NHS Borders clinical guidelines
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Aims of rapid tranquilisation
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Practice Points (for further details refer to the general principles section of the protocol):
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Drug Treatment of Acute Behavioural Disturbance in 6-17 year olds
Warning
Objectives
Aims of rapid tranquilisation:
- Minimise harm and distress to the patient.
- Reduce risk of harm to others.
- Maintain the safety of the current environment.
Scope
This guideline is intended to support the short-term management of acute behavioural disturbances in children and adolescents aged 6 to 17 years within clinical settings under the care of CAMHS or Paediatrics, including those admitted to Huntlyburn ward and in the A&E department. Each case should be assessed on an individual basis. This guidance is based on best practice, and prescribers must be aware that medications used may be unlicensed in this age group. This guideline does not cover the non-pharmacological management of acute behavioural disturbance.
Audience
Any appropriately trained staff involved in the care of children and adolescents in clinical settings under the care of CAMHS, Paediatrics, when admitted to the Huntlyburn ward or A&E.
The guideline has been produced following consultation with psychiatrists in CAMHS, general adult, liaison and other psychiatric specialisms who may provide care out of hours, and consultants in paediatrics and the emergency department.
This guideline is to be used to support the short-term management of acute behavioural disturbances in children and adolescents aged 6 to 17 years in clinical settings under the care of CAMHS, Paediatrics and in the A&E. This guidance is based on best practice, and prescribers must be aware that medications used may be unlicensed in this age group. This guideline does not cover the non-pharmacological management of acute behavioural disturbance.
- Young people are more likely to have side effects than adults. E.g. paradoxical agitation with Benzodiazepines, and extrapyramidal side effects (EPSEs) with antipsychotics.
- When patients have never been prescribed antipsychotic medication before, use lower doses.
- When patients present with no evidence of psychotic symptoms, use lorazepam alone except for people with learning disability or Autism spectrum disorder (ASD) when Risperidone can be used alone or together with Lorazepam.
- Young people are less likely to have been treated with rapid tranquilising medication, and their response may be unpredictable.
- Consider body weight when prescribing, especially for those with low body weight and/or affected by eating disorders; lower doses may be required in these situations.
- Before administering rapid tranquilisation, assess the possibility that the young person may have used recreational drugs or alcohol.
- Young people may rapidly decompensate following a cardiovascular challenge compared to adults, therefore have a low threshold for increasing observation frequency or requesting additional medical support.
Assessment
- Consider physical causes and conditions that could cause acute behavioural disturbance (e.g. constipation, urinary retention, dental or ear pain, neurological issues, infections and other sources of pain/confusion).
- Consider metabolic problems such as changes in electrolytes, hypoxia, and hypoglycaemia or drug and alcohol withdrawal.
- Check medical history and psychiatric history for co-occurring conditions (e.g. asthma, presence of neurodevelopmental disorders, intellectual disability), previous adverse reactions and allergic reactions to medications.
- Obtain previous and current medication history. If antipsychotics (oral and depot form) or psychotropic medication, including Benzodiazepines, have ever been administered and the response, especially if any history of paradoxical reactions to Benzodiazepines.
- Obtain, where possible, information on whether there is a family history of any cardiac issues or adverse drug reactions.
- Consider consent, legal status, and parents/guardians/carers' concerns.
- If prescribing for patients who are not detained under the Mental Health Act, there must be a clear and detailed rationale documented in case notes.
- If a patient is detained under the Mental Health Act, ensure relevant paperwork, such as T3/T4 forms, is completed as soon as possible in the administration of IM medication.
Prescribing
- Oral medication should be offered before intramuscular medication.
- Take into account the age and bodyweight of the child.
- A risk-benefit analysis should be undertaken to determine the appropriate dose for the patient.
- This should include assessing the precautions for prescribing rapid tranquillisation on an individual patient basis.
- The minimum effective dose should be used and always allow time for the drug to take effect.
- Where patients have never previously been prescribed antipsychotic medication, use lower doses.
- Do not go beyond the maximum recommended dose without senior advice.
- Total daily dose over 24 hours should include both oral and intramuscular doses as well as regular dose (if already taking the medication regularly).
- Where the maximum daily recommended BNF dose for any prescribed drug is exceeded, document the reasons for this clearly in the patient’s notes. Where the total combined antipsychotic dose exceeds 100% of the maximum, then please refer to NHS Borders High Dose Antipsychotic Monitoring Guidelines.
- Benzodiazepines should be avoided in adolescents who are physically unwell/delirious or have significant respiratory impairment, e.g. asthma and if concerns, please contact the duty paediatrician for advice.
- Avoid Haloperidol in 12 and under 12year olds during rapid tranquilisation.
Administration
- Vital signs must be monitored after intramuscular administration.
- Mixing drugs in the same syringe is hazardous and should NEVER be done.
- Always have resuscitation facilities available.
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STEP 1 De-escalation / non-pharmacological measures |
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STEP 2 ORAL medication
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LORAZEPAM 0.5mg -1mg ORAL (Max 2mg including IM in 24 hours) OR PROMETHAZINE 5 - 10mg ORAL (Max 25mg including IM in 24 hours) OR/AND ANTIPSYCHOTIC [THIS MUST ONLY BE UNDER CONSULTANT OR SENIOR MEDICAL ADVICE IF SEVERELY AGITATED AND/OR PSYCHOSIS IS THOUGHT TO BE THE CAUSE] OLANZAPINE 2.5mg – 5 mg ORAL (Max 10mg including IM in 24 hours) [Do not administer within 1 hour of lorazepam] OR RISPERIDONE 0.5mg – 2mg ORAL [First choice for Learning Disability patients, consider previous use & response]
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STEP 3 Repeat ORAL medication |
If the patient remains agitated,
If the patient or others are at significant risk,
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STEP 4 INTRAMUSCULAR medication
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LORAZEPAM 0.5mg – 1mg IM (Max 2mg in 24 hours, including ORAL) [Factors to consider with dosing include weight and a lower dose if intellectual disability and benzodiazepine naïve] [Ensure Flumazenil is available for benzodiazepine-induced respiratory depression. Refer to the antidotes section of the protocol for the dose] OR PROMETHAZINE 6.25 -12.5mg IM (Max 25mg in 24 hours, including ORAL) [Useful option in benzodiazepine tolerant patients] [Caution: can cause QT prolongation] OR OLANZAPINE 2.5mg – 5mg IM (Max 10mg in 24 hours, including ORAL) Usually used as a second line, if the patient fails to respond to Lorazepam. Occasionally used as a first line. [DO NOT administer with IM Lorazepam or within 1 hour of lorazepam] [Avoid if known cardiac problems, ECG abnormalities or on other medication known to interact or cause QT prolongation] [Consider giving PROCYCLIDINE or a suitable other anticholinergic and having an injectable form ready due to the higher risk of extrapyramidal side effects such as acute dystonic reactions with antipsychotics in children. Refer to the antidotes section of the protocol for the dose]
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STEP 5 |
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STEP 6 |
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STEP 1 De-escalation/ Non-pharmacological measures |
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STEP 2 ORAL medication |
LORAZEPAM 0.5mg – 2mg ORAL (Max 4mg including IM in 24 hours) OR PROMETHAZINE 10mg – 25mg ORAL (Max 50mg including IM in 24 hours) OR/AND ANTIPSYCHOTIC [ THIS MUST ONLY BE UNDER CONSULTANT OR SENIOR MEDICAL ADVICE IF SEVERELY AGITATED AND/OR PSYCHOSIS IS THOUGHT TO BE THE CAUSE] OLANZAPINE 2.5mg – 10mg ORAL (Max 20mg including IM in 24 hours) [Do not administer within 1 hour of lorazepam] OR QUETIAPINE 25mg – 50mg ORAL OR RISPERIDONE 0.5mg – 2mg ORAL [First choice for Learning Disability patients, consider previous use & response]
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STEP 3 Repeat ORAL medication |
If the patient remains agitated,
If the patient or others are at significant risk,
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STEP 4 INTRAMUSCULAR medication
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LORAZEPAM Patients < 30Kg 0.5 - 1mg IM Patients > 30Kg or more 0.5mg - 2mg IM (max 4mg including oral/24hrs) [If patient has a partial response to 1st dose, a 2nd dose may be given after 1 hr] [Factors to consider with dosing include weight and a lower dose if intellectual disability and benzodiazepine naïve] [Ensure Flumazenil is available for benzodiazepine-induced respiratory depression. Refer to the antidotes section of the protocol for the dose] OR PROMETHAZINE 10-25 mg IM (Max 50mg in 24 hours, including ORAL) [Useful option in benzodiazepine tolerant patients] [Caution: can cause QT prolongation] OR OLANZAPINE 2.5mg – 10mg IM (Max 20mg in 24 hours, including ORAL) Usually used as a second line if the patient fails to respond to Lorazepam. Occasionally used as a first line. [DO NOT administer with IM Lorazepam or within 1 hour of lorazepam] [Avoid if known cardiac problems, ECG abnormalities or on other medication known to interact or cause QT prolongation] [Consider giving PROCYCLIDINE or a suitable other anticholinergic and keep an injectable form ready due to the higher risk of extrapyramidal side effects such as acute dystonic reactions with antipsychotics in children. Refer to the antidotes section of the protocol for the dose]
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STEP 5 |
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STEP 6 |
Senior advice: HALOPERIDOL can be considered as a further option if necessary. Please be aware of the likelihood of EPSEs with haloperidol. A pre-treatment ECG is advised, if possible. Consider ORAL or INTRAMUSCULAR formulations of HALOPERIDOL 1mg – 5mg (Max 5mg in 24 hours, including INTRAMUSCULAR and ORAL doses)
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FLUMAZENIL
- Always have FLUMAZENIL available to reverse respiratory depression from lorazepam. Give flumazenil if the respiratory rate drops below 10 per minute.
- Flumazenil is administered by intravenous injection.
- If required, it must be prescribed and administered by a doctor who has knowledge of prescribing and administering flumazenil.
- Initial dose is 10 micrograms/kg (up to 200 micrograms) administered intravenously over 15 seconds. If the desired level of consciousness is not obtained after waiting an additional 45 seconds, further injection of 10 micrograms/kg may be administered (up to 200 micrograms) and repeated at 60-second intervals where necessary (a maximum of 4 times) to a maximum total dose of 50 micrograms/kg or 1000 micrograms, whichever is lower.
- The half-life of flumazenil is short; continue monitoring for the full half-life of the causative agent, as the patient may become over-sedated again once flumazenil has worn off.
PROCYCLIDINE
- Always have an injectable anticholinergic available to reverse an acute dystonic reaction due to an antipsychotic medication, such as procyclidine IM/IV.
- In 6 -11year olds, 2 - 5mg for one dose and in 12–17year olds, 5–10 mg, occasionally, more than 10 mg. Dose usually effective in 5–10 minutes but may need 30 minutes for relief. (from BNF).
- Consider simultaneous use of procyclidine (or suitable other anticholinergic) with atypical antipsychotics, as extrapyramidal side effects are more common in adolescents, even when using atypical antipsychotic medication.
BENZTROPINE
- Benztropine mesylate injection is an injectable anticholinergic used to manage acute dystonic reactions.
- Benztropine is also known as benzatropine.
- Use is contraindicated in children under 3 years of age.
- The IM injection is reported to have a similar onset of action as the IV injection so intravenous administration is rarely necessary.
- Administer 20-50 micrograms per kg (maximum 2mg) intramuscularly (IM) or intravenously (IV).
- Administer a repeat dose if there has been no response after 30 minutes (IM) or 10 minutes (IV).
- The duration of action of benztropine may persist for up to 24 to 48 hours following a single 2mg IM injection.
Monitoring
- After intramuscular rapid tranquilisation, monitor the following:
- Alertness.
- Temperature.
- Pulse.
- Blood pressure.
- Respiratory rate.
- When to record – baseline on admission/prior to RT, then every 15 minutes in the 1st hour and hourly until no concerns.
- This should be contemporaneously documented, e.g. in the NEWS or paediatric observation charts.
- If the patient is asleep or unconscious, a pulse oximeter should be used to continuously measure oxygen saturation and be woken up to assess the level of consciousness. A nurse should remain with the patient until they are ambulatory again.
- If unable to monitor, this must be documented in the patient's notes. Record anything that you can monitor through observation, i.e. alertness/awake, pallor, respiratory rate, etc.
- ECG and carrying out blood tests are also strongly recommended when feasible, especially when higher doses are used. Hypokalaemia, stress, and agitation can put the patient at risk of cardiac arrhythmias.
- Enhanced observations, if required with 1:1 nursing support following the incident.
- Ensure adequate hydration.
- Seek urgent medical assessment if any signs of respiratory depression or signs of extrapyramidal side effects (EPSEs). Extrapyramidal side effects include tremor, rigidity, dystonias (abnormal facial and body movements), akathisia (restlessness), and tardive dyskinesia.
- Seek urgent medical assessment if there are signs of neuroleptic malignant syndrome following the administration of antipsychotics, i.e. increased temperature, sweating, restlessness or muscular rigidity.
- Any incident requiring rapid tranquillisation (or physical intervention) must be documented on paper notes and/or electronic notes as soon as possible. (e.g. EMIS/Vision template for IM medications, InPhase if restrained)
- Where the maximum daily recommended BNF dose for any prescribed drug is exceeded, document the reasons for this clearly in the patient’s notes. Where the total combined antipsychotic dose exceeds 100% of the maximum, please refer to NHS Borders High Dose Antipsychotic Monitoring Guidelines.
Post incident Review/Debrief
- Should take place within 72hrs of an incident.
- This will be led by nursing staff.
- Include relevant medical and nursing staff members; those who were directly involved, and the young person’s regular team members if available. If regular team members are unavailable, e.g., out of hours or on weekends, ensure they are informed of the events and any further management plans discussed as soon as possible.
- The review should address:
- What happened during the incident, including a record of the behavioural interventions and the medications used
- What worked and what didn’t
- Each person's role in the incident
- Any adverse reactions or medical issues from rapid tranquilisation
- Any trigger factors
- Immediate plans such as enhanced observations and interventions to manage triggers if identified.
- Any concerns raised by staff, parents and family members
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Medication / Formulations |
Route /
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Pharmacokinetics |
Major side effects / Risks |
Notes |
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BENZODIAZEPINES |
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Lorazepam Tablets; Injection
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Oral /IM
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Onset: 10-30mins Peak: 60-90 mins T1/2: 12-16 hrs The pharmacokinetics are similar whether given orally or parenterally |
Respiratory depression Disinhibition |
A wide therapeutic index & respiratory depression is readily reversed with the specific antagonist flumazenil.
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ANTIHISTAMINES |
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Promethazine Tablet, Elixir, Injection |
Oral
IM
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Onset: 15-30 mins Peak: 2 hours T1/2: 7-15 hrs
Onset: 20mins t½ 7-15 hours |
Headache, drowsiness, excessive sedation, dry mouth, seizures, blurred vision, constipation, NMS, cardio-respiratory depression |
Well absorbed orally
Look out for: Enhanced anti-muscarinic effects
Cardiovascular toxicity – hypotension and arrhythmias |
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ANTIPSYCHOTICS |
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Olanzapine Tablet, Orodispersible tab Injection |
Oral (orodispersible/ plain) IM |
Onset 5 hrs T1/2 32-50hrs Onset 15-30mins |
Hypotension Bradycardia
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Less likely to cause EPSE than haloperidol |
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Quetiapine Tablet, MR tablet |
Oral |
Onset 1-2 hrs T1/2 7-12 hrs |
Drowsiness, dizziness EPSE |
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Risperidone Tablet, Liquid Orodispersible tab
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Oral
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Onset 1-2 hrs T1/2 24 hrs |
EPSE Hypotension |
Consider for management of severe and persistent agitation/aggression associated with autism spectrum conditions or conduct disorder, the usual dose starting dose is 250 or 500 micrograms (please see BNF for Children) |
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Haloperidol Tablet, Liquid Injection |
Oral
IM
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Peak 2-6 hrs T1/2 10-36 hrs
Peak 15-60 min T1/2 10-36 hrs |
EPSE, NMS Hypotension, Increased QTc, Arrhythmias
Sudden death |
Note that risk of acute dystonia is higher in young people and ensure that an appropriate IM antimuscarinic is available as required basis (PRN) |
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