Transcript Slide 1
Rapid Tranquillization Training Programme
(for medical and nursing staff)
Updated July 2011
Aims of RT Training Programme
To understand the basic principles of RT To review the medication used including drug selection, doses and routes To understand potential complications of RT (and solutions) To review patient monitoring requirements To review local policy & further information sources
Basic principles
Rapid tranquillization (RT) is the short term use of tranquillizing medication to control potentially destructive behaviour.
RT should only be considered once de escalation/other methods have failed.
RT is used to avoid prolonged physical intervention Tranquillization means calming without sedation (sedation is not the optimal result)
Basic principles continued
Aim is to safely and quickly calm the patient,
without
sedation to ↓ risk of imminent violence.
RT does not aim to treat the underlying cause of aggression or violence.
Underlying condition does not always predict the response to RT Physical health of patient and concurrent medication must be considered before using RT
Medication aims
Reduce suffering of patient, both psychological or physical (for example self harm) Reduce risk of harm to others (safe environment) To do no harm Document reason for prescribing RT & prescribing plan
Medication
Need to consider; Advance directives Contra-indications, warnings, precautions of individual drugs Co-existing medical illness/allergies (liver/renal/cardiac/seizures/pregnancy) Concurrent meds, alcohol, illicit drugs Previous exposure to neuroleptic drugs Previous response to RT
Medication continued
Need rapid onset of action Frequent small doses are safer and more effective than single large doses (but risk of accumulation) Always offer oral medication first Main groups used are antipsychotics and benzodiazepines (alone or in combinations)
Drug selection
Traditionally antipsychotics have been used for RT (now choice of 1 st generation or 2 nd generation) Antipsychotics are not used in RT for their antipsychotic action Benzodiazepines are commonly used (advantages over antipsychotics e.g. side-effects, toxicity) Combination therapy may give better results and often allows lower doses of each drug to be used Consider Mental Health Act (form T2/T3/section 62) Follow SPT policy
Rapid Tranquillization Policy (SPT)
Three separate flow charts (one for children and adolescents, working age, one for over 65yrs)
Step 1
- non pharmacological methods
Step 2
- oral treatment with lorazepam and/or olanzapine or haloperidol Oral can be repeated if ineffective after 45 minutes
Step 3
- I/M medication (baseline monitoring if possible) Patients over 65-use lower doses Consider co-existing medical illnesses No antipsychotics in dementia with Lewy bodies Caution olanzapine in dementia/vascular disease
Algorithm 1 - Children and Adolescents Algorithm 3.
Step 1 CAMHS NON-PHARMACOLOGICAL MEASURES
De -escalation, distraction, seclusion etc
-
Consult any Advance Directives Check Consent has been given
PSYCHOTIC ILLNESS
+/-
Step 2 Oral Treatment
(If oral is refused consider going to step 3) [a,b]
Olanzapine
<12 years: N/A >12 years: 5mg (Max. 20mg/day) `
Promethazine
<12 years: 5 -10mg (Max 25mg/day) >12 years: 10 -25mg (Max 50mg/day)
OR Lorazepam
<12 years: 0.5-1mg >12 years: 1 -2mg (Max. 4mg/day)
NON-PSYCHOTIC ILLNESS Lorazepam
<12 years: 0.5 -1mg >12 years: 1 -2mg (Max 4mg/day)
OR Promethazine
<12 years: 5 -10mg (Max 25mg/day) >12 years: 10 -25mg (Max 50mg/day)
Step 3 I/M Treatment
MONITOR PATIENT CLOSELY!
[c,d] - ALLOW AT LEAST 45 MINUTES FOR ORAL MEDICATION TO WORK - IF INEFFECTIVE, REPEAT ORAL MEDICATION AT SAME DOSES - ALLOW AT LEAST 45 MINUTES FOR REPEATED ORAL MEDICATION TO WORK Ensure baseline measurements are recorded where possible: TEMPERATURE, PULSE, BP, RESPIRATORY RATE before IM administration, and reapeat every 5 10 minutes for 1 hour, then half – hourly until patient is ambulatory. Use pulse oximetry if patient asleep or unconscious.
+/-
Olanz apine
<12 years: N/A [e,f] >12 years: 5mg (Max. 20mg/day)
Promethazine
[g] <12 years: 5 -10mg (Max 25mg/day) >12 years: 10 -25mg (Max 50mg/day)
OR Lorazepam
<12 years: 0.5-1mg >12 years: 1-2mg (Max. 4mg/day)
Lorazepam
<12 years: 0.5 -1mg >12 years: 1 -2mg (Max 4mg/day) [g]
OR Promethazine
<12 years: 5 -10mg (Max 25mg/day) >12 years: 10 -25mg (Max 50mg/day) 1.
ALLOW AT LEAST 30 MINUTES FOR I/M LORAZEPAM TO WORK.
MINUTES FOR EFFECT.
2.
IF INEFFECTIVE, REPEAT AT SAME DOSES AND ALLOW A FURTHER 30
Caution – See note [e].
DO NOT PROCEED FURTHER WITHOUT ADVICE FROM CONSULTANT IF INEFFECTIVE, SEEK SPECIALIST ADVICE FROM CONSULTANT
NB,Max doses stated are for [a-g] see notes.
Notes :
a.
Choice depends on current treatment. If patient b.
c.
d.
e.
f.
g.
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. For the majority of patients, best response will be with combination therapy.
Ensure procyclidine injection is available. Antipsychotic may cause acute dystonic reaction. As in (a), either antipsychotic or benzodiazepine may be used alone, but best results are likely with combination therapy.
Ensure flumazenil injection is available to reverse effects of lorazepam injection.
The maximum dose of olanzapine is 20mg/24 hours by any (combined) route(s) – this should not be exceeded without obtaining specialist advice – and not more than 3 I/M doses may be given in any 24-hour period.
Intramuscular olanzapine and intramuscular lorazepam must not be administered within 1 hour of each other.
Olanzapine IM needs to be diluted before administration in 2.1ml water for injection. It is stable for up to 1 hour after reconstitution. Lorazepam should be mixed 1:1 with water before injecting. The maximum dose of haloperidol is either 30mg orally or 18mg by intramuscular injection. Maximum doses will need to be adjusted if a combination of both routes is used.The bioavailable equivalence of haloperidol being approximately 10mg oral: 6mg intramuscular.
Notes:
a.
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. For the majority of patients, best response will be with combination therapy.
b.
Ensure procyclidine injection is available. Antipsychotic may cause acute dystonic reaction. As in (a), either antipsychotic or benzodiazepine may be used alone, but best results are likely with combination therapy.
c.
d.
e.
Ensure flumazenil injection is available to reverse effects of lorazepam injection.
The maximum dose of olanzapine is 20mg/24 hours by any (combined) route(s) – this should not be exceeded without obtaining specialist advice – and not more than 3 I/M doses may be given in any 24 hour period.
Intramuscular olanzapine and intramuscular lorazepam must not be administered within 1 hour of each other.
Olanzapine IM needs to be diluted before administration in 2.1ml water for injection. It is f.
g.
h.
stable for up to 1 hour after reconstitution. Lorazepam should be mixed 1:1 with water before injecting. The maximum dose of haloperidol is either 30mg orally or 18mg by intramuscular injection.
Maximum doses will need to be adjusted if a combination of both routes is used. The bioavailable equivalence of haloperidol being Approximately 10mg oral: 6mg intramuscular.
Rapid Tranquillization Policy (SPT) Continued
I/M olanzapine or haloperidol and/or lorazepam (But allow one hour between I/M olanzapine and lorazepam) Allow at least 30 minutes for I/M lorazepam and/or I/M haloperidol to work If ineffective, repeat at same doses Repeat I/M olanzapine should not be given within 2 hours of the first Be aware of maximum doses in 24 hours Lorazepam can be used sublingually-?faster absorption Velotabs/Quicklets-no faster absorption
Olanzapine
Maximum licensed dose 20mg/24 hours by ANY COMBINED route No more than 3 olanzapine injections in 24 hours (and for no longer than 3 days) Oral onset time 1 hour, time to max plasma concentration 5-8 hours I/M onset time 15-30mins, max plasma concentration 15-45mins A minimum of 2 hours between injections
Haloperidol
Maximum licensed dose 30mg orally
or
18mg I/M in 24 hours If combination of oral and I/M used then maximum doses need to be adjusted Bioequivalence:
10mg oral:6mg I/M
Oral time to onset >1hour (max plasma concentration 2-6hours) I/M time to onset < 20mins (max plasma concentration 1-2hours)
Lorazepam
Maximum licensed dose oral 4mg/24 hours I/M- calculate according to body weight (30mcg/kg adult, 15mcg/kg elderly) Oral time to onset 20-30mins (max plasma concentration 2 hours) I/M time to onset <20-30mins (max plasma concentration 60-90mins) If >BNF doses are used document risk/benefit analysis & ↑ pt monitoring Dilution 1:1 with water Don’t forget it is stored in the Fridge!
In Summary
Choice of drugs(s) depends on current treatment/use of street drugs/individual patient Prescribe oral and I/M separately Ensure procyclidine prescribed prn Ensure flumazenil is available Don’t mix 2 drugs of the same class for RT Routes other than oral/IM decided by consultant only
Treatments used on specialist advice
Prescribed only by appropriate specialist Unlicensed and often small evidence base Aripiprazole I/M (licensed) Midazolam I/M Promethazine I/M Levomepromzine I/M Risperidone oral Quetiapine oral ECT
Potential complications
Benzodiazepines-loss of consciousness, respiratory depression, cardiovascular collapse Antipsychotics-loss of consciousness, cardiovascular/respiratory complications & collapse, seizures, akathisia, dystonia, dyskinesia, NMS, excessive sedation Antihistamines-excess sedation, painful injection, antimuscarinic effects Risks ↑ if pt highly aroused/drug misuse /dehydrated/physically ill
Complications & Management
Hypotension-Close monitoring, lie patient flat NMS-STOP ANTIPSYCHOTICS, seek medical team advice (or call an ambulance if severe), monitor, urgent creatine kinase level (if raised indicative of NMS) Acute dystonia- I/M procyclidine 5-10mg Arrhythmias-medical team advice Respiratory depression if RR<10/min in patient who has received benzodiazepines give flumazenil
(IV – doctors only
) Disinhibition with benzodiazepines Consider patient/staff relationship Review regular and PRN medication frequently
Monitoring
Baseline observations if possible Temperature, pulse, blood pressure, respiratory rate every 5-10 minutes for the first hour then every 30mins until ambulatory If patient is asleep use pulse oximetery If antipsychotic given monitor for EPSE’s ECG-recommended when antipsychotics are administered especially in high doses Fluid & electrolyte balance PANSS-EC scoring
Physical monitoring
Patient’s name: Gender: D.O.B.
IMPORTANT – If baseline monitoring cannot be undertaken, explain why in the comments box.
Time Temp Pulse BP Resp Rate Pulse* Oximeter Comments
Ward: (Baseline) Repeat every 5 to 10 minutes for the first hour then every 30 minutes until the patient is walking around
Signature
* The pulse oximeter reading need only be taken if the patient is asleep or unconscious Please retain the original in the patient’s notes. A copy must be made and reviewed by the team involved to reflect on whether the use of IM medication could have been avoided. Please record any learning points overleaf and store on the ward for a minimum of two years.
Flumazenil
IV – Doctors must administer
Benzodiazepine antagonist Give if RR<10/minute due to benzodiazepine dosing Dose-200mcg IV over 15 seconds Repeat-100mcg over 10 seconds (if needed) after 60 seconds Max dose 1mg in 24 hours Short half-life so repeated doses may be needed.
QTc prolongation
Obtained from ECG If above normal limits may predict a risk factor for Torsade de Pointes Normal limits;Men-440ms, women-470ms Many drugs associated with QTc prolongation QTc prolongation can occur more frequently with high doses, IV administration, predisposed patients
Neuroleptic Malignant Syndrome
Rare but potentially fatal Can occur with any antipsychotic Signs/symptoms-fever, muscle rigidity, sweating, incontinence, raised temperature, confusion, altered conciousness/BP/LFT’s, tachycardia, leucocytosis, ↑ creatine kinase Risk factors-high potency typicals, recent/rapid dose ↑ or ↓, dehydration Get advice regarding re-challenge
Further information/cross references
SPT policy (on website)- Rapid Tranquillization Policy NICE guidance (clinical guideline 25) BNF SPC’s available at www.medicines.org.uk
Trust Resuscitation Policy Policy-Prevention & management of violence & aggression(PMVA) Pharmacy Team