evidence �GPP� = Good Practice Points

8. NICE Violence Guideline Clear instructions IM haloperidol/lorazepam IM olanzapine for moderate disturbance Staff should be trained to ILS Monitoring post RT essential Use of pulse oximeters

9. NICE Violence Guideline Recommendations for pharmacological management Offer oral medication first If the parenteral route is necessary IM is safer than IV Oral and IM formulations are not bio-equivalent Oral and IM forms should be prescribed separately Sufficient time should be allowed for a response to occur before the dose is increased If maximum doses are exceeded monitoring must be increased Two meds from the same class should not be used Meds should not be mixed in the same syringe The parenteral route should be switched to the oral route as soon as possible

10. NICE Violence Guideline Options When the behavioural disturbance occurs in the context of psychosis, to achieve early onset of calming/sedation, or to keep the dose of antipsychotic to the minimum required, an oral antipsychotic combined with oral lorazepam should be considered initially* National Institute for Clinical Excellence. Violence: The short-term management of disturbed/violent behaviour in in-patient psychiatric settings and emergency departments. Clinical Guideline 25, February 2005 Early use of an antipsychotic may be doubly beneficial: antipsychotic or anti-manic effects may be seen in addition to the sedation due to a benzodiazepine alone

11. Antipsychotics as �PRN�

12. Why is this a problem?

13. THE EFFECT OF PRN ON HIGH DOSE PRESCRIBING 

14. PRN���������

15. Which drugs? Antipsychotics Benzodiazepines Antihistamines �Others�

16. Antipsychotics: side effects (1) Acute dystonia (10%) More at risk if: Young Male Neuroleptic naieve High potency drug given (eg HPD). Have procyclidine at hand

17. Antipsychotics; side effects (2) Akathisia (25%) A subjectively unpleasant state of inner restlessness where there is a strong desire or compulsion to move. Linked with impulsive aggression & self harm

18. Antipsychotics; side effects (3) Pseudoparkinsonism (20%) Tremor Slowed movement & thinking Tardive dyskinesia Variety of abnormal movements.

19. Antipsychotics; side effects (4) Oversedation Reduced respiratory rate/volume Hypotension Reflex tachycardia/bradycardia Cardiac arrhythmias (via prolonged QTc) NMS

20. QTc prolongation Increases time that ventricles are receptive to electrical stimulation. This increases the chance of response to extra/abnormal electrical signals. Results in torsades de pointes. Cause of sudden cardiac death.

21. Acutely disturbed patients�.. �����may be at increased risk of harm Adrenaline Electrolyte disturbances Illicit drugs

22. �Sudden death� 41 cases/year of sudden unexplained death in inpatient services* Most are male, have a diagnosis of psychosis and are prescribed antipsychotic drugs Detailed investigation of some cases found a lack of clinical protocols for Drugs used in RT Observation post RT Use of high dose antipsychotics *5 year report of the national confidential inquiry into suicide and homicide by people with mental illness

23. Benzodiazepines; side effects (1) Oversedation Reverse with flumazenil Disinhibition Extremes of age Head injury Impulse control problems �..are at more risk.

24. Antihistamines; side effects (1) Poorly documented Oversedation Antipsychotic side effects possible QTc prolongation possible

25. Others Paraldehyde Amytal

26. Maudsley Guidelines

27. Buccal midazolam Pilot work on the Tarn Midazolam is rapidly absorbed via the buccal mucosa Maintains dignity Early experience positive

28. What of street drugs? Dual diagnosis is common Knowledge base is poor Clinical intervention is often essential

29. Cannabis Often a complicating factor Induces CYP1A2 Sedative Weight gain Dose related tachycardia

30. Alcohol Hepatic damage possible Sedative Hypotensive Complicates overdoses

31. Cocaine Tachycardia Increased BP Arrhythmias Cerebral/cardiac ischaemia

32. If street drugs suspected Urine drug screen desirable Physical examination desirable Patient may be benzodiazepine tolerant

33. If we can�t do these things What do we think the patient may have taken? What pharmacological effects does that substance have? Is it essential to administer medication before we are sure? Is it possible that the patient has hepatic damage/other physical illness? Which drug would be safest?