Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: De-escalation and rapid tranquillisation

Abstract

The British Association for Psychopharmacology and the National Association of Psychiatric Intensive Care and Low Secure Units developed this joint evidence-based consensus guideline for the clinical management of acute disturbance. It includes recommendations for clinical practice and an algorithm to guide treatment by healthcare professionals with various options outlined according to their route of administration and category of evidence. Fundamental overarching principles are included and highlight the importance of treating the underlying disorder. There is a focus on three key interventions: de-escalation, pharmacological interventions pre-rapid tranquillisation and rapid tranquillisation (intramuscular and intravenous). Most of the evidence reviewed relates to emergency psychiatric care or acute psychiatric adult inpatient care, although we also sought evidence relevant to other common clinical settings including the general acute hospital and forensic psychiatry. We conclude that the variety of options available for the management of acute disturbance goes beyond the standard choices of lorazepam, haloperidol and promethazine and includes oral-inhaled loxapine, buccal midazolam, as well as a number of oral antipsychotics in addition to parenteral options of intramuscular aripiprazole, intramuscular droperidol and intramuscular olanzapine. Intravenous options, for settings where resuscitation equipment and trained staff are available to manage medical emergencies, are also included.

Management of mental health emergencies in elite athletes: a narrative review

“…In these circumstances, inpatient care may be required and under statutory arrangements if necessary 42. The associated behavioural disturbance may need to be managed by de-escalation techniques,78 augmented if necessary by calming medication 1…”

“…The management of behavioural disturbance (that may arise in any mental health emergency) begins with attempts to de-escalate the situation, augmented if necessary by oral medications, which typically should be considered before parenterally administered drugs 1. Occasionally, physical restraint may be used but rarely, if ever, is mechanical restraint indicated 81…”

“…Lorazepam is most commonly recommended 1. Other antipsychotic medications such as haloperidol, risperidone, olanzapine or droperidol can be used alongside or as an alternative to benzodiazepines,1 especially if a patient presents with mania or psychosis 2. Midazolam via the buccal route or inhaled loxapine can also be used 1.…”

Janssen in China and insights in treating schizophrenia

“…Joint guidelines from the British Association for Psychopharmacology (BAP) and the National Association of Psychiatric Intensive Care and Low Secure Units (NAPICU) (Patel 2018) on management of acute disturbance address oral medication, which they describe as ‘pre-rapid tranquillisation’ or ‘as required’ ( pro re nata , PRN), given to avert violence while the agitated patient is still willing to accept oral medication. Risperidone is included as one of the options, along with haloperidol and other alternative agents.…”

Multidisciplinary management of acute disturbance

“…In this Journal issue, Patel, Sethi et al (2018a) present the Joint BAP NAPICU Evidenced-Based Consensus Guidelines for the Clinical Management of Acute Disturbance: De-escalation and Rapid Tranquillisation. The guideline supports clinicians in determining the most appropriate clinical intervention for the right clinical scenario at the right time, and is co-published in the Journal of Psychopharmacology (Patel, Sethi et al 2018b). It takes a multidisciplinary approach, including the patient perspective.…”