Hostname: page-component-78c5997874-94fs2 Total loading time: 0 Render date: 2024-11-10T13:32:39.687Z Has data issue: false hasContentIssue false
  • English
  • Français

What is new in rapid tranquillisation?

Published online by Cambridge University Press:  17 December 2010

Caroline Parker  and
Masum G Khwaja
Caroline Parker*
Affiliation:
Consultant Pharmacist, Adult Mental Health, St Charles' Hospital, Central & North West London NHS Foundation Trust, UK
Masum G Khwaja
Affiliation:
Consultant Psychiatrist and Honorary Senior Lecturer, Central & North West London NHS Foundation Trust, West End Community Mental Health Team, London, UK
*
Correspondence to: Mrs Caroline Parker, Pharmacy Offices, St Charles' Hospital, Exmoor Street, London W10 6DZ. Tel: 0208 206 7361;E-mail: caroline.parker@nhs.net
Get access

Abstract

Giving medicines to quickly calm the severely agitated patient, in order to reduce the risk of imminent and serious violence to self or others, is referred to as rapid tranquillisation (RT).

Despite national guidelines on the management of violence, several Royal College of Psychiatrists guidelines, consensus statements, best practice guidelines, and numerous reviews of the evidence, there is no current consensus as to the first line pharmacological agent in RT.

Over the last few years there have been a number of new medicines for RT, new formulations, and new evidence. The discontinuation of droperidol injection led to more widespread use of haloperidol. The maximum dose of haloperidol has decreased, baseline ECGs are now recommended, and it is no longer licensed for IV administration. These developments have led to changes in RT practice.

In order to safely use the new medicines and new formulations it is imperative that all staff involved in prescribing and administration should be familiar with the practical use of these medicines. This includes methods of preparation and administration, specific side effects and monitoring requirements, as well as their own responsibilities in regard to these medicines.

Keywords

Rapid tranquillisationmedicinesprescribing
Type
Review
Information
Journal of Psychiatric Intensive Care , Volume 7 , Issue 2 , December 2011 , pp. 91 - 101
Copyright
Copyright © NAPICU 2011

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Actavis UK (2008) Diazepam (Diazemuls®). Summary of Product Characteristics. Last updated on the electronic medicines compendium 19/9/2008. http://www.medicines.org.uk/EMC/medicine/520/SPC/Diazemuls/Google Scholar
Alexander, J., Tharyan, P., Adams, C., John, T., Mol, C. and Philip, J. (2004) Rapid tranquillisation of violent or agitated patients in psychiatric emergency setting: pragmatic randomised trial of intramuscular lorazepam versus haloperidol plus promethazine. British Journal of Psychiatry. 185: 63–69.CrossRefGoogle ScholarPubMed
Allen, M.H., Currier, G.W., Carpenter, D. et al. (2005) Expert consensus guideline series: treatment of behavioural emergencies. Journal of Psychiatric Practice. 11(supplement 1): 1–108.Google Scholar
Andrezina, R., Josiassen, R.C., Marcus, R.N., Oren, D.A., Manos, G., Stock, E., Carson, W.H. and Iwamato, T. (2006) Intramuscular aripiprazole for the treatment of acute agitation in patients with schizophrenia or schizoaffective disorder: a double-blind, placebo-controlled comparison with intramuscular haloperidol. Psychopharmacology. 188(3): 281–292.CrossRefGoogle ScholarPubMed
Aupperle, P. (2006) Management of aggression, agitation, and psychosis in dementia: focus on atypical antipsychotics. American Journal of Alzheimer’s Disease and Other Dementias. 21(2): 101–108.CrossRefGoogle ScholarPubMed
Baker, J.A. (2008) A best-evidence synthesis review of the administration of psychotiropic pro re nata (PRN) medication in in-patient mental health settings. Journal of Clinical Nursing. 17: 1122–1131.CrossRefGoogle ScholarPubMed
Barak, Y., Mazeh, D., Plopski, I. and Baruch, Y. (2006) Intramuscular ziprasidone treatment of acute psychotic agitation in elderly patients with schizophrenia. The American Journal of Geriatric Psychiatry. 14(7): 629–633.CrossRefGoogle ScholarPubMed
Barzman, D.H., DelBello, M.P., Forrester, J.J., Keck, P.E. Jr and Strakowski, S.M. (2007) A retrospective chart review of intramuscular ziprasidone for agitation in children and adolescents on psychiatric units: prospective studies are needed. Journal of Child and Adolescent Psychopharmacology. 17(4): 503–509.CrossRefGoogle ScholarPubMed
Battaglia, J. (2005) Pharmacological management of acute agitation. Drugs. 65(9): 1207–1222.CrossRefGoogle ScholarPubMed
Belgamwar, R.B. and Fenton, M. (2005) Olanzapine IM or velotab for acutely disturbed/agitated people with suspected serious mental illnesses. Cochrane Database of Systematic Reviews. Issue 2. Art. No.: CD003729. DOI: 10.1002/14651858.CD003729.pub2.CrossRefGoogle ScholarPubMed
Bristol-Myers Sqibb Pharmaceuticals Ltd. (2010) Abilify 7.5 mg/ml solution for injection (intramuscular). Summary of Product Characteristics. Last updated in the Electronic Medicines Compendium 28/4/10. http://www.medicines.org.uk/EMC/medicine/20802/SPC/Abilify+7.5+mg+ml+solution+for+injection+(intramuscular)+(Bristol-Myers+Squibb+Pharmaceuticals+Ltd)/Google Scholar
British National Formulary (2009) British National Formulary for Children. London. BMJ Publishing Group Ltd and RPS Publishing.Google Scholar
Brook, S., Lucey, J.V. and Gunn, K.P., for the Ziprasidone IM study group (2000) Intramuscular ziprasidone compared with intramuscular haloperidol in the treatment of acute psychosis. Journal of Clinical Psychiatry. 61(12): 933–941.CrossRefGoogle ScholarPubMed
Caine, E.D. (2006) Clinical perspective on atypical antipsychotics for treatment of agitation. Journal of Clinical Psychiatry. 67(supplement 10): 22–31.Google ScholarPubMed
Citrome, L. (2004) New treatments for agitation. Psychiatric Quarterly. 75(3): 197–213.CrossRefGoogle ScholarPubMed
Coburn, V.A., and Mycyk, M.B. (2009) Physical and chemical restraints. Emergency Medicine Clinics of North America. 27: 655–667.CrossRefGoogle ScholarPubMed
Eli Lilly and Company Ltd. (2010) Zyprexa Powder for Solution for Injection. Summary of Product Characteristics. Last updated in the Electronic Medicines Compendium 19/1/10. http://www.medicines.org.uk/EMC/medicine/7284/SPC/Zyprexa+Powder+for+Solution+for+Injection/Google Scholar
Gillies, D., Beck, A., McCloud, A., and Rathbone, J. (2005) Benzodiazepines alone or in combination with antipsychotic drugs for acute psychosis. Cochrane Database of Systematic Reviews. Issue 4. Art. No.: CD003079. DOI: 10.1002/14651858.CD003079.pub2.Google ScholarPubMed
Goedhard, L.E., Stolker, J.J., Heerkink, E.R., Nijman, H.L.I., Olivier, B. and Egberts, T.C.G. (2006) Pharmacotherapy for the treatment of aggressive behaviour in general adult psychiatry: a systematic review. Journal of Clinical Psychiatry. 67: 1013–1024.CrossRefGoogle ScholarPubMed
Hassaballa, H.A. and Balk, R.A. (2003a) Torsade de pointes associated with the administration of intravenous haloperidol. American Journal of Therapeutics. 10(1): 58–60.CrossRefGoogle ScholarPubMed
Hassaballa, H.A. and Balk, R.A. (2003b) Torsade de pointes associated with the administration of intravenous haloperidol: a review of the literature and practical guidelines for use. Expert Opinion on Drug Safety. 2(6): 543–547.Google ScholarPubMed
Huf, G., Coutinho, E.S.F., Adams, C.E. and TREC Collaborative Group (2007) Rapid tranquillisation in psychiatric emergency settings in Brazil: pragmatic randomised controlled trial of intramuscular haloperidol versus intramuscular haloperidol plus promethazine. British Medical Journal. 335(7625): 869–875.CrossRefGoogle ScholarPubMed
Huf, G, Alexander, J., Allen, M.H. and Raveendran, N.S. (2009) Haloperidol plus promethazine for psychosis-induced aggression. Cochrane Database of Systematic Reviews. Issue 3: CD005146. doi: 10.1002/14651858.CD005146.pub2.CrossRefGoogle ScholarPubMed
Janssen-Cilag Ltd. (2010) Haldol (haloperidol) 5mg/ml Injection. Summary of Product Characteristics. Last updated on the Electronic Medicines Compendium 23/4//2010. http://www.medicines.org.uk/emc/medicine/7267/spc/haldol+injection/Google Scholar
Joint Formulary Committee (2010) British National Formulary, 59th ed. London: British Medical Association and Royal Pharmaceutical Society.Google Scholar
Khan, S.S. and Mican, L.M. (2006) A naturalistic evaluation of intramuscular ziprasidone versus olanzapine for the management of acute agitation and aggression in children and adolescents. Journal of Child and Adolescent Psychopharmacology. 16(6): 671–677.CrossRefGoogle ScholarPubMed
Kohen, I., Preval, H., Southard, R. and Francis, A. (2005) Naturalistic study of intramuscular ziprasidone versus conventional agents in agitated elderly patients: retrospective findings from a psychiatric emergency service. The American Journal of Geriatric Pharmacotherapy. 3(4): 240–245.CrossRefGoogle ScholarPubMed
Marder, S.R. (2006) A review of agitation in mental illness: treatment guidelines and current therapies. Journal of Clinical Psychiatry. 67(supplement 10): 13–21.Google ScholarPubMed
Martel, M., Sterzinger, A., Miner, J., Clinton, J. and Biros, M. (2005) Management of acute undifferentiated agitation in the emergency department: a randomized double-blind trial of droperidol, ziprasidone, and midazolam. Academic Emergency Medicine. 12(12): 1167–1172.Google ScholarPubMed
MHRA (2009) Off-label or unlicensed use of medicines: prescribers’ responsibilities. Drug Safety Update. 2(9): 6–7. http://www.mhra.gov.uk/Publications/Safetyguidance/DrugSafetyUpdate/CON043809Google Scholar
MHRA (2001) QT Interval prolongation with antipsychotics. Current Problems in Pharmacovigilance. 27(Feb): 4.Google Scholar
NICE (2005) Violence – The short-term management of disturbed/violent behavior in in-patient psychiatric settings and emergency departments. NICE Clinical Guideline No. 25. http://www.nice.org.uk/guidance/CG25Google Scholar
Raveendran, N.S., Tharyan, P., Alexander, J. and Adams, C.E. (2007) Rapid tranquillisation in psychiatric emergency settings in India: pragmatic randomised controlled trial of intramuscular olanzapine versus intramuscular haloperidol plus promethazine. British Medical Journal. 335(7625): 865–872.CrossRefGoogle ScholarPubMed
Reilly, J.G., Ayis, S.A., Ferrier, I.N., Jones, S.J. and Thomas, S.H.L. (2000) QTc-interval abnormalities and psychotropic drug therapy in psychiatric patients. Lancet. 355:1048–1052.CrossRefGoogle ScholarPubMed
Roche Products Ltd. (2010) Hypnovel 10 mg/2 ml solution for injection. Summary of Product Characteristics. Last updated on the Electronic Medicines Compendium 14/5/10. http://www.medicines.org.uk/EMC/medicine/1692/SPC/Hypnovel+10mg+2ml+solution+for+injection/Google Scholar
Rossi, J. and Swan, M.C. (2010) The violent or agitated patient. Emergency Medicine Clinics of North America. 28: 235–256.CrossRefGoogle ScholarPubMed
Royal College of Psychiatrists (1995) Strategies for the Management of Disturbed and Violent Patients in Psychiatric Units. Royal College of Psychiatrists, Council Report CR41.Google Scholar
Royal College of Psychiatrists (1998) Management of Imminent Violence: Clinical Practice Guidelines to Support Mental Health Services. Royal College of Psychiatrists, Occasional Paper OP41.Google Scholar
Royal College of Psychiatrists (2000) Good Medical Practice in the Psychiatric Care of Potentially Violent Patients in the Community. Royal College of Psychiatrists, Council Report CR80.Google Scholar
Royal College of Psychiatrists (2005) The Evidence Base for the Management of Imminent Violence in Learning Disability Settings. Royal College of Psychiatrists, Occasional Paper OP57.Google Scholar
Royal College of Psychiatrists (2006) Consensus Statement on High-Dose Antipsychotic Medication. Royal College of Psychiatrists, Council Report CR138.Google Scholar
Schwagmeier, R., Alincic, S. and Striebel, H.W. (1998) Midazolam pharmacokinetics following intravenous and buccal administration. British Journal of Clinical Pharmacology. 46(3): 203–206.CrossRefGoogle ScholarPubMed
Sweetman, S. (2009) Martindale: The Complete Drug Reference. London: Pharmaceutical Press. http://www.medicinescomplete.com/mc/martindale/current/Google Scholar
Taylor, D., Paton, C. and Kerwin, R. (2007) Maudsley Prescribing Guidelines, 9th ed. London: Informa Healthcare.CrossRefGoogle Scholar
Taylor, D., Paton, C. and Kapur, S. (2009) Maudsley Prescribing Guidelines, 10th ed. London: Informa Healthcare.CrossRefGoogle Scholar
Tran-Johnson, T.K., Sack, D.A.Marcus, R.N., Auby, P., McQuade, R.D. and Oren, D. A. (2007) Efficacy and safety of intramuscular aripiprazole in patients with acute agitation: a randomized double blind, placebo-controlled trial. Journal of Clinical Psychiatry. 68(1): 111–119.CrossRefGoogle ScholarPubMed
TREC Collaborative Group (2003) Rapid tranquillisation for agitated patients in psychiatric rooms: a randomised trial of midazolam versus haloperidol plus promethazine. British Medical Journal. 327(7417): 708–711.CrossRefGoogle Scholar
Wright, P., Birkett, M., David, S.R., Meehan, K., Ferchland, I., Alaka, K.J., Saunders, J.C., Krueger, J., Bradley, P., San, L., Bernando, M., Reinstein, M. and Breier, A. (2001) Double blind, placebo-controlled comparison of intramuscular olanzapine and intramuscular haloperidol in the treatment of acute agitation in schizophrenia. American Journal of Psychiatry. 158: 1149–1151.CrossRefGoogle ScholarPubMed
Wright, et al. (1999) Safety and efficacy of intramuscular (IM) olanzapine in patients with acute nonorganic psychosis (abstract). Schizophrenia Research. 36(1–3): 318.Google Scholar
Zeller, S.L. and Rhoades, R.W. (2010) Systematic review of assessment measures and pharmacologic treatments of agitation. Clinical Therapeutics. 32(3): 403–425.CrossRefGoogle Scholar
Zimbroff, D.L., Marcus, R.N., Manos, G., Stock, E., McQuade, R.D., Auby, P. and Oren, D.A. (2007) Management of acute agitation in patients with bipolar disorder: efficacy and safety of intramuscular aripiprazole. Journal of Clinical Psychopharmacology. 27(2): 171–176.CrossRefGoogle ScholarPubMed