6 General adult psychiatry6.4 Emergency psychiatry
6.4.4 Emergency treatment and use of legislation
6 min read2 figures
Written by Resident Doctor Committee · Published
De-escalation first
Verbal de-escalation and a change of environment come first when nothing has yet been tried, and they continue during any restrictive intervention.
Staff reduce noise and the audience, offer a quieter space, keep exits clear and let one person speak calmly.
Staff ask about pain, hunger, nicotine or other withdrawal, fear and practical frustrations.
Immediate danger may need urgent action without waiting for a prolonged attempt.
Rapid tranquillisation
Rapid tranquillisation aims to reduce severe agitation and danger, not to make the patient unconscious. Intramuscular (IM) lorazepam follows only once de-escalation and oral medication have failed.
Step | Choice |
|---|---|
Oral, antipsychotic-naive, no electrocardiogram (ECG) | Olanzapine 10 mg, which treats psychosis, sedates and needs no baseline ECG, unlike haloperidol |
IM, adult | Lorazepam alone, or haloperidol with promethazine (National Institute for Health and Care Excellence, NICE) |
Intravenous | Only in a monitored medical setting with resuscitation at hand |
Lorazepam alone is preferred when the patient has never taken an antipsychotic, no ECG is available, or cardiovascular disease or a prolonged QT interval makes haloperidol unsuitable.
Promethazine is given with IM haloperidol because it adds sedation and reduces acute dystonic reactions.
IM olanzapine is given at no more than 10 mg per injection, with a daily ceiling of 20 mg.
If a benzodiazepine is needed after IM olanzapine, staff wait at least one hour and never give the two together.
Inhaled loxapine is licensed, with placebo-controlled trial support, for rapid control of agitation in schizophrenia and bipolar disorder.
Zuclopenthixol acetate is unsuitable because its effect is delayed.
Acute dystonia is treated with procyclidine 5 to 10 mg IM or intravenously.
Monitoring after rapid tranquillisation
Staff check pulse, blood pressure, respiratory rate, temperature, hydration and consciousness at least hourly until concerns resolve.
Checks rise to every 15 minutes if the maximum dose was exceeded, the patient is asleep or sedated, has taken alcohol or illicit drugs, has physical illness, or was harmed by restraint.
Problem | Sign | Management |
|---|---|---|
Postural hypotension | Fall of more than 30 mmHg, or diastolic below 50 mmHg | Lie flat with the foot of the bed raised; observe closely |
Respiratory depression after a benzodiazepine alone | Rate below 10 per minute or saturation below 90% | Intravenous flumazenil, with continued observation because it acts for less time than lorazepam |
Respiratory depression after haloperidol or promethazine | Same | Transfer to a medical bed for ventilation, because flumazenil blocks only the benzodiazepine site |
Neuroleptic malignant syndrome | Fever, sweating, fast pulse, new stiffness | Urgent creatine kinase; hold further antipsychotic doses |
Airway and ventilation support come before reversal, and flumazenil can provoke seizures in benzodiazepine dependence or mixed overdose.
Restraint, seclusion and observation
Restraint can impair breathing and circulation, so staff avoid the floor where possible, prefer supine positioning if it is unavoidable and keep any prone restraint as brief as possible.
Staff never press on the neck, chest or abdomen and do not routinely restrain for more than ten minutes.
Seclusion is supervised isolation in a place the patient cannot leave, and the English Code normally limits it to detained patients.
A secluded patient is observed continuously, with a record at least every 15 minutes and a first medical review within one hour.
One staff member should not carry out enhanced observation for more than two hours without a break.
The Mental Health Units (Use of Force) Act 2018 requires a statutory record of force alongside the clinical notes.
Drug-induced emergencies
Syndrome | Features | Management |
|---|---|---|
Neuroleptic malignant syndrome | Fever, lead-pipe rigidity, confusion, unstable blood pressure, very high creatine kinase | Stop the antipsychotic at once; urgent medical care with cooling, fluids and renal monitoring; dantrolene or bromocriptine if severe |
Serotonin toxicity (Hunter criteria) | Clonus, hyperreflexia, sweating, fever after serotonergic drugs | Cyproheptadine, a 5-HT2A antagonist, with cooling and benzodiazepines |
Antidepressant discontinuation | Dizziness, shock-like sensations, vivid dreams, irritability after abruptly stopping a short half-life drug | Restart the drug, which usually relieves symptoms within about a day, then taper slowly or switch to fluoxetine |
Catatonia is treated with benzodiazepines, often starting with a lorazepam challenge of 1 to 2 mg intravenously or IM, or with electroconvulsive therapy (ECT).
Malignant catatonia needs early ECT, and further dopamine blockade is avoided whenever it or neuroleptic malignant syndrome is suspected.
Overdose and antidotes
Activated charcoal binds large organic molecules but not small polar or ionised substances, so it has no role in overdose of lithium, alcohols, iron or corrosives.
Paracetamol
Acetylcysteine replenishes glutathione, which conjugates the toxic metabolite NAPQI before it injures liver cells.
The treatment graph is valid from 4 to 24 hours after a single acute ingestion, including the broken segment after 15 hours.
A staggered overdose, or one of uncertain timing, gets intravenous acetylcysteine at once whatever the plasma level, because the graph applies only to a single ingestion at a known time.
Intravenous acetylcysteine runs as three consecutive infusions over 21 hours.
Anaphylactoid reactions to acetylcysteine are not true allergy and do not forbid further use.
Other antidotes
Poison | Features | Treatment |
|---|---|---|
Opioids | Pinpoint pupils, slow breathing | Naloxone, repeated as boluses or an infusion with prolonged observation, because methadone lasts a day or more and naloxone about an hour |
Benzodiazepines | Respiratory rate below 10 per minute | Flumazenil, a competitive antagonist at the benzodiazepine site of the GABA-A receptor; naloxone does not work |
Tricyclic antidepressants | Fast sodium channel blockade: QRS above about 120 ms, arrhythmia, hypotension, acidosis, seizures, anticholinergic signs | Intravenous sodium bicarbonate, whose sodium load and rise in pH narrow the QRS |
Beta-blockers | Bradycardia, hypotension, low glucose, unresponsive to atropine | Glucagon, which raises intracellular cyclic adenosine monophosphate through its own receptor and bypasses the blocked beta-adrenoceptor |
Tramadol overdose characteristically causes seizures, because its serotonin and noradrenaline reuptake inhibition lowers the seizure threshold, whereas other opioids cause respiratory depression and miosis.
Legal authority in England and Wales
Section 63 of the Mental Health Act 1983 permits treatment for mental disorder of detained patients under the approved clinician in charge.
Section 58 requires certified consent or second opinion authorisation for medication after three months, and ECT has separate section 58A safeguards.
Section 62 allows immediately necessary treatment to save life, to prevent serious deterioration if not irreversible, or, if neither irreversible nor hazardous, to relieve serious suffering or prevent violence.
Detention does not authorise unrelated physical treatment, so a fractured femur needs consent or separate authority.
For a patient lacking capacity, Mental Capacity Act sections 5 and 6 cover best-interests care and proportionate restraint, but deprivation of liberty needs further authority.
Power | Who uses it | Duration |
|---|---|---|
Section 5(2) | Doctor or approved clinician | 72 hours |
Section 5(4) | Nurse | 6 hours |
Section 4 | One medical recommendation plus an approved mental health professional, when a second doctor would cause undesirable delay | 72 hours |
Section 136 | Police, anywhere except a dwelling, garden or garage | 24 hours, plus 12 |
Section 135(1) | Police, private premises, with a justice's warrant | 24 hours, plus 12 |
Section 2 admission lasts 28 days.
Police stations cannot be places of safety for under-18s.
Scotland, Northern Ireland and the Republic of Ireland have separate statutes, with urgent treatment under Scotland's section 243 and Northern Ireland's Article 68.
The Mental Health Act 2025 received Royal Assent on 18 December 2025 and commences in phases from 6 April 2026, so not every reform yet applies.