Rapid Tranquillisation
Rapid tranquillisation is sometimes used with disturbed violent patients in adult in-psychiatric settings and emergency departments. It’s only a small part of the algorithm for the short term management of these patients. Other aspects are prediction, prevention, other interventions than medication and a post incident review.
There’s a guideline from the UK’s National Institute for Health and Clinical Excellence (NICE). This guideline makes a distinction between psycotic and non psychotic context. With psychotic context the combination of lorazepam and haloperidol is advised and olanzapine i.m. is also advised with moderate disturbance. The evidence for the latter is mainly from industry sponsored studies and drug industry authored papers. As with most industry sponsored studies they used seldom used rating scales, many exclusion criteria were used in these trials, e.g. the exclusion of alcohol and drugs use, those who needed restraint and with violence against others. Not your average patient and thus hard to generalize the findings of these studies with olanzapine.
The combination of haloperidol and promethazine is not recommended by the NICE guideline due to insufficient data. Luckily since 2005 three studies with haloperidol and promethazine were published, research of excellent quality. All three Randomized Controled Trials RCT. One comparing intramuscular haloperidol against haloperidol plus promethazine. The haloperidol group (n=156) were treated mostly, 71% of participants, with 10 mg i.m., the other 29% were given 5 mg of haloperidol. The combination with promethazine did much better in tranquillisation within 20 minutes. The number needed to treat was 6. Moreover, at least 7% of patients with only haloperidol suffered from side effects: acute dystonia. Number needed to treat is the number of patients who must receive a particular therapy for one to benefit. In this case it takes 6 patients to treat with the combination in order for 1 patient more to benefit over haloperidol alone.
When comparing this combination with intramuscular olanzapine the number needed to treat is 30. This means that in the short term both treatments are efficacious in reaching tranquillisation after 15 minutes. Both are effective at rapidly tranquillising or sedating agitated violent patients. Unfortunately this effect subsides with olanzepine very fast. These patients needed additional medical interventions within the four hours of the intervention. Adverse effects were uncommon with both treatments.
The combination of haloperidol and promethazine compared to intramuscular lorazepam resulted in a faster onset of tranquillisation and sedation and more clinical improvement over the first 2 hours for the combination.
These randomized controlled trials also have their limitations. Allocation to treatment was blinded, evaluation after allocation was not. Moreover, evaluation was done by different raters as is usual in busy psychiatric emergency departments. These studies were done in India and Brasil, this could have effect on generalization of the results.
Huf, G., Coutinho, E., Adams, C., & , . (2007). Rapid tranquillisation in psychiatric emergency settings in Brazil: pragmatic randomised controlled trial of intramuscular haloperidol versus intramuscular haloperidol plus promethazine BMJ, 335 (7625), 869-869 DOI: 10.1136/bmj.39339.448819.AE
Raveendran, N., Tharyan, P., Alexander, J., Adams, C., & , . (2007). Rapid tranquillisation in psychiatric emergency settings in India: pragmatic randomised controlled trial of intramuscular olanzapine versus intramuscular haloperidol plus promethazine BMJ, 335 (7625), 865-865 DOI: 10.1136/bmj.39341.608519.BE
Alexander, J. (2004). Rapid tranquillisation of violent or agitated patients in a psychiatric emergency setting: Pragmatic randomised trial of intramuscular lorazepam v. haloperidol plus promethazine The British Journal of Psychiatry, 185 (1), 63-69 DOI: 10.1192/bjp.185.1.63
Otte
December 1, 2010 @ 12:15 pm
It is good practise to differentiate a RT treatment to “calm” a patient from one that “sedates”. Sedation is in fact an effect of most neuroleptics depending on their H1 affinity and as such to be considered a side effect.
Moreover rapid tranquillisation often is needed in patient that we don’t know (we have no prior idea about QTc value and ofte that is hard to obtain in already agitated or violent patients.
I found aripiprazole IM to be both safe (no QT effect) and effective in RT without those annoying sedative side effects that patient often find difficult to tolerate (ask them the day after..!).
Sincerely
Dr. G. Otte
Dr Shock
December 2, 2010 @ 5:12 pm
May be you should do a RCT? Thnx for the comment, take care Dr shock
Otte Georges
December 2, 2010 @ 8:33 pm
I can do it but perhaps we can also and much more appropriated ask prof Fagioloni who used it intensively at his 200 bed emergency pstychiatry in Pittsberg (is now at Sienna Univ). Could save me time and $$$$$
🙂
G. Otte
Benny G
January 30, 2011 @ 12:45 am
To witness effects of drugs pushed see dystonic reaction (oculogyric crisis with retrocollis within hours of receiving Haldol) in autistic patient, see “Autistic Patient In Crisis Goes Unnoticed” on you tube. Dystonic reaction in this patient was quickly reversed with ‘cogentin” and ‘benadryl”, after mom notices reaction and calls for treatment. Good reminder for physicians to remind nurses caring for patients in hospital settings, to observe for EPS, following anti-psychotic treatment.