Rapid tranquillisation: the NICE steps, the cautions and the monitoring after

It's eleven at night. A man admitted two days ago is shouting on the ward and has thrown a chair, and the nurse in charge asks if you'll prescribe rapid tranquillisation. It's one of the commonest urgent calls you'll take as a new psychiatry doctor. It's also one of the few where your prescription can harm someone within the hour.

I've written this for foundation doctors and core trainees starting on-calls. By the end you'll know what to do before any injection, how NICE asks you to choose the drug, which patients change that choice, and what has to happen after the dose.

The doses here come from the Maudsley Prescribing Guidelines 15th edition and the UK product information. When you prescribe, use the BNF and your trust's rapid tranquillisation policy. Policies differ, and yours is the one you'll be held to.

What rapid tranquillisation is, and when it's allowed

NICE defines rapid tranquillisation as medication given by injection, usually intramuscular (IM), when oral medication isn't possible or appropriate and urgent sedation is needed. The aim is calm, not unconsciousness. The Code of Practice asks that the patient can still understand and respond to what's said to them.

Before any injection: de-escalation and the oral offer

On the phone

Ask what's happening now and whether anyone is hurt. Then ask the questions that decide your prescription:

• what p.r.n. has been given today, and when;

• whether there's an ECG on file, and what the QTc was;

• whether they've ever taken an antipsychotic;

• any alcohol or drugs, physical illness or pregnancy;

• whether the care plan or an advance statement says what helps.

Then go and see them. Don't prescribe an injection for someone you haven't seen unless the nurses can't wait, and if so, see them straight after.

On the ward

NICE asks that one member of staff leads the talking, and that the patient is given space away from others without staff being left alone. Keep your voice low and your posture open, stand side on, and don't hold a stare. You're the doctor, but the nurse who knows the patient may be the better lead.

"I'm Dr Shah, one of the doctors. I can see something's really upset you. Can you tell me what's happened?"

"What would help right now? Some time in your room, or the garden with a nurse?"

"There's medication that can take the edge off. Would you take a tablet now?"

While you talk, think about a physical cause. Delirium, hypoglycaemia, hypoxia, a head injury, intoxication and withdrawal can all look like psychiatric agitation. The Maudsley's first instruction is to look for one.

The Code says oral medication should always be considered before an injection. For someone already on a regular antipsychotic, the Maudsley suggests oral lorazepam 1 to 2 mg or promethazine 25 to 50 mg. For someone who isn't, it lists an oral antipsychotic such as olanzapine 10 mg. It suggests repeating after 45 to 60 minutes if needed.

What catches people out: the p.r.n. dose given an hour ago counts. Before you prescribe anything, add up the last 24 hours: regular, p.r.n. and any earlier rapid tranquillisation.

The rapid tranquillisation NICE sequence

NICE NG10 gives adults two options: IM lorazepam on its own, or IM haloperidol combined with IM promethazine. NICE doesn't offer haloperidol on its own, and the Maudsley advises against it. You choose using the patient's preference or advance statement, their physical health, pregnancy, possible intoxication, past response, interactions and the total daily dose.

Two questions narrow it down. If the person has never had an antipsychotic, or you don't have enough information, use lorazepam. If there's heart disease, a long QT interval, or no ECG on record, avoid haloperidol with promethazine and use lorazepam. Out of hours, with a new patient, that usually makes lorazepam the choice.

If the response is partial, consider a further dose of the same drug. If lorazepam does nothing, consider haloperidol with promethazine. If that does nothing, consider lorazepam if it hasn't been used yet. If both have failed, NICE asks for an urgent team review and, if needed, a second opinion. I'd have rung my senior long before that point.

The Maudsley also lists IM olanzapine and IM aripiprazole. Both still have UK product licences, and your trust's policy may include them. If yours includes olanzapine, never give it with an IM benzodiazepine.

Lorazepam IM, promethazine IM and haloperidol IM: doses and prescribing

How you write it matters as much as the drug:

• One dose at a time. NICE asks that the first prescription is a single dose, not repeated until someone has reviewed its effect.

• Separate syringes. Never mix two drugs in one syringe.

• The day's total. Regular, p.r.n. and rapid tranquillisation doses together shouldn't exceed the BNF maximum. Going above it needs a planned goal, a written record and a senior doctor's direction.

• The site. The Code asks the prescriber to state the preferred injection site, avoiding the need for prone restraint.

Haloperidol IM and the ECG

NICE's ECG rule is the one I'd learn first. No ECG, known cardiac disease or a prolonged QT interval means no IM haloperidol with promethazine. The haloperidol injection SmPC recommends a baseline ECG before IM dosing and continuous ECG monitoring for repeated IM doses.

The same SmPC lists contraindications worth knowing:

• a comatose state or CNS depression;

• known QTc prolongation, recent myocardial infarction, uncompensated heart failure, or a history of ventricular arrhythmia;

• uncorrected hypokalaemia, or another drug that prolongs the QT interval;

• Parkinson's disease, dementia with Lewy bodies and progressive supranuclear palsy.

An agitated patient is at higher risk anyway. The Maudsley points out that stress, agitation and low potassium all predispose to arrhythmia. It adds that promethazine may slow haloperidol's breakdown, which matters if both are repeated.

Acute dystonia is the other risk, and it's frightening for the patient. Know how to spot it and treat it; I've covered it in extrapyramidal side effects.

What catches people out: zuclopenthixol acetate is not rapid tranquillisation. The Maudsley is clear that it acts too slowly, and shouldn't be given to someone physically resisting or who has never had an antipsychotic.

Cautions: older people, pregnancy, intoxication and under-18s

• Older adults. The haloperidol and lorazepam injection SmPCs both suggest starting at about half the adult dose, and haloperidol's ceiling drops to 5 mg a day. I'd treat new agitation in an older person as delirium until proven otherwise, and treating the cause beats sedating it.

• Pregnancy. NICE CG192 says to choose an antipsychotic or a short half-life benzodiazepine. Use the lowest effective dose of an antipsychotic because of neonatal extrapyramidal symptoms. Weigh floppy baby syndrome with a benzodiazepine. Adapt restraint to protect the baby, and don't seclude her afterwards.

• Alcohol or drugs. Intoxication is one of NICE's listed factors, and it moves observations to every 15 minutes. Sedatives add together, and breathing is what you're protecting.

• Under 18. NICE recommends IM lorazepam for children and young people, with the dose adjusted for age and weight. I'd always get senior advice here.

Monitoring after rapid tranquillisation

This is where harm happens, and it's where I'd spend my attention once the injection is in. After rapid tranquillisation, NICE asks you to watch for side effects and to record level of consciousness, pulse, blood pressure, temperature, breathing rate and hydration. Check at least hourly until there are no further concerns.

Step up to every 15 minutes if any of these apply:

• they seem to be asleep or sedated;

• they've taken alcohol or illicit drugs;

• they have a physical health problem already;

• they were hurt during restraint or another restrictive intervention;

• the dose given took them over the BNF maximum.

Many patients meet one of those, so in practice you'll often be asking for 15-minute observations. The Maudsley protocol goes further: every 15 minutes for the first hour after any injection, then hourly until they're walking. It also says that someone should keep them in sight for at least an hour and until they're walking. If they're asleep, continuous pulse oximetry is the safest way to watch breathing.

Tap to enlarge

When to act

The Maudsley sets out the warning signs:

• Respiratory rate under 10 a minute, or saturations under 90%. Call for help, give oxygen, and make sure they're not face down. If a benzodiazepine is the cause, give flumazenil. The Maudsley regimen starts at 200 micrograms IV over 15 seconds, then 100 micrograms every 60 seconds, up to 1 mg in 24 hours.

• Pulse under 50, or irregular. Get urgent medical help.

• Diastolic under 50, or a postural drop over 30 mmHg. Lie them flat and tilt the bed head down.

• A rising temperature. Think neuroleptic malignant syndrome and check creatine kinase urgently.

• Acute dystonia. Procyclidine 5 to 10 mg IM or IV.

Flumazenil wears off faster than lorazepam, so breathing can improve and then fall again. Keep watching. If breathing doesn't recover after the first doses, assume something else is causing it. It can also cause seizures in people on long-term benzodiazepines.

If the patient won't let anyone near them, watch breathing, colour and responsiveness from a safe distance and record it. Know where the resuscitation bag is before you need it. NICE expects one on the ward, checked weekly.

What I'd do before your next on-call

Find your trust's rapid tranquillisation policy and read it once, in daylight. Find the resuscitation bag, the flumazenil and the IM procyclidine on each ward you cover. When you clerk a new patient, get the ECG done early. It's the single thing that most widens your options at 11pm.

Rapid tranquillisation comes up in Paper B and in the CASC. In a station, you might explain to a worried relative why their son was given an injection. Walk through the steps you took before it, the reason for the drug and the checks afterwards.

Raj

References

1. National Institute for Health and Care Excellence. Violence and aggression: short-term management in mental health, health and community settings (NG10). 2015. https://www.nice.org.uk/guidance/ng10

2. National Institute for Health and Care Excellence. Antenatal and postnatal mental health: clinical management and service guidance (CG192). 2014, updated 2020. https://www.nice.org.uk/guidance/cg192

3. Department of Health. Mental Health Act 1983: Code of Practice. 2015. https://www.gov.uk/government/publications/code-of-practice-mental-health-act-1983