Rapid tranquillisation: the science and advice

Abstract

SUMMARY‘Rapid tranquillisation’ refers to the use of medication to calm highly agitated individuals experiencing mental disorder who have not responded to non-pharmacological approaches. Commonly it is the initial stage in the treatment of severe and enduring illness. Using medication in this way requires particularly robust evidence of efficacy and the management of side-effects. This article attempts to integrate current understanding of the neurochemical mechanisms of underlying illness and drug actions with therapeutic interventions. It distinguishes arousal from agitation, and effects on sedation from tranquillisation. It reviews critically the practice of rapid tranquillisation in the light of new evidence, changes in the NICE guidelines and British National Formulary recommendations and a national audit (POMH-UK). Broader aspects of management, known as ‘restrictive practices’ (such as control and restraint and seclusion), psychological support of team members, incident reporting, risk assessment, monitoring and medico-legal aspects are not covered.LEARNING OBJECTIVES•Recognise the role of brain transmitter pathways leading to arousal and to agitation•Be aware of mechanisms of action of benzodiazepines, antipsychotics and antihistamines and distinguishing sedation from calming effects•Know the recommendations of NICE guidelines for rapid tranquillisation and the findings of the national POMH-UK audit and be able to contribute to local policiesDECLARATION OF INTERESTNone.

Histamine in psychiatry: promethazine as a sedative anticholinergic

“…In 2016 promethazine reached the pinnacle of its fame in psychiatry when it was endorsed by National Institute for Health and Care Excellence (NICE) guidelines as one of the best-evidenced treatments for the management of violence, in combination with haloperidol (Cookson 2018). This apparent benefit is the result of a combination of sedative and anti-Parkinsonian (anticholinergic) effects – counteracting the potential side-effects of haloperidol, which is itself very efficacious for agitation in psychosis.…”

Janssen in China and insights in treating schizophrenia

“…The 2005 guidelines (National Collaborating Centre for Nursing and Supportive Care 2005) recommended oral antipsychotics without specifying a particular drug. The updated edition of these guidelines (National Collaborating Centre for Mental Health 2015) does not include discussion of oral medication, having re-defined rapid tranquillisation as the use of intramuscular medication only (see Cookson 2018).…”

The Difference Scores of Positive and Negative Syndrome Scale Exited Components in Psychotic Agitation Patients of Haloperidol Injection and those Prescribed with the Injection of Haloperidol and Diazepam

“…The amnesic effects of benzodiazepine benefits to patients who have been suffering by tragic moments such as frequent medications, restraining, and isolation. Favorable combination in oral treatments is haloperidol (with the addition of procyclidine) and diazepam, whereas intramuscular treatments were performed by injecting haloperidol (with procyclidine) and lorazepam [6].…”

“…Haloperidol is an antagonist receptor of dopamine-2 which has minimal effects to vital sign, anticholinergic activities, antihistamine, and low interactions to any non-psychotic drugs. The side effects are extrapyramidal symptoms (EPSs) such as parkinsonism, dystonia, and akathisia, which can be treated by anticholinergic medications (diphenhydramine and benztropine), QTc prolongation-torsade de pointes (Tdp), particularly for intravenous injections, neuroleptic malignant syndrome, and catatonic reaction specifically in high dosages prescription [5], [6].…”

“…Meanwhile, benzodiazepine drugs which are commonly prescribed in treating psychotic agitation are diazepam, lorazepam, clonazepam [6], and midazolam [7], [8]. Midazolam has higher superiority than that in haloperidol in controlling agitation, however, it is extremely sedative which is sleep-inducing effects.…”