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Clinical Atlas Prestige · Evidence-first

Psych VivasEmergency psychiatry

Psych Vivas · Emergency psychiatry

Acute agitation and rapid tranquillisation — structured clinical viva

Fellowship viva on RT ladder, combination ban, TREC and ANZ ED options, monitoring, capacity, and rescue pathways.

clinical
On this page & tools

Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
You are the on-call psychiatry registrar. ED calls about a 26-year-old man with known schizophrenia who is extremely agitated after de-escalation failed. He refuses oral medication. Staff ask whether to give IM olanzapine 10 mg with IM midazolam 5 mg now. Discuss your approach including assessment, pharmacology with doses, monitoring, legal/capacity issues, and what you would do if standard RT fails.

Interpretation

Reveal interpretation

Reject the proposed combination. IM olanzapine must not be given with a parenteral benzodiazepine (midazolam). Risk is profound respiratory depression and hypotension. This is a non-negotiable viva fail if missed.[1]

Assessment. Scene safety, ABCDE, glucose, vitals, ECG QTc before or ASAP with antipsychotics, exclude medical mimics, emergency MSE (threat/command content), capacity for treatment decisions, legal status.[1]

Safer RT plan. Prefer single IM agent: lorazepam 1–2 mg IM, or olanzapine 5–10 mg IM alone (then wait ≥1 h before any parenteral BZD), or aripiprazole ~9.75 mg IM, or haloperidol 5 mg IM + promethazine 25–50 mg IM (TREC-backed). In ANZ ED undifferentiated SBD, droperidol 5–10 mg IM is a common evidence-supported first-line with monitoring. Endpoint calm and rousable; observations every 15 minutes for ≥1 hour.[1][3]

If standard RT fails. Senior review; environmental control; do not stack banned combinations. In ED with airway readiness, ketamine rescue for difficult-to-sedate SBD has evidence under local governance — not default general-ward first-line.[2]

Legal/ethics. Capacity is decision-specific; document least-restrictive rationale; apply local Mental Health Act without inventing foreign section numbers.[4]

Key points

Combination ban

Never IM olanzapine with parenteral benzodiazepines.

Name doses

Lorazepam 1–2 mg IM; olanzapine 5–10 mg IM; H 5 mg + promethazine 25–50 mg; droperidol 5–10 mg IM (ANZ ED).

Monitor

Every 15 minutes for at least 1 hour after parenteral RT.
[1]

References

  1. [1]Patel MX, Sethi FN, Barnes TR, et al. Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: De-escalation and rapid tranquillisation J Psychopharmacol, 2018.PMID 29882463
  2. [2]Isbister GK, Calver LA, Downes MA, et al. Ketamine as Rescue Treatment for Difficult-to-Sedate Severe Acute Behavioral Disturbance in the Emergency Department Ann Emerg Med, 2016.PMID 26899459
  3. [3]Huf G, Coutinho ES, Adams CE, et al. Rapid tranquillisation in psychiatric emergency settings in Brazil: pragmatic randomised controlled trial of intramuscular haloperidol versus intramuscular haloperidol plus promethazine BMJ, 2007.PMID 17954515
  4. [4]Spencer BWJ, Gergel T, Hotopf M, et al. Unwell in hospital but not incapable: cross-sectional study on the dissociation of decision-making capacity for treatment and research in in-patients with schizophrenia and related psychoses. Br J Psychiatry, 2018.PMID 29909778