Agitation and rapid-tranquilisation

Question 1

What are some warning signs that a patient may become violent?

Answer 1

Verbal warnings

• Direct threats: take these seriously
• Abuse: swearing or insults
• Tone: angry, sarcastic, threatening, or rude
• Volume: shouting or prolonged silence

Physical warnings:

• Prolonged staring/narrowed eyes/angry frown/dilated pupils
• Fast breathing/sweating/facial reddening or blanching
• Gritting teeth/clenching fists/trembling/agitation
• Leaning over you
• Pacing (don’t let people walk behind you)
• Violent gestures, e.g. pounding the table.

Question 2

What are some de-escalation strategies that can be used if a patient becomes aggressive? What should not be done?

Answer 2

De-escalation and escape - while exiting or resolving mild hostility..
DO

• Keep your tone and body language calm—no sudden movements.
• Give your patient space.
• Apologize if you’ve upset them.
• Empathize and feed back their feelings, e.g. ‘It’s frustrating for you’.
• Tell them that they are frightening you.
• Back out. Never turn your back on someone who threatens you.
• Tell staff immediately.

DON’T

• Say, ‘Calm down’. This implies that you think they are unreasonably angry; it is inflammatory.
• Touch them.
• Make jokes.
• Stand to ‘match’ a patient who stands; stay seated or back out. If currently standing, don’t stand face to face
• or put your hands on your hips. Standing to their side, shoulder-on, is less confrontational and makes you a
• smaller target.

Question 3

List the causes of agitation in hospital patients.

Answer 3

Question 4

What are some risk factors for violence in an inpatient setting regarding the patient?

Answer 4

• Being young
• History of violence
• Being compulsorily admitted
• Co-morbid substance misuse
• Being in the acute phase of the illness

Question 5

What are some risk factors for violence in an inpatient setting in relation to the environment?

Answer 5

• Lack of structured activity
• High use of temporary staff
• Low levels of staff-patient interaction
• Poor staffing levels
• Poorly defined staffing roles
• Unpredictable ward programmes
• Lack of privacy
• Overcrowding
• Poor physical facilities
• Availability of weapons

Question 6

Define rapid tranquilisation.

Answer 6

Use of medication by the parenteral route (usually IM) if oral medication is not possible or appropriate and urgent sedation with medication is needed.

Question 7

Define de-escalation.

Answer 7

The use of techniques (including verbal and non-verbal communication skills) aimed at defusing anger and averting aggression

PRN medication can be used as part of a de-escalation strategy but PRN medication used alone is not de-escalation.

Question 8

What patient risk factors must be considered before administering RT?

Answer 8

• Total dose of daily medication prescribed/administered
• PMH
• Pregnancy
• Cardiac problems, prolonged QTc

Question 9

Summarise the protocol for rapid tranquilisation.

Answer 9

Question 10

If there is no response to lorazepam after 1 hour, what combination of drugs can be tried for RT?

Answer 10

Consider another dose lorazepam 1mg

Then consider: IM promethazine 25mg to 50mg + haloperidol IM 2 to 5 mg

Then if no response: senior help (pharmacist and consultant)

Question 11

What should be done before haloperidol is used as RT?

Answer 11

Baseline ECG should be done before giving IM haloperidol

Question 12

What should be monitored during RT and how often?

Answer 12

Response should be monitored within 1 hour.

Also monitor:

• HR
• BP
• RR
• consciousness
• temperature
• level of hydration

Intervals determined by senior doctors. If there are preexisting health problems of if maximum dose has been reached then monitor often e.g. every 15 min. This should be documented on NEWS2 chart. If monitoring of sats not possible then do ABCDE assessments.

Question 13

What is the treatment of a patient whose RR drops below 10breaths/min after rapid tranquilisation?

Answer 13

If the patient’s respiratory rate drops below 10/min due to benzodiazepine administration staff should call an ambulance immediately and unless contra indicated Flumazenil IV needs to be administered.

Question 14

What is the maxmimum lorazepam IM dose in 24 hours?

Answer 14

1-2mg given per dose and can be repeated after 1 hour

Up to 4mg in 24 hours

Question 15

What is the maximum dose of IM haloperidol that can be given over 24 hours?

Answer 15

2-5mg per dose

Dose can be repeated after 2 hours

Max dose 12mg in 24 hours

Question 16

When should haloperidol be avoided in RT?

Answer 16

1. If no ECG
2. If there is evidence of QTc prolongation, cardiovascular disease, electrolyte abnormalities
3. The patient is known to be prescribed other medications that can cause QTc prolongation

Intramuscular lorazepam used instead

Question 17

What is the maximum dose of IM promethazine that can be given over 24 hours?

Answer 17

25-50mg per dose

Dose can be repeated after 2 hours

Max dose 100mg in 24 hours

Question 18

Which antipsychotic can be used instead of haloperidol in RT where there is cardiovascular disease?

Answer 18

Olanzapine 5-10mg (max 20mg/24hrs)

Question 19

In what groups should lower doses be used for RT?

Answer 19

Elderly: when urgent sedation is required to prevent injury or harm consider:

• 1st line - Lorazepam 500micrograms to 1mg IM, not more frequently than every 1 hours (maximum 2 mg in 24 hours).
• 2nd line - Promethazine IM 12.5mg plus haloperidol IM 500micrgrams to - 1mg. Repeat if necessary no more frequently than every 2 hours (promethazine maximum 50mg in 24 hours. Haloperidol maximum 5mg in 24 hours).

NB: antipsychotics should be used with caution in dementia and increase the risk of stroke.

Intellectual disability: Disinhibition is more likely to occur in organic brain disease. Always consider non-pharmacological treatments first:

• 1st line - Lorazepam 500micrograms to 1mg IM, repeated not more frequently than every 1 hours (maximum 2 mg in 24 hours).
• 2nd line - Promethazine IM 12.5mg plus haloperidol IM 3-5mg. Repeat no more frequently than every 2 hours (promethazine maximum 50mg in 24 hours. Haloperidol maximum 12mg in 24 hours).

Question 20

What are the SE of promethazine (especially in the elderly)?

Answer 20

Promethazine has anticholinergic effect such as:

• dry mouth,
• blurred vision,
• urinary retention
• constipation

Question 21

What is acuphase and when is it used?

Answer 21

Clopixol Acuphase® is licensed for “the initial treatment of acute psychoses including mania and exacerbation of chronic psychoses, particularly where rapid onset of action*, and duration of effect of 2-3 days is desirable”

NB: onset of action is not actually rapid and usually takes ~8-36hrs

Question 22

Define chemical restraint.

Answer 22

The use of medication which is prescribed, and administered (whether orally or by injection) for the purpose of controlling or subduing disturbed/violent behaviour, where it is not prescribed for the treatment of a formally identified physical or mental illness.

Question 23

Define seclusion.

Answer 23

The supervised confinement and isolation of a patient, away from other patients, in an area from which the patient is prevented from leaving, where it is of immediate necessity for the purpose of the containment of severe behavioural disturbance which is likely to cause harm to others.

Question 24

What are the principles of seclusion?

Answer 24

Can be:

• Short-term or long term segregation
• Locked or unlocked
• Patient is 1:1 when in seclusion room with 15 min obs
• Regular reviews – by nurses and medics
• Aim shortest time possible.

Question 25

What techniques are used for agitation in PICU?

Answer 25

• Rapid tranquilisation
• Acuphase - if rapid tranqilisation doesn’t work
• Physical restraint
• Seclusion

Question 26

Summary from PICU lecture: