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Rapid tranquillisation: an issue for all nurses in acute care settings

13 August 2020
Volume 29 · Issue 15

Abstract

The management of challenging behaviour, violence and aggression is not only an issue for mental health and learning disability nurses. Increasingly, nurses working in emergency departments (EDs), medical assessment units and general medical or surgical wards may encounter acts of challenging behaviour, violence and aggression on a regular basis. Restraint is sometimes used as a tool in the management of these patients; this may be in the form of physical, mechanical or chemical restraint. Rapid tranquillisation (RT) is often considered a form of chemical restraint, which may be used in an emergency situation when prescribed. If RT is given it should be done so as the least restrictive option, with intramuscular and intravenous administration as a last resort. Patient monitoring following administration is paramount. This article explores best practice in the administration of RT from a clinical perspective.

The management of challenging behaviour, violence and aggression in emergency departments (EDs), and increasingly in general hospital wards, is often traumatic for both patients and the staff involved (Hext et al, 2018). Guidelines from the Department of Health (2014) stipulate the use of the least restrictive practices and interventions when caring for people who exhibit behaviour that may challenge staff and others. This article explores the role of nurses in relation to the administration of contemporary rapid tranquillisation as a restrictive intervention to manage aggression and violence in acute care settings. It will review drugs used, routes of administration, dosing, potential adverse effects and their management, and offer practical guidelines for acute care settings.

Specific training and education surrounding the causes and management of challenging behaviour, aggression and violence is essential for nurses working in all fields. An understanding of the biological causes of challenging behaviour is crucial, especially regarding reactive psychiatric symptoms and behavioural responses to pain, fear, infection or chronic disease. Patients with intellectual impairments, mental health problems and those with dementia or acute confusional states may be particularly prone to exhibiting challenging behaviour as a result of biological aetiology (Clark and Clarke, 2014). Healthcare staff should have an awareness of groups where there are known higher risks of violence and aggression such as young males, those with a forensic history and or/social restlessness, street drug and alcohol misusers, those with antisocial personality disorders or traits and those involved in gang culture (Mason and Chandley, 1999; Dickinson et al, 2018)

Restrictive practices and interventions

It is important to differentiate between restrictive practices and restrictive interventions; however, the former may result in the latter. Restrictive practices involve restriction of a person's rights of choice, self-determination, privacy and liberty (Department of Health, 2014). They include the use of ward ‘rules’, limit setting and authoritarian staff attitudes, while restrictive interventions include the use of bed rails, mittens, rapid tranquillisation, restraint (physical, mechanical and chemical) and seclusion (Xyrichis et al, 2018). The use of restrictive practices and restrictive interventions is not only an issue for mental health and learning disability nurses, but also for nurses working across the adult nursing field including EDs, medical assessment units (MAUs), intensive care units (ICUs) and general medical or surgical wards.

The role of rapid tranquillisation

Rapid tranquillisation (RT) is defined as giving medicines to a person who is very agitated or displaying aggressive behaviour to help quickly calm them (National Institute for Health and Care Excellence (NICE), 2015). It is often considered a form of chemical restraint, therefore it should be administered with a clear rationale for its necessity, delivered in the least restrictive manner and documented in detail. Monitoring and observation of the patient is essential following administration of RT, using appropriate National Early Warning Score 2 (NEWS 2) scoring charts. The administration of RT should be humane, legal and evidence based, in addition to being justifiable and arising from clinical necessity (Dickinson et al, 2009; NICE, 2019). Patients in EDs or general acute wards may be administered RT in an emergency situation if it is considered to be in the patient's best interests and is administered as prescribed by medical staff. It should only ever be given when it is considered the least restrictive option, as part of an emergency treatment plan and in the patient's best interests. RT should never be given as a form of ‘punishment’ or as an automatic response following an episode of violence, aggression or restraint.

Oral medication for RT should always be offered initially where possible as the least restrictive option (Department of Health, 2014). This is often not possible in EDs, ICUs or on general wards as ingestion via an oral route may be contraindicated on medical grounds, or by refusal of the patient to take oral medication. Therefore, alternative routes of administration would need to be considered, which could include intramuscular injection and intravenous injection. Box 1 outlines the recommended drugs and dosage for each of these routes of administration.

Rapid tranquillisation: summary

In an emergency situation: assess to see if there may be a medical cause. Optimise regular prescription. The aim of pharmacological treatment is to calm the patient but not to oversedate. Note: lower doses should be used for children, adolescents and older adults

Patient monitoring and observation is vital after administration of rapid tranquillisation (see relevant section of article for more on this)

Step intervention

Step 1. De-escalation

Step 2. Offer oral treatment

If patient is prescribed a regular antipsychotic:

  • Lorazepam 1–2 mg
  • Promethazine 25–50 mg
  • Monotherapy with buccal midazolam 10 mg may avoid the need for intramuscular treatment (note that this preparation is unlicensed)
  • If patient is not already taking a regular oral or depot antipsychotic:

  • Olanzapine 10 mg, or
  • Risperidone 1–2 mg, or
  • Quetiapine 50–100 mg, or
  • Haloperidol 5 mg (best with promethazine 25 mg). Note that the summary of product characteristics (SPC) for haloperidol recommends a pre-treatment ECG and to avoid concomitant antipsychotics
  • Inhaled loxapine 10 mg. Note that the use of this preparation requires the co-operation of the patient, and that bronchospasm is a rare adverse effect (have a salbutamol inhaler to hand)
  • Repeat after 45–60 minutes, if necessary. Consider combining sedative and antipsychotic treatment. Go to step 3 if two doses fail or sooner if the patient is placing themselves or others at significant risk

    Step 3. Consider intramuscular (IM) treatment

  • Lorazepam 2 mg. Have flumazenil available in case of benzodiazepine-induced respiratory depression. Use with caution in the very young and elderly and those with pre-existing brain damage or impulse control problems, as disinhibition reactions are more likely
  • Promethazine 50 mg. IM promethazine is a useful option in a benzodiazepine-tolerant patient. Promethazine has a slow onset of action but is often an effective sedative. Dilution is not required before IM injection. May be repeated up to a maximum of 100 mg/day. Wait 1–2 hours after injection to assess response. Promethazine alone has been reported, albeit very rarely, to cause neuroleptic malignant syndrome
  • Olanzapine 10 mg. IM olanzapine should not be combined with an IM benzodiazepine, particularly if alcohol has been consumed
  • Aripiprazole 9.75 mg. Less hypotension than olanzapine, but possibly less effective
  • Haloperidol 5 mg. Haloperidol should be the last drug considered
  • The incidence of acute dystonia is high if combined with IM promethazine, and ensure IM procyclidine is available
  • The SPC recommends a pre-treatment ECG
  • Repeat after 30–60 minutes, if insufficient effect. Combinations of haloperidol and lorazepam or haloperidol and promethazine may be considered if single-drug treatment fails. Drugs must not be mixed in the same syringe. IM olanzapine must never be combined with any IM benzodiazepine (including lorazepam)

    Step 4. Consider intravenous (IV) treatment

  • Diazepam 10 mg over at least 2 minutes
  • Repeat after 5–10 minutes if insufficient effect (up to 3 times)
  • Have flumazenil to hand
  • Seek expert advice from the consultant or senior clinical pharmacist on call.

    (Options at this point are limited. IM amylobarbitone and paraldehyde have been used previously, but are used now only extremely rarely and are generally not readily available. IV olanzapine, IV/IM droperidol and IV haloperidol are possible but serious adverse effects are fairly common. Ketamine is an option in medical units. Behavioural disturbance secondary to the use of illicit drugs can be very difficult to manage. Time and supportive care may be safer than administering more sedative medication)

    Source: adapted from Taylor et al, 2018

    Preferred injection sites

    The use of prone (face down) restraint should be avoided wherever possible (Department of Health, 2014), including when administering RT. Mental health nurses in particular tend to use the dorsogluteal site for intramuscular injections of RT, especially when administration follows incidents where the patient has been physically restrained, thus increasing the use of prone restraint (Santos and Cutcliffe, 2018). Alternatively, use of the vastus lateralis may reduce the need to place a patient in the prone position.

    The vastus lateralis is situated on the anterior aspect of the thigh in the quadriceps muscle, a hand's breadth above the knee and a hand's breadth below the greater trochanter of the femur (Ogston-Tuck, 2014). This site gives easy access to the muscle and there are few major blood vessels in that area (Ogston-Tuck, 2014). Intramuscular injections should be administered using a Z-track technique (Delves-Yates et al, 2018). Box 2 outlines fundamental principles that nurses should follow when administering RT.

    Key elements of practice when carrying out rapid tranquillisation

  • Ensure that there are no other alternatives to the administration of RT
  • Follow all usual procedures for the management of medication
  • Always offer RT in oral form initially (where possible)
  • Avoid the use of prone restraint (or any form of restraint) where possible and consider the use of the vastus lateralis site for intramuscular administration. This can be performed with the patient in a lying or sitting position
  • Always use a Z-track technique for intramuscular administration
  • Explain to the patient what you are going to do before beginning the procedure and maintain dialogue to reassure them throughout, even if the patient is non-compliant
  • Maintaining competence

    Specific guidelines should be consulted when administering RT, including individual hospital policies. Many EDs now have their own specific guidelines and policies to cover the management of challenging behaviour, violence and aggression; this usually includes a policy surrounding the use of RT. Other useful guidelines include the Maudsley Prescribing Guidelines in Psychiatry (Taylor et al, 2018) and NICE (2015) guidelines on managing violence and aggression.

    Nurses who are responsible for the administration of RT must be confident that they have exhausted verbal de-escalation skills. Therefore, it is essential that training and education on this be provided during nurses' pre-registration education, with regular updates following registration (Mencap, 2012; Hext et al, 2018).

    Guidance from the Royal Pharmaceutical Society and Royal College of Nursing (2019) on the administration of medicines in healthcare settings should be adhered to at all times and nurses must be proficient and up to date in basic life support techniques (BLS) (Resuscitation Council UK, 2015). All patients should be assessed by the multidisciplinary team from a bio-psycho-pharmaco-social perspective (Clark and Clarke, 2014) to avoid diagnostic overshadowing. Diagnostic overshadowing occurs when health professionals ignore the signs and symptoms of a secondary diagnosis and attribute certain ‘behaviours’ to the primary condition (Clark and Clarke, 2014). This is more likely to occur in people where communication may be problematic such as those with dementia, intellectual disability or a mental health problem (Parish, 1987). In circumstances such as these, vital warning signs of a medical emergency or disease may be overlooked and an accurate and timely diagnosis delayed. Often the patient is subsequently stigmatised as exhibiting ‘challenging behaviour’ (While and Clark, 2009).

    Documentation

    Incident and circumstances leading to the administration of RT should be recorded in the patient's clinical notes, along with the rationale for administration. The date, time, nurse administering, and nurse witnessing checking and administration of the drug (including injection site) should be recorded in addition to related physical restraint. This should appear on the patient's medication chart, individual clinical notes and the relevant incident reporting systems.

    Patient monitoring following rapid tranquillisation

    Patient monitoring is paramount after administration of RT. Vital signs must be monitored and charted using the NEWS 2 system. This must include temperature, pulse, respiration rate, oxygen saturation levels and blood pressure. This should be initially recorded every 5–10 minutes for the first hour, then every half hour until the patient becomes ambulatory and stable (Dickinson et al, 2009). The patient should also be placed on one-to-one constant observation for the first 2 hours, which should also be recorded. Patient monitoring after RT needs to be increased if:

  • The patient appears sedated or asleep
  • The Maudsley prescribing guidelines (Taylor et al, 2018) limits for prescribing have been exceeded
  • Illicit substances or alcohol have been ingested
  • A relevant medical disorder, such as cardiac abnormalities, is present (NICE, 2015)
  • Where the patient's vital signs cannot be recorded because, for example, the patient refuses or it may add to their distress or potential for aggression or violence, medical staff must be informed in a timely manner. Local policy regarding recording should also be adhered to regarding RT, monitoring of vital signs and restraint. Nurses should always seek medical advice if in doubt about a clinical situation. Box 3 discusses actions that RNs should take if a patient has an adverse reaction to RT. Early detection and appropriate management of such complications is vital, as failure to rescue could lead to avoidable death (Simmonds, 2019).

    Adverse effects following rapid tranquillisation

  • Cardiac arrest. In the event of this basic life support (BLS) should be administered, the cardiac arrest team should be alerted, and local resuscitation policy should be instigated (Resuscitation Council UK, 2015)
  • Acute dystonia. This may be a brief or sustained muscle spasm involving any muscle group, but more commonly facial muscles (eyes, jaw, and tongue). Treatment includes procyclidine 5–10 mg. The dose should be repeated after 20 minutes if the patient's response is incomplete. Procyclidine 2.5 mg should then be administered orally every 8 hours for 2 days (Dickinson et al, 2009)
  • Reduced respiratory rate. Oxygen should be administered if saturation levels fall below 90% and medical staff should be alerted (Peate et al, 2012)
  • Bradycardia or irregular beats. Medical staff should be informed immediately (Burns, 2015)
  • Decreased blood pressure. If the systolic pressure is less than 80 mmHg and the diastolic less than 50 mmHg medical staff should be informed immediately. Meanwhile the patient should be placed flat with legs raised and hydration ensured (Antai-Otong, 2008)
  • Neuroleptic malignant syndrome. Symptoms include high fever, unstable blood pressure, altered consciousness, diaphoresis and muscle rigidity. This is a life-threatening condition and medical assistance must be sought urgently (Dubin and Feld, 1989). This may involve the critical care outreach team offering intensive care skills to the patient in the acute setting
  • An episode of restraint can be distressing for both the patient and staff involved. Therefore, staff and patients involved in such incidents should be offered debriefing and support (Wilder and Sorensen, 2001). The patient should be offered an explanation of the decision to use RT, the medication and its effects, and a discussion of his or her experiences. The nurse should ensure that the use of RT is discussed at the earliest opportunity with the multidisciplinary team, and any lessons learned should be incorporated into future practice (NICE, 2015).

    Conclusions

    The administration of RT is often a traumatic event for both the patient and those involved. Nurses should always exhaust verbal de-escalation techniques before administering RT and it must then be considered by the multidisciplinary team to be in the patient's best interests. The least restrictive options should always be adopted throughout the procedure, with oral forms of RT being offered, where appropriate, in the first instance. Mechanical and physical restraint (especially in the prone position) should be avoided where possible and the vastus lateralis site considered in order to enable this. Nurses need to maintain clinical competency in administration of RT, including standards for medication management, accurate documentation and record keeping.

    KEY POINTS

  • The management of challenging behaviour, violence and aggression is an issue for nurses across all fields of nursing
  • Restraint is sometimes used as an intervention in the management of patients whose behaviour challenges; this may be in the form of physical, mechanical or chemical restraint
  • Rapid tranquillisation (RT) is often considered a form of chemical restraint, which may be used in an emergency situation when prescribed
  • If RT is given it should be done so as the least restrictive option, preferably in oral form, with intramuscular or intravenous administration as a last resort
  • If intramuscular administration is necessary, the vastus lateralis site is often preferable to avoid the use of prone (face down) restraint
  • Monitoring of the patient is essential following administration of RT using the National Early Warning Score 2 (NEWS 2)
  • All incidents involving RT should be documented appropriately
  • CPD reflective questions

  • Consider the relationship between restrictive practices and how they may lead to patients exhibiting violence, aggression or challenging behaviour
  • Devise ways that you could encourage a distressed and angry patient to take RT orally in order to avoid intramuscular administration
  • Explore how you may position a patient to administer RT and which injection sites you would use to cause minimal distress to the patient
  • Consider the adverse effects that may occur following administration of rapid tranquillisation and how you would identify and manage them