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
  2003,1065-72
• Greenberg et al. Bull Am Acad Psychiatry Law
  1996,24513-524

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 2003,327708.
• TREC 2 BJPsych 2004,18563-69

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

• Prescription of PRN
• antipsychotics is
• common in hospitalised
• patients
• PRN is a major cause of
• combined antipsychotics
• In the UK, haloperidol is
• the most frequently
• prescribed PRN
• antipsychotic

POMH-UK Proportion of acute adult inpatients
prescribed combined antipsychotics (n3492)
12
Why is this a problem?

• Haloperidol negates the
• EPS advantage of SGAs
• and
• SPC revised
• Concomitant use of antipsychotics should be
  avoided
• Baseline ECG is recommended prior to treatment
  in all patients

13
THE EFFECT OF PRN ON HIGH DOSE PRESCRIBING
100
100
2/2
2/2
114/
114/
19/
19/
122
122
21
21
80
80
586
586
/73
/736
6
60
60
Regular only
Regular only
211/
211/
Regular PRN
Regular PRN
404
404
40
40
prescribed a high dose
prescribed a high dose
30/
30/
92
92
20
20
158/
1894
158/1
894
0
0
0
1
2
3
0
1
2
3
Number of regular antipsychotics prescribed
Number of regular antipsychotics prescribed
14
PRN

• Paucity of evidence to
• support efficacy and safety
• Part of culture and practice
• Nursedoctornurse
• Maybe prescribed for one
• indication and administered
• for another

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 cant 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?