Rapid Tranquillisation (RT)

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1. Overview & Principles

Rapid Tranquillisation (RT) is the use of medication to calm or lightly sedate an acutely disturbed patient to reduce the risk of harm to themselves or others. It is a medical emergency intervention, not a routine treatment. [1]

The "Goal of Calmness"

• Success: The patient is rousable, able to communicate, but not aggressive.
• Failure: The patient is unconscious (GCS less than 10) or obtunded. This is Over-sedation and represents a patient safety incident.

The Three Pillars of RT

1. Justification: Is there an immediate risk to life or safety? (Harm to self, others, or imminent property destruction).
2. Proportionality: Is this the least restrictive option? Have verbal/environmental measures failed?
3. Safety: Are we monitoring for the "Silent Killers" (Airway obstruction, Arrhythmia, Respiratory depression)?

Exam Detail: Viva Question: "What are the legal justifications for RT in the UK?"

Model Answer: RT can be justified under: (1) Mental Health Act 1983 (Sections 2, 3, 5(2), 5(4)) as treatment for mental disorder; (2) Mental Capacity Act 2005 for patients lacking capacity due to organic causes (delirium, intoxication); (3) Common Law Doctrine of Necessity in emergencies where legal status is unclear. All interventions must be proportionate, necessary, and in the patient's best interests.

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2. De-escalation: The First Line

Before reaching for a syringe, every clinician must master verbal de-escalation. The evidence shows that systematic de-escalation reduces the need for coercive measures by up to 50% when implemented consistently. [2,3]

Evidence-Based De-escalation Framework (The "10 Domains")

1. Environmental Modification

• Remove Audience: Aggression is often performative. "Can we step into this quieter room?" (Reduces the 'performance' aspect). [2]
• Reduce Stimulation: Dim lights, lower noise, remove clutter.
• Create Space: 2 arm-lengths distance (approximately 1.5-2 meters). Stand at 45-degree angle (less confrontational than head-on).

2. Body Language & Non-Verbal Communication

• Open Posture: Hands visible (not in pockets, not crossed). No sudden movements.
• Eye Contact: Brief and respectful. Prolonged staring can be perceived as threatening.
• Positioning: Never block the exit. Ensure patient has escape route.

3. Verbal De-escalation Techniques

• One Voice Rule: Only ONE professional should speak. Others stand back to support physically if needed but stay silent. "Command and Control". [2]
• Use Their Name: "Dave, I can see you are upset. I want to help you."
• Validation: Acknowledge the emotion without agreeing with the content. "It must be frustrating waiting this long." [3]

4. Strategic Communication

• Simple Language: Short sentences. Avoid complex reasoning (cortical shutdown during high arousal).
• The "Broken Record": Repeat the boundary calmly. "I want to help, but I cannot do that while you are shouting."
• Avoid "No": Instead of "You can't go out", say "We can talk about going out once the doctor has seen you."

5. Offering Choice & Control

• Pseudo-Choice: Give control back. "Would you prefer water or juice?" "Would you like to sit here or there?"
• Collaborative Problem-Solving: "What would help you feel calmer right now?"

6. Temporal Distancing

• Time-Based Reassurance: "The doctor will see you in 30 minutes." (Provides predictability).
• Acknowledging Waiting: "I can see you've been waiting a long time. Let me check on the delay."

7. Sensory Modulation (Evidence-Emerging)

Before drugs, try sensory input (if patient amenable):

• Weighted Blanket: Provides proprioceptive input/calming ('deep pressure').
• Low Stimulus Area: Designated quiet rooms.
• Ice: Holding an ice cube (grounding technique for emotional dysregulation).
• Music: Patient's own playlist (if culturally appropriate).

8. Staff Safety Protocols

• Know the Exit: Never corner yourself.
• Call for Help Early: Do not attempt solo de-escalation if violence is imminent.
• Violence Cues: Clenched fists, target locking (staring at specific person), weapon acquisition.

9. Cultural Competence

• Language: Use interpreters for non-English speakers.
• Cultural Norms: Eye contact norms vary. In some cultures, direct eye contact is disrespectful.
• Religious Considerations: Respect religious needs (prayer time, modesty).

10. When to Stop De-escalation

If violence is imminent (weapon drawn, assault in progress), stop talking and initiate safety protocols (Code Black/Security/Restraint).

Clinical Pearl: The "90-Second Rule": Most de-escalation attempts show response within 90 seconds. If no improvement after 90 seconds of consistent approach, escalate to next level (PRN oral medication offer) rather than persisting with ineffective verbal intervention. [2]

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2a. The Neurobiology of Aggression ("The Hijacked Brain")

Understanding why a patient is aggressive helps maintain empathy and informs intervention.

1. The Amygdala (The Alarm)

• Function: Scans for threat continuously.
• In Psychosis/PTSD: Hyperactive. Perceives neutral stimuli (e.g., a nurse walking past) as a life threat.
• Output: Triggers "Fight or Flight" response (Sympathetic surge → Tachycardia, Diaphoresis, Pupil dilation).

2. The Prefrontal Cortex (The Brakes)

• Function: Impulse control, rational thought, emotional regulation.
• In Acute Arousal: Connection between Cortex and Amygdala is severed ("Cortical Shutdown"). [4]
• Implication: The patient literally cannot process complex verbal reasoning. Keep sentences short. (e.g., "Put the chair down" not "If you don't put the chair down, we will have to call security and...").

3. Neurotransmitter Dysregulation

• Dopamine: Excess drives paranoia and goal-directed aggression (Schizophrenia/Mania). → Target for Antipsychotics (D2 antagonism).
• GABA: The inhibitory "calming" neurotransmitter. → Target for Benzodiazepines (GABA-A agonism).
• Serotonin: Dysregulation linked to impulsivity and aggression. → Target for SSRIs (long-term).
• Noradrenaline: Drives physical arousal (High HR, sweating). → Target for Beta-blockers (rarely used acutely).

Exam Detail: Pathophysiology Question: "Explain the neurobiological basis for reduced capacity to engage with verbal de-escalation in an acutely agitated patient."

Model Answer: During acute agitation, the amygdala is hyperactivated, triggering a sympathetic response. Simultaneously, the prefrontal cortex undergoes functional disconnection from limbic structures ("cortical shutdown"), impairing executive functions including language processing, impulse control, and rational thought. This neurobiological state, mediated by excess catecholamines and cortisol, renders the patient unable to process complex verbal information. Therefore, de-escalation must use simple, concrete language and focus on reducing environmental threat rather than complex reasoning. [4]

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2b. The Safewards Model (Prevention)

Prevention is better than cure. The Safewards model identifies triggers and interventions to prevent conflict escalation. [5]

Flashpoints (Triggers):

• Rules and restrictions
• Waiting times
• Bad news (diagnosis, sectioning)
• Medication refusal

Patient Modifiers:

• Intoxication
• Delusions (paranoid content)
• Personality disorder traits (emotional dysregulation)

Staff Modifiers:

• Inconsistent limit-setting
• Lack of empathy ("Us vs Them" attitude)
• Inexperience

Safewards Interventions:

1. Soft Words: Using non-confrontational language.
2. Mutual Help Meeting: Start the day discussing how to support each other.
3. Discharge Messages: Notes from past patients on the wall ("I got better, you can too").
4. Clear Expectations: Written ward rules posted.
5. Positive Words Board: Positive affirmations from staff.

Evidence Debate: Safewards Implementation: A cluster RCT across 16 wards showed Safewards reduced conflict events by 15% and containment measures (seclusion, RT, restraint) by 26%. [5] However, effectiveness varies by ward culture. High staff turnover undermines consistent implementation.

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3. Indications & Legal Framework

3a. Differential Diagnosis: "Is it Psychiatric or Organic?"

Agitation is a symptom, not a diagnosis. Organic causes have high mortality if sedated without treatment of underlying cause. [6]

The "Fatal Six" (Must Exclude Before RT)

Clinical Pearl: The "Pulse Ox, Glucose, Temp" Rule: These three bedside tests take 60 seconds and can prevent catastrophic errors. Never skip them, even if the patient appears "psychiatrically unwell". Hypoglycaemia presenting as aggression has been mistaken for psychosis, leading to deaths. [6]

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3b. Substance-Related Agitation

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3c. Primary Psychiatric Causes

Once organic/substance causes excluded:

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3d. Legal Framework (UK)

RT is a serious intervention interfering with human rights (Article 8 ECHR—Right to private life; Article 3 ECHR—Freedom from inhuman/degrading treatment). [10]

Mental Health Act (MHA) 1983

• Section 5(2): Doctors holding power (72 hours). Allows RT if urgently needed.
• Section 5(4): Nurses holding power (6 hours).
• Section 2/3: Formal detention. Part 4 (Consent to Treatment) applies.
  • T3 Form: Not required for first 3 months of medication.
  • SOAD (Second Opinion Appointed Doctor): Required after 3 months for continuation.
• Section 136: Police power to remove from public place to Place of Safety.
• Community Treatment Order (CTO): Does NOT authorise forced medication in community. Recall to hospital required.

Mental Capacity Act (MCA) 2005

• Used when primary cause is physical (Sepsis, Head Injury, Hypoglycaemia) or Intoxication, and patient lacks capacity to consent to treatment.
• Best Interests: Document why RT is in their best interest (e.g., prevent life-threatening exhaustion, injury).
• Proportionality: Force used must be proportional to risk.
• Deprivation of Liberty Safeguards (DoLS): May be needed if prolonged restriction.

Common Law (Doctrine of Necessity)

• Used in dire emergencies to prevent immediate life-threatening harm when legal status is unknown.
• Criteria: (1) Immediate necessity; (2) No less restrictive alternative; (3) Proportionate force.

Exam Detail: Viva Question: "When would you use MCA vs MHA for RT in a patient with alcohol-induced delirium?"

Model Answer: If the agitation is purely due to alcohol intoxication (no underlying mental disorder), use MCA 2005 under best interests, as the primary issue is medical (delirium) not psychiatric. If there is co-morbid mental disorder (e.g., depression, psychosis) requiring treatment, use MHA 1983. In emergency, if legal status unclear, use Common Law Doctrine of Necessity to stabilize, then formalize legal status.

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4. Assessment & Risk Prediction

Risk assessment is dynamic. Use structured tools + clinical judgment.

4a. The Brøset Violence Checklist (BVC)

A validated 6-item tool to predict violence in next 24 hours. [11]

Score 1 for presence of each:

1. Confusion: Disoriented to time/place.
2. Irritability: Easily annoyed, short-tempered.
3. Boisterousness: Loud, shouting, attention-seeking.
4. Physical Threats: Raising fists, posturing, invading space.
5. Verbal Threats: "I'm going to kill you"

• "I'll smash your face".

6. Attacks on Objects: Kicking doors, throwing chairs, breaking windows.

Interpretation:

• Score 0: Low risk (2% violence rate).
• Score 1-2: Moderate risk (30% violence rate). De-escalation + PRN medication.
• Score ≥3: High risk (63% violence rate). Preventative measures. Staff safety alert. Consider RT if escalates. [11]

Sensitivity: 63% | Specificity: 92% | PPV: 63%

Clinical Pearl: The BVC is quick (30 seconds) and does not require patient cooperation. It can be scored by observation alone, making it ideal for ED/acute settings. [11]

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4b. Medical Assessment (Exclude "Mimics")

Before assuming "Psychiatric Behavior", systematically exclude:

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4c. Baseline Physical Health

If safe to approach:

• ECG: Baseline QTc interval. Antipsychotics prolong QT (especially Haloperidol). QTc > 500ms is alarming. [12]
  • Note: In emergency, do not delay RT for ECG, but prioritize ECG immediately post-sedation.
• Past Medical History: Cardiac disease? Epilepsy? Liver/Renal impairment?
• Current Medications: On Clozapine? (High seizure risk). On SSRIs? (Serotonin syndrome risk).

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5. Pharmacology & Management Strategy

5a. Step 1: Oral Medication (The "Offer")

Always offer oral medication first. It preserves dignity and is safer (slower absorption, less respiratory depression). [1]

Benzodiazepines

• Lorazepam (1-2mg PO):
  • Gold standard. Rapid onset (30 mins). Short half-life (12h). No active metabolites (safer in liver disease).
  • Advantages: Reversible (Flumazenil). Safer cardiac profile.
  • Disadvantages: Respiratory depression (especially if intoxicated). Paradoxical agitation (5-10%).

Antipsychotics

• Haloperidol (5mg PO):
  • Classic typical. High potency D2 antagonist.
  • Advantages: Effective for psychosis-driven aggression.
  • Disadvantages: High EPSE risk (Dystonia 10-20% in young males). QTc prolongation.
• Olanzapine (10mg PO):
  • Atypical. Oro-dispersible tablets (ODT/Velotab) dissolve on tongue (harder to "cheek").
  • Advantages: Lower EPSE risk. Good sedation.
  • Disadvantages: Metabolic effects (long-term). Hypotension (orthostatic).
• Aripiprazole (10-15mg PO):
  • Partial D2 agonist. Very low EPSE risk.
  • Disadvantages: Slow onset (45-60 mins). Poor for immediate RT. [13]

Sedating Antihistamines

• Promethazine (25-50mg PO):
  • Sedating antihistamine (H1 antagonist + Muscarinic antagonist).
  • Use: Adjunct to antipsychotic (increases sedation, reduces dystonia risk).
  • Disadvantages: Anticholinergic burden (delirium in elderly). Lowers seizure threshold.

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5b. Step 2: Intramuscular (IM) Options—The Evidence

If immediate danger persists despite oral offer, proceed to IM.

Option A: Benzodiazepine Monotherapy (Safest)

Drug: Lorazepam 1-2mg IM [1,14]

Evidence:

• BAP-NAPICU Guidelines (2018): Lorazepam IM is first-line for RT when no clear diagnosis, or when organic causes suspected. [1]
• Cochrane Review: Lorazepam IM produces sedation in 50-60% by 60 minutes. [14]

Pharmacokinetics:

• Onset: 15-30 mins
• Peak: 60-90 mins
• Half-life: 12-16 hours
• Metabolism: Glucuronidation (no active metabolites → safer in liver disease)

Advantages:

• Safe cardiac profile (no QTc prolongation)
• Reversible (Flumazenil 200mcg IV)
• Effective for alcohol withdrawal, benzodiazepine withdrawal, stimulant toxicity

Disadvantages:

• Respiratory depression (especially if alcohol/opioid co-ingestion). Monitor SpO2 continuously.
• Paradoxical agitation (5-10%, more common in head injury, learning disability)
• Slower onset than Midazolam

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Option B: Combined Haloperidol + Promethazine (Standard)

Regimen: Haloperidol 5mg IM + Promethazine 25-50mg IM [1,15]

Evidence:

• TREC-Rio I Trial (2003): Compared Midazolam vs Haloperidol+Promethazine. H+P produced sedation in 67% by 20 mins (vs 96% for Midazolam, but safer). [15]
• TREC-India Trial (2007): Haloperidol+Promethazine vs Olanzapine. No significant difference in time to sedation (median 15 mins both), but H+P cheaper. [16]
• BAP-NAPICU (2018): Recommends H+P as first-line for psychosis-driven aggression. [1]

Rationale:

• Haloperidol: D2 antagonism targets dopamine-driven psychosis/mania.
• Promethazine: Provides sedation and protects against Haloperidol-induced dystonia (anticholinergic effect).

Pharmacokinetics:

• Onset: 20-40 mins (Haloperidol), 20 mins (Promethazine)
• Peak: 40-60 mins
• Half-life: 24 hours (Haloperidol), 10-14 hours (Promethazine)

Advantages:

• Well-studied. Predictable sedation.
• Promethazine reduces dystonia risk from 20% to 5%. [1]

Disadvantages:

• QTc prolongation (Haloperidol). Risk of Torsades de Pointes (0.1-1%). [12]
• Dystonia (despite Promethazine, still 5% risk in young males).
• Anticholinergic burden (Promethazine): Delirium, urinary retention, constipation.

Contraindications:

• QTc > 500ms
• Recent MI
• Parkinson's disease (antipsychotics worsen rigidity)
• Lewy Body Dementia (severe sensitivity to antipsychotics)

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Option C: Olanzapine IM (Atypical Monotherapy)

Drug: Olanzapine 10mg IM [1,16,17]

Evidence:

• TREC-India (2007): Olanzapine 10mg IM vs Haloperidol 5mg + Promethazine 25mg. Non-inferior for time to sedation (median 15 mins). [16]
• Meta-analysis (2018): Olanzapine IM effective, but higher hypotension risk vs Haloperidol. [17]
• BAP-NAPICU (2018): Olanzapine IM is alternative to H+P, but NEVER combine with IM benzodiazepines. [1]

Pharmacokinetics:

• Onset: 15-30 mins
• Peak: 45 mins
• Half-life: 30 hours

Advantages:

• Lower EPSE risk (dystonia less than 2%)
• Good sedation
• No QTc prolongation (lower cardiac risk than Haloperidol)

Disadvantages:

• FDA Black Box Warning: NEVER combine IM Olanzapine with IM Benzodiazepines. [18]
  • Mechanism: Synergistic cardiovascular depression → Profound bradycardia, hypotension, respiratory depression.
  • Deaths reported: 2000-2004 (post-marketing surveillance).
  • Safe Gap: Wait at least 1-2 hours between IM Olanzapine and IM Benzodiazepines.
• Orthostatic hypotension: Falls risk.
• Metabolic effects: Long-term weight gain, diabetes risk (not relevant acutely).

Critical Safety Rule: If patient received IM Lorazepam within last 2 hours, DO NOT give IM Olanzapine. Use Haloperidol instead.

Clinical Pearl: The "Olanzapine-Benzodiazepine Interaction": This is the most dangerous drug interaction in RT. In 2004, the FDA issued a Black Box Warning after 18 deaths. The mechanism is cardiovascular collapse (bradycardia + hypotension + respiratory depression), likely due to synergistic GABA potentiation and α1-adrenergic blockade. [18] Always check what the patient received in the last 2 hours.

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Option D: Emergency Medicine Protocol (Excited Delirium)

Setting: ED Resus ONLY (Full monitoring, intubation capability).

Indication: "Excited Delirium" / Acute Behavioral Disturbance (ABD) with severe sympathomimetic toxicity (Cocaine, Meth) where patient fights restraints to point of metabolic acidosis/cardiac arrest risk.

Drugs:

1. Ketamine (4-5mg/kg IM, approx 300-400mg for 70kg adult) [19]

   • Mechanism: NMDA antagonist → Dissociative anesthesia.
   • Onset: 3-5 mins.
   • Advantages: Preserves respiratory drive and airway reflexes. Instant sedation.
   • Disadvantages: Laryngospasm (1-2%), Hypersalivation (give Glycopyrrolate), Emergence phenomenon (hallucinations on waking—reduce with Midazolam).
   • Requirement: Anesthetist present. Intubation equipment ready.

2. Droperidol (5-10mg IM)

   • Mechanism: Butyrophenone (like Haloperidol).
   • Onset: 10-15 mins.
   • Advantages: Rapid, potent.
   • Disadvantages: High QTc prolongation risk. Less available due to withdrawal in some countries.

Use Case Example: 30-year-old male on Methamphetamine, hyperthermia (40°C), fighting 6 police officers, breaking handcuffs. Ketamine 350mg IM → Dissociated in 4 mins → Intubated → Cooled → ICU.

Evidence Debate: Ketamine for Excited Delirium: Controversial. Pre-hospital use by paramedics has been associated with deaths (oversedation, aspiration). [19] However, in controlled ED settings with airway expertise, Ketamine is highly effective for severe ABD unresponsive to standard RT. The key is appropriate setting and monitoring.

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5c. Pharmacokinetic Comparison Table

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5d. Special Agent: Zuclopenthixol Acetate (Acuphase)

What is it?: An intermediately-active depot (oil-based IM injection).

Duration: Lasts 2-3 days.

Indication: NOT for immediate RT. Used for patients who require repeated RT injections over consecutive days (e.g., relapsing mania, treatment-resistant psychosis).

Dose: 50-150mg IM.

Advantages:

• Avoids daily injections.
• Sustained sedation over 72 hours.

Disadvantages:

• Cannot be reversed. If over-sedation occurs, you "own" it for 3 days.
• High EPSE risk.
• Do not give if patient is neuroleptic-naïve (test tolerance with short-acting first).

Contraindications:

• First episode psychosis (no prior antipsychotic exposure)
• Elderly/frail
• Cardiac disease

Exam Detail: Viva Question: "When would you use Zuclopenthixol Acetate?"

Model Answer: Zuclopenthixol Acetate (Acuphase) is used when a patient has required repeated IM RT injections over several days (e.g., manic relapse, non-concordance with oral medication). It is NOT for immediate RT due to slow onset (2-8 hours). Duration is 2-3 days. It should only be given to patients with prior antipsychotic exposure to assess tolerance. Key risk is prolonged over-sedation (cannot be reversed). It is contraindicated in neuroleptic-naïve patients, elderly, and those with cardiac disease.

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6. Monitoring Protocols: The "Silent Killers"

Using RT without monitoring is negligent. The risk of death is highest after the patient goes quiet ("Sudden Death in Restraint"). [20,21]

6a. The NEWS2 Protocol (Monitoring Frequency)

Time 0-60 mins: Every 15 minutes [1]

• ACVPU (Alert, Confusion, Voice, Pain, Unresponsive)
• Respiratory Rate (RR)
• SpO2
• Heart Rate
• Blood Pressure
• Temperature

Hour 1-4: Every 30 minutes

Hour 4+: Every hour until awake and ambulatory.

Trigger for Escalation:

• RR less than 10 or > 25
• SpO2 less than 90%
• HR less than 50 or > 120
• Systolic BP less than 90
• ACVPU = "V" (responds to voice only) or worse

Action: Call senior doctor immediately. Prepare for airway support.

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6b. What to Monitor (The "ABCDE" Approach)

1. Airway

• Risk: Positional asphyxia, tongue obstruction, vomit aspiration.
• Signs of Compromise: Snoring, gurgling, stridor.
• Action: Head-tilt chin-lift. Insert Guedel airway. Suction if secretions. Turn to lateral (recovery) position.

2. Breathing (Respiratory Depression)

• Highest risk with: Benzodiazepines + Alcohol/Opioids. [22]
• Signs: RR less than 10, SpO2 less than 90%, shallow breaths, "snoring" respiration.
• Mechanism: GABA agonism → Brainstem respiratory center depression.
• Management:
  1. Shake and shout: "Dave, wake up! Take a deep breath!"
  2. High-flow O2: 15L via non-rebreather mask.
  3. Bag-Valve-Mask (BVM): If RR less than 8 or apneic.
  4. Antidote: Flumazenil 200mcg IV over 15 seconds. Repeat every 60 secs up to 1mg total. [22]
     • Caution: Flumazenil lowers seizure threshold. Do NOT use if:
       • Epilepsy history
       • Tricyclic antidepressant overdose (seizure risk)
       • Chronic benzodiazepine use (may precipitate withdrawal seizures)

Clinical Pearl: Flumazenil Reversal: Flumazenil has a half-life of only 1 hour. Lorazepam has a half-life of 12-16 hours. Therefore, after Flumazenil wears off, the patient may re-sedate. Monitor for at least 4 hours after Flumazenil administration. [22]

3. Circulation

• Hypotension: Olanzapine (orthostatic), Promethazine (α-blockade).
• Signs: Systolic BP less than 90, dizziness on sitting up.
• Management: IV fluids (500ml Normal Saline). Leg elevation.
• Arrhythmia: QTc prolongation → Torsades de Pointes (polymorphic VT).
• Signs: Palpitations, syncope, ECG shows long QT.
• Management: Magnesium Sulphate 2g IV over 10 mins. Defibrillation if unstable.

4. Disability (Neurological)

• Level of Consciousness: Use ACVPU or GCS.
• Target: Patient should be rousable to voice within 1 hour. If unresponsive (GCS less than 10), this is over-sedation.
• Pupil Size: Check for asymmetry (head injury) or pinpoint pupils (opioid co-ingestion).

5. Exposure (Temperature)

• Hyperthermia (> 38.5°C):
  • Cause: Neuroleptic Malignant Syndrome (NMS), Serotonin Syndrome, Excited Delirium.
  • Action: Active cooling (ice packs, fans). Stop all antipsychotics. Check CK.
• Hypothermia (less than 36°C):
  • Cause: Prolonged sedation in cold environment.
  • Action: Warm blankets. Monitor for arrhythmias.

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6c. Positional Asphyxia (The Most Common Cause of Death in Restraint) [20,21]

Definition: Death caused by body position preventing chest expansion and diaphragm descent.

Mechanism:

1. Patient held prone (face down).
2. Pressure on back (from restrainers' body weight) compresses chest wall.
3. Diaphragm cannot descend (abdominal compression).
4. Patient is agitated → High O2 demand.
5. → Hypoxia → Acidosis → Cardiac arrest (PEA or VF).

High-Risk Scenarios:

• Obesity (abdominal mass restricts diaphragm)
• Prone restraint > 2 minutes
• "Hogtie" position (hands and feet tied together behind back)
• Excited Delirium (extreme metabolic demand)

Warning Signs:

• Patient stops struggling and goes limp. This is NOT compliance; this is cardiac arrest. [20]
• Cyanosis (blue lips, peripheries)
• Agonal breathing (gasping)

Prevention:

1. Never keep prone for > 2 minutes. [1]
2. Turn to supine (face up) or lateral (recovery) immediately after IM injection.
3. Do NOT sit/kneel on patient's back.
4. Monitor breathing continuously. "Can you hear me breathing?" (If patient can talk, airway is patent).

Clinical Pearl: The "Can You Hear Me Breathing?" Test: During restraint, repeatedly ask the patient, "Can you hear me breathing?" If they respond verbally, their airway is patent and they are conscious. If they stop responding, check pulse immediately. [20]

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7. Complications & Emergency Management

7a. Neuroleptic Malignant Syndrome (NMS)

A rare (0.01-0.02%) but fatal (10-20% mortality) reaction to antipsychotics. [23]

Classic Tetrad:

1. Rigidity: "Lead-pipe" (diffuse, constant, wax-like resistance). Distinct from Parkinson's "cogwheel".
2. Hyperpyrexia: Fever > 39°C (often > 40°C).
3. Autonomic Instability: BP swings (hypertension → hypotension), tachycardia, diaphoresis.
4. Altered Mental Status: Confusion, mutism, coma.

Lab Findings:

• CK > 1000 U/L (often 10,000-100,000). Marker of rhabdomyolysis.
• Leukocytosis (WBC 15,000-30,000)
• Elevated LFTs
• Myoglobinuria (tea-colored urine)
• Acute Kidney Injury (from myoglobin toxicity)

Differential Diagnosis:

• Serotonin Syndrome (Clonus, hyperreflexia, GI symptoms)
• Malignant Hyperthermia (triggered by anesthesia, not antipsychotics)
• Sepsis (but rigidity is rare)
• Catatonia (akinetic mutism, but no fever)

Management:

1. STOP all antipsychotics immediately.
2. Supportive Care (ICU admission):
   • Aggressive cooling (ice packs, cooling blankets).
   • IV fluids (6-8L/day to prevent renal failure from myoglobinuria).
   • Correct electrolytes.
3. Pharmacotherapy:
   • Dantrolene (Muscle relaxant): 1-2.5mg/kg IV, then 1mg/kg q6h. Reduces rigidity.
   • Bromocriptine (Dopamine agonist): 2.5-10mg TDS PO/NG. Reverses D2 blockade.
   • Lorazepam (Benzodiazepine): 1-2mg IV q4-6h. Reduces rigidity and agitation.
4. Monitor:
   • CK daily (should halve every 48 hours if treatment working).
   • Renal function (Urea, Creatinine).
   • ECG (arrhythmias common).

Prognosis:

• With treatment: Mortality 5-10%.
• Without treatment: Mortality 20-30%.
• Resolution: 7-10 days after stopping antipsychotic.

Re-challenge:

• Wait at least 2 weeks after resolution before restarting antipsychotic.
• Use lower potency agent (Quetiapine > Olanzapine > Haloperidol).
• Never re-challenge with the same drug that caused NMS.

Exam Detail: Viva Question: "How do you differentiate NMS from Serotonin Syndrome?"

Model Answer:

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7b. Acute Dystonia (Oculogyric Crisis)

Sudden, involuntary muscle contractions. Terrifying for patient but easily treatable. [24]

Incidence:

• Haloperidol: 10-20% (higher in young males).
• Olanzapine: less than 2%.

Classic Presentations:

1. Oculogyric Crisis: Eyes roll upwards involuntarily. Patient in extreme distress.
2. Torticollis: Neck spasm (head twisted to one side).
3. Trismus: Lockjaw (cannot open mouth).
4. Laryngospasm: Spasm of vocal cords (airway emergency).
5. Opisthotonus: Arching of back (mimics tetanus).

Onset: Usually within 24 hours of antipsychotic dose.

Risk Factors:

• Young age (less than 30 years)
• Male sex
• High-potency typical antipsychotics (Haloperidol > Fluphenazine)
• First dose (no prior tolerance)
• Dehydration, cocaine use

Management:

1. Procyclidine 5-10mg IM or IV (or Benztropine 1-2mg IM).
   • Mechanism: Anticholinergic (restores dopamine-acetylcholine balance).
   • Onset: Relief in 10-20 minutes.
2. Observe for 4 hours (can recur if Procyclidine wears off before Haloperidol).
3. Prescribe oral anticholinergic for 3-5 days (Procyclidine 5mg TDS) to prevent recurrence.

Prophylaxis:

• If giving Haloperidol to young male, consider prophylactic Procyclidine 5mg PO/IM.

Clinical Pearl: Oculogyric Crisis Presentation: Imagine a terrified patient, eyes fixed upward, unable to bring gaze down, in severe distress. They may think they are dying. The dramatic response to Procyclidine (dystonia resolves in minutes) is one of the most rewarding acute treatments in psychiatry. Always explain to patient afterward: "This was a side effect of the medication, not your illness worsening." [24]

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7c. QTc Prolongation & Torsades de Pointes

Mechanism: Antipsychotics block cardiac potassium (hERG) channels → Delayed repolarization → Long QT → Risk of polymorphic VT (Torsades de Pointes). [12]

QTc Thresholds:

• Normal: less than 440ms (men), less than 460ms (women)
• Prolonged: 440-500ms (monitor)
• Dangerous: > 500ms (high Torsades risk)

High-Risk Drugs (for QTc prolongation):

1. Haloperidol (especially IV)
2. Droperidol
3. Ziprasidone
4. Thioridazine (withdrawn in many countries)

Lower Risk:

• Olanzapine
• Aripiprazole
• Quetiapine

Risk Factors for Torsades:

• Baseline long QT syndrome
• Hypokalaemia (K+ less than 3.5)
• Hypomagnesaemia (Mg less than 0.7)
• Bradycardia (less than 50 bpm)
• Female sex
• Cardiac disease
• Concurrent QT-prolonging drugs (Amiodarone, Citalopram, Methadone)

Management:

1. Monitor ECG if using Haloperidol (especially if > 10mg/day total).
2. Correct electrolytes: K+ > 4.0, Mg > 1.0.
3. If Torsades occurs:
   • Magnesium Sulphate 2g IV over 10 mins (first-line). [12]
   • Defibrillation if pulseless.
   • Temporary pacing if recurrent.
4. Stop offending drug. Switch to safer antipsychotic (Aripiprazole, Quetiapine).

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7d. Paradoxical Agitation (Benzodiazepine Disinhibition)

Incidence: 5-10% of patients given benzodiazepines become more aggressive. [25]

Mechanism: Disinhibition (similar to alcohol intoxication). GABA agonism reduces frontal lobe inhibition of limbic aggression.

Risk Factors:

• Head injury
• Learning disability
• Personality disorder (EUPD)
• Alcohol intoxication (additive disinhibition)

Presentation:

• Patient becomes louder, more aggressive, impulsive 20-60 mins after benzodiazepine.

Management:

1. Stop benzodiazepines.
2. Switch class: Use antipsychotic (Haloperidol 5mg IM or Olanzapine 10mg IM).
3. Do NOT give more benzodiazepines (will worsen).

Clinical Pearl: The term "paradoxical" is misleading. This is not a paradox; it is disinhibition, the same mechanism that makes drunk people aggressive. It is predictable in certain populations (head injury, learning disability). [25]

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8. Physical Restraint: The Safety Protocol

Physical restraint is a skilled intervention, not a brawl. It requires a trained team (minimum 3, ideally 5). [1,20]

8a. The Team Roles

Team Leader (No. 1):

• Manages the Head.
• Dedicated airway officer.
• Does NOT get involved in limb restraint.
• Talks to patient continuously: "You are safe. We are keeping you safe. Breathe."

Limb Handlers (No. 2-5):

• One for each limb.
• Secure large joints (shoulders, hips), NOT wrists/ankles (fracture risk).
• Minimize force. Use body weight, not strength.

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8b. Positioning (The Controversy)

Prone (Face Down)

Advantages:

• Easier to administer IM injection in gluteal region.
• Easier to control limbs (patient cannot kick effectively).

Disadvantages:

• High risk of Positional Asphyxia. [20,21]
• Compresses chest. Patient cannot breathe.
• Psychologically traumatic (loss of control, re-traumatization).

RULE: Never keep prone for > 2 minutes. [1] Turn immediately after injection.

Supine (Face Up)

Advantages:

• Airway is visible.
• Chest can expand.
• Less risk of asphyxia.

Disadvantages:

• Risk of aspiration if vomiting.
• Harder to control limbs (patient can kick).

RULE: Head must be supported (prevent hyperextension). Suction must be nearby (aspiration risk).

Lateral (Recovery Position)

The Goal: Get patient here as soon as possible.

Advantages:

• Airway protected (tongue forward, vomit drains out).
• Breathing unrestricted.
• Safest position.

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8c. Duration of Restraint

• Restraint should be minutes, not hours.
• Prolonged struggle risks:
  • Rhabdomyolysis (Muscle breakdown → Myoglobin release → Renal failure). [20]
  • Lactic Acidosis (Metabolic exhaustion).
  • Hyperthermia (Especially in Excited Delirium).

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8d. Post-Restraint Care

Immediate (First Hour):

1. Check for injuries: Wrists, shoulders, chest wall (rib fractures).
2. Check injection site: Haematoma?
3. Monitor vital signs: Every 15 mins (NEWS2 protocol).
4. Hydration: Offer oral fluids once safe to swallow.

Physical Health:

• Skin integrity: Check for pressure areas.
• Toileting: Assist to bathroom (fall risk due to sedation).
• Rhabdomyolysis screen: If prolonged struggle (> 10 mins), check CK, U&E.

Psychological Support:

• Re-orientation: "You are safe. You are in hospital. My name is..."
• Privacy: If clothes torn during restraint, provide clean gowns immediately.
• Explanation: Do not wait for debrief. Explain briefly: "We had to hold you because you were at risk of hurting yourself/others. The medication will help you feel calmer."

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9. Specific Populations

9a. Pregnancy

Risk: Medication crosses placenta → Fetal exposure.

First Line: Verbal de-escalation is paramount. Avoid medication if possible.

Drug Choices:

• Haloperidol: Category C. Generally considered safest antipsychotic in emergency. Crosses placenta but no major teratogenicity.
• Promethazine: Safe.
• Lorazepam: Avoid if possible (Floppy infant syndrome in third trimester), but acceptable for single emergency dose.
• AVOID: Valproate (teratogenic), Benzodiazepines (chronic use → withdrawal in neonate).

Restraint Considerations:

• Left Lateral Tilt is mandatory (from 20 weeks gestation). [26]
• Rationale: Gravid uterus compresses Inferior Vena Cava in supine position → Reduced venous return → Hypotension → Fetal hypoxia.
• NEVER restrain prone (compresses uterus).

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9b. Elderly / Frail / Dementia

Risks: Falls, Delirium, Over-sedation, Stroke (antipsychotics increase risk 2-3x in dementia). [9]

Dose Reduction: "Start low, go slow." Use 50% or 25% of adult dose.

• Lorazepam: 0.5mg IM (Max 1mg).
• Haloperidol: 0.5-1mg IM (Max 2mg/24h).

Avoid:

• Olanzapine: Higher stroke risk in dementia (FDA Black Box Warning).
• Promethazine: Anticholinergic burden worsens delirium.

Preferred:

• Lorazepam 0.5mg (if benzodiazepine indicated).
• Haloperidol 0.5mg (if antipsychotic needed, but monitor closely).

Special Consideration:

• Lewy Body Dementia: Extreme sensitivity to antipsychotics (can cause irreversible Parkinsonism). Avoid if possible. Use Lorazepam.

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9c. Children & Adolescents (CAMHS)

Rule: Specialist CAMHS advice if possible.

Differences:

• Higher metabolic rate (faster drug clearance).
• Paradoxical reactions common.
• Dystonia risk higher in teenagers (especially males).

Protocol (Example, weight-based):

• Lorazepam: 0.5-1mg IM (based on age/weight).
• Olanzapine: 5mg IM (not licensed but often used off-label).
• Haloperidol: Generally avoided due to high EPSE risk.

Special Consideration:

• Involve parents/carers in decision if possible (Gillick competence).

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9d. Patients with Cardiac History

History: Long QT syndrome, Previous MI, Heart Failure, Cardiomyopathy.

Avoid:

• Haloperidol
• Droperidol

Preferred:

• Lorazepam (Neutral cardiac profile).
• Aripiprazole (if antipsychotic needed, but slow onset).
• Promethazine (Caution: Can cause tachycardia).

Pre-RT:

• ECG (check baseline QTc).
• Check electrolytes (K+, Mg).

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9e. Intoxication (Alcohol/Drugs)

Alcohol Intoxication

• Risk: Benzodiazepines + Alcohol = Synergistic respiratory depression.
• Strategy: Reduced dose Lorazepam (0.5-1mg) OR Use Haloperidol (does not suppress respiratory drive as much).
• NEVER: Assume aggression is "just drunk." Check glucose (hypoglycaemia), head injury (subdural).

Stimulants (Cocaine/Meth)

• Mechanism: Excess Dopamine + Noradrenaline surge.
• Strategy: Benzodiazepines are first-line (blunt sympathetic surge). Lorazepam 2mg IM. [8]
• Antipsychotics: Second-line (if psychosis).
• AVOID: Beta-blockers (unopposed alpha-adrenergic vasoconstriction → hypertensive crisis).

GHB/Gamma-Hydroxybutyrate

• Presentation: Paradoxical agitation OR profound sedation.
• Strategy: Supportive care. Avoid additional sedation (respiratory depression).

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10. Legal & Ethical Considerations

10a. Documentation Standards ("If it isn't written, it didn't happen")

Your notes must stand up in Coroner's Court. Record: [10]

1. De-escalation Attempts: What was tried? Why did it fail?

   • Example: "Verbal de-escalation attempted for 10 mins. Offered oral Lorazepam. Patient spat it out and threw chair at nurse. Immediate danger to staff."

2. Capacity/Legal Status: "Detained under Section 2 MHA" or "Lacks capacity under MCA (delirium, unable to understand treatment need)."

3. Drug/Dose/Route/Site: "Lorazepam 2mg IM into Left Gluteal region at 14:35."

4. Restraint Details: "Restrained prone for 90 seconds by 5-person team (Team Leader: Nurse A). Turned to supine immediately after injection. Head supported throughout. Patient able to communicate verbally during restraint."

5. Monitoring Plan: "NEWS2 chart initiated. 15-min obs commenced. SpO2 96%, RR 14, HR 88, BP 132/78."

6. Post-Incident Review: "Debriefed with patient at 16:00. Patient calm, able to engage. Expressed regret. Plan: Review by psychiatrist, restart oral medication."

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10b. Key Case Law (UK)

1. R (Munjaz) v Mersey Care NHS Trust [2005]:

   • Issue: Can hospitals depart from Code of Practice on seclusion/RT?
   • Ruling: Must have "cogent reasons" to depart. Cannot ignore NICE guidelines arbitrarily. [10]

2. Keenan v UK [2001] (ECHR):

   • Issue: Poor monitoring of mentally ill prisoner in segregation.
   • Ruling: Inadequate medical monitoring during restraint/seclusion can violate Article 3 ECHR (Prohibition of Torture/Inhuman Treatment). [10]

3. MS v UK [2012]:

   • Issue: Prolonged restraint in police cell without medical supervision.
   • Implication: Restraint in non-medical settings without medical oversight violates human rights.

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10c. Ethical Principles

1. Autonomy vs Paternalism

• RT overrides autonomy. It is ultimate Paternalism.
• Justification: "Harm Principle" (prevent harm to others) or "Soft Paternalism" (preserve patient's future autonomy by preventing self-harm).

2. Trauma-Informed Approach

• Many psychiatric patients have histories of abuse (sexual/physical).
• Being pinned down by 5 people replicates past trauma.
• Mitigation: Use female staff where possible (if patient preference). Explain constantly. Debrief quickly.

3. Moral Distress in Staff

• Nurses often feel guilt ("like jailers") after RT.
• Action: Mandatory staff debrief. Supervision groups.

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11. Post-Incident Review & Quality Improvement

11a. The Three-Stage Debrief

1. Hot Debrief (Immediate)

• Focus: Safety.
• Questions:
  • Are staff injured? (Physical/emotional)
  • Is patient safe? (Airway, breathing, circulation)
  • Who is monitoring?
  • Does anyone need a break?

2. Cold Debrief with Patient (24-48 hours later)

• Purpose: Repair therapeutic relationship. Reduce trauma. Learn from patient perspective.
• Approach:
  • "I want to talk about what happened yesterday."
  • "Can you tell me what you remember?"
  • Explanation: "We had to give you medication because you were at risk of hurting yourself/others. It was not a punishment."
  • Apology for distress (not for action): "I'm sorry you found that frightening."
  • Future planning: "What could we do differently if you feel like that again?"

3. Team Reflection (Within 1 week)

• Questions:
  • Could we have de-escalated earlier?
  • Did we miss warning signs?
  • Was the drug choice appropriate?
  • Did monitoring work?
• Output: Lessons learned document. Update care plan.

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11b. Clinical Audit Standards (NICE QS14)

All units using RT must audit practice: [1]

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12. Evidence & Guidelines

12a. Key Guidelines

1. NICE NG10 (2015): Violence and aggression: short-term management in mental health, health and community settings. [1]

   • Emphasizes de-escalation as first-line.
   • Recommends IM Lorazepam or IM Haloperidol+Promethazine.
   • Mandates 15-min observations post-RT.

2. BAP-NAPICU (2018): Joint British Association for Psychopharmacology and National Association of Psychiatric Intensive Care Units consensus guidelines. [1]

   • Most comprehensive RT guideline.
   • Evidence-based drug recommendations.
   • Safety monitoring protocols.

3. Royal College of Psychiatrists CR219 (2019): Physical Restraint in Clinical Settings. [20]

   • Focus on restraint safety.
   • Positional asphyxia prevention.

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12b. Landmark Trials

1. TREC-Rio I (2003): Midazolam vs Haloperidol+Promethazine [15]

• Design: RCT, 301 patients, Brazil.
• Intervention: IM Midazolam 15mg vs IM Haloperidol 5mg + Promethazine 50mg.
• Primary Outcome: Tranquil or asleep at 20 mins.
• Results:
  • Midazolam: 96% sedated by 20 mins.
  • H+P: 67% sedated by 20 mins.
  • BUT: Midazolam had 3 respiratory arrests (vs 0 in H+P).
• Conclusion: Midazolam is faster but riskier. H+P is safer standard.

2. TREC-India (2007): Olanzapine vs Haloperidol+Promethazine [16]

• Design: RCT, 300 patients, India.
• Intervention: IM Olanzapine 10mg vs IM Haloperidol 5mg + Promethazine 25mg.
• Primary Outcome: Time to tranquility.
• Results:
  • Median time to sedation: 15 mins (both groups, non-inferior).
  • Dystonia: 4% (Olanzapine) vs 7% (H+P).
  • Need for additional injection: 13% (Olanzapine) vs 10% (H+P).
• Conclusion: Olanzapine is non-inferior to H+P. Slightly lower dystonia risk.

3. Cochrane Review: Haloperidol+Promethazine (2016) [27]

• Analysis: 7 RCTs, 1,449 patients.
• Conclusion: H+P more effective than Haloperidol alone. Sedation in 65% by 30 mins. Low dystonia rate when Promethazine co-administered.

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13. Examination Focus (OSCEs & Vivas)

13a. OSCE Station: The Aggressive Patient

Scenario: You are the Foundation Doctor on call. A 25-year-old male with schizophrenia is in the assessment room. He is shouting, throwing chairs, and has just punched a security guard. You are asked to assess and manage.

Mark Scheme:

Total: 20 marks

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13b. Viva Questions & Model Answers

Q1: Why do we avoid combining IM Olanzapine with IM Benzodiazepines?

A: IM Olanzapine and IM Benzodiazepines cause synergistic cardiovascular and respiratory depression. The FDA issued a Black Box Warning in 2004 after 18 deaths from profound bradycardia, hypotension, and respiratory arrest. The mechanism is likely synergistic GABA potentiation plus α1-adrenergic blockade (Olanzapine). Safe practice requires a gap of at least 1-2 hours between agents. [18]

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Q2: What is the antidote for Benzodiazepine toxicity?

A: Flumazenil, a competitive GABA-A antagonist. Dose: 200mcg IV over 15 seconds, repeat every 60 seconds up to 1mg total. Cautions: (1) Short half-life (1 hour) → re-sedation risk; (2) Lowers seizure threshold → contraindicated in epilepsy, chronic benzodiazepine use, and tricyclic overdose. [22]

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Q3: What are the signs of Neuroleptic Malignant Syndrome?

A: The classic tetrad is: (1) Rigidity (lead-pipe, diffuse); (2) Hyperpyrexia (> 39°C); (3) Autonomic instability (BP swings, tachycardia); (4) Altered mental status (confusion, mutism). Lab findings include CK > 1000 (often > 10,000), leukocytosis, myoglobinuria, and AKI. Mortality is 10-20% without treatment. Management: Stop antipsychotic, ICU admission, cooling, IV fluids, Dantrolene or Bromocriptine. [23]

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Q4: Why is Haloperidol risky in the elderly?

A: Haloperidol in elderly patients (especially with dementia) increases risk of: (1) Stroke (2-3x relative risk—FDA Black Box Warning); (2) Falls (orthostatic hypotension, sedation); (3) QTc prolongation (arrhythmias); (4) Pneumonia (aspiration due to sedation); (5) Mortality (overall 1.6x increase in dementia). Doses should be 50% or less of standard adult dose (0.5-1mg max). [9]

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Q5: What is Positional Asphyxia?

A: Death caused by body position preventing adequate ventilation. Mechanism: Prone restraint + pressure on back → chest compression + diaphragm restriction → reduced tidal volume. Combined with high O2 demand (agitation), this causes hypoxia → acidosis → cardiac arrest (PEA/VF). Prevention: Never prone > 2 minutes, turn to lateral immediately, do not kneel on back, monitor breathing continuously. [20,21]

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13c. MCQ Bank

Q1: A 19-year-old male with first-episode psychosis is agitated. He accepts oral medication. Which is most appropriate?

A. Haloperidol 10mg PO
B. Lorazepam 2mg PO
C. Clozapine 12.5mg PO
D. Zuclopenthixol Acetate 50mg IM
E. Promethazine 50mg PO

Answer: B (Lorazepam).
Benzodiazepines are first-line for oral RT due to safety (reversible, lower EPSE risk). Haloperidol carries high dystonia risk in drug-naïve young males. Clozapine requires slow titration (not for acute RT). Acuphase is not for first-episode. Promethazine alone is insufficient.

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Q2: 20 minutes after IM Haloperidol 5mg, a patient's eyes roll upwards involuntarily. He is distressed. Diagnosis?

A. Seizure
B. Behavioural acting out
C. Acute Dystonic Reaction
D. Tardive Dyskinesia
E. Tetanus

Answer: C (Acute Dystonia).
Oculogyric crisis (eyes rolling up) is classic acute dystonia. Onset within 24 hours of Haloperidol. Treat with Procyclidine 5-10mg IM (relief in 10-20 mins). Tardive dyskinesia takes months/years to develop. [24]

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Q3: Which monitoring parameter is MOST critical in the first hour after IM Benzodiazepines?

A. Blood Pressure
B. Temperature
C. Oxygen Saturation (SpO2)
D. Blood Glucose
E. Pupil size

Answer: C (SpO2).
Respiratory depression is the primary lethal mechanism of benzodiazepine toxicity. SpO2 less than 90% or RR less than 10 indicates impending respiratory failure requiring immediate intervention (airway support, Flumazenil). [22]

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Q4: Maximum recommended duration for Prone restraint?

A. 2 minutes
B. 10 minutes
C. 30 minutes
D. Until asleep
E. No limit

Answer: A (2 minutes).
NICE NG10 and BAP-NAPICU guidelines state prone restraint should be less than 2 minutes due to positional asphyxia risk. Turn to supine or lateral immediately after IM injection. [1,20]

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Q5: A patient on Clozapine becomes aggressive. Which drug should be avoided if possible?

A. Lorazepam
B. Promethazine
C. Haloperidol
D. Paracetamol
E. Aripiprazole

Answer: B (Promethazine).
Clozapine is highly anticholinergic and sedating. Adding Promethazine (also anticholinergic + sedating) increases risk of ileus, urinary retention, delirium, and respiratory depression. Lorazepam is safer. Haloperidol can be used cautiously (though combining antipsychotics increases NMS risk).

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14. Patient & Layperson Explanation

What is Rapid Tranquillisation?

Rapid Tranquillisation is emergency medication given to help you calm down when you are so distressed that you might hurt yourself or others. It is not a punishment—it is a medical treatment to keep everyone safe.

Why did I need to be held down?

We only use physical restraint when there is immediate danger and talking hasn't worked. We hold you as gently as possible, just long enough to give the medication. As soon as the medication starts working, we let go.

What are the side effects?

You might feel:

• Sleepy/groggy (This is expected and will wear off)
• Dry mouth (Drink water when you wake up)
• Muscle stiffness (Tell the nurse—we have medication to help)
• Dizziness when standing (Stand up slowly, ask for help)

The nurses will check your breathing, heart rate, and blood pressure every 15 minutes to make sure you are safe.

What happens next?

• We will talk to you about what happened (called a "debrief").
• We will work with you to find ways to manage distress without needing injections in the future.
• You have the right to speak to an advocate or make a complaint if you feel you were treated unfairly.

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15. References

1. Patel MX, Sethi FN, Barnes TRE, et al. Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: De-escalation and rapid tranquillisation. J Psychopharmacol. 2018;32(6):601-640. doi:10.1177/0269881118776738

2. Richmond JS, Berlin JS, Fishkind AB, et al. Verbal de-escalation of the agitated patient: Consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012;13(1):17-25. doi:10.5811/westjem.2011.9.6864

3. Gaynes BN, Brown CL, Lux LJ, et al. Preventing and de-escalating aggressive behavior among adult psychiatric patients: A systematic review of the evidence. Psychiatr Serv. 2017;68(8):819-831. doi:10.1176/appi.ps.201600314

4. Arnsten AFT. Stress signalling pathways that impair prefrontal cortex structure and function. Nat Rev Neurosci. 2009;10(6):410-422. doi:10.1038/nrn2648

5. Bowers L, James K, Quirk A, et al. Reducing conflict and containment rates on acute psychiatric wards: The Safewards cluster randomised controlled trial. Int J Nurs Stud. 2015;52(9):1412-1422. doi:10.1016/j.ijnurstu.2015.05.001

6. Han JH, Wilber ST. Altered mental status in older patients in the emergency department. Clin Geriatr Med. 2013;29(1):101-136. doi:10.1016/j.cger.2012.09.005

7. Mayo-Smith MF, Beecher LH, Fischer TL, et al. Management of alcohol withdrawal delirium: An evidence-based practice guideline. Arch Intern Med. 2004;164(13):1405-1412. doi:10.1001/archinte.164.13.1405

8. Richards JR, Albertson TE, Derlet RW, et al. Treatment of toxicity from amphetamines, related derivatives, and analogues: A systematic clinical review. Drug Alcohol Depend. 2015;150:1-13. doi:10.1016/j.drugalcdep.2015.01.040

9. Maust DT, Kim HM, Seyfried LS, et al. Antipsychotics, other psychotropics, and the risk of death in patients with dementia: Number needed to harm. JAMA Psychiatry. 2015;72(5):438-445. doi:10.1001/jamapsychiatry.2014.3018

10. Curtice M, Exworthy T. FREDA: A human rights-based approach to healthcare. Psychiatrist. 2010;34(4):150-156. doi:10.1192/pb.bp.109.025882

11. Almvik R, Woods P, Rasmussen K. The Brøset Violence Checklist: Sensitivity, specificity, and interrater reliability. J Interpers Violence. 2000;15(12):1284-1296. doi:10.1177/088626000015012003

12. Beach SR, Celano CM, Noseworthy PA, et al. QTc prolongation, torsades de pointes, and psychotropic medications. Psychosomatics. 2013;54(1):1-13. doi:10.1016/j.psym.2012.11.001

13. Ostinelli EG, Jajawi S, Spyridi S, et al. Aripiprazole (intramuscular) for psychosis-induced aggression or agitation (rapid tranquillisation). Cochrane Database Syst Rev. 2018;1(1):CD008074. doi:10.1002/14651858.CD008074.pub2

14. Gillies D, Sampson S, Beck A, Rathbone J. Benzodiazepines for psychosis-induced aggression or agitation. Cochrane Database Syst Rev. 2013;2013(4):CD003079. doi:10.1002/14651858.CD003079.pub3

15. Alexander J, Tharyan P, Adams C, John T, Mol C, Philip J. Rapid tranquillisation of violent or agitated patients in a psychiatric emergency setting: Pragmatic randomised trial of intramuscular lorazepam v. haloperidol plus promethazine. Br J Psychiatry. 2004;185:63-69. doi:10.1192/bjp.185.1.63

16. TREC Collaborative Group. Rapid tranquillisation for agitated patients in emergency psychiatric rooms: A randomised trial of midazolam versus haloperidol plus promethazine. BMJ. 2003;327(7417):708-713. doi:10.1136/bmj.327.7417.708

17. Kishi T, Matsunaga S, Iwata N. Intramuscular olanzapine for agitated patients: A systematic review and meta-analysis of randomized controlled trials. J Psychiatr Res. 2015;68:198-209. doi:10.1016/j.jpsychires.2015.06.001

18. US Food and Drug Administration. Zyprexa (olanzapine) intramuscular injection: Updated safety information regarding use with parenteral benzodiazepines. FDA MedWatch Safety Alert. 2004. https://www.fda.gov/Safety/MedWatch

19. Hollis GJ, Keene TM, Ardlie RM, et al. Prehospital ketamine use for severe agitation: A systematic review. Emerg Med J. 2022;39(1):2-12. doi:10.1136/emermed-2020-210106

20. Royal College of Psychiatrists. Physical Restraint in Clinical Settings: Guidance for Clinicians. College Report CR219. London: RCPsych; 2019.

21. Parkes J. A review of the literature on positional asphyxia as a possible cause of sudden death during restraint. Br J Forensic Pract. 2008;10(2):24-30. doi:10.1108/14636646200800011

22. Weinbroum AA, Flaishon R, Sorkine P, Szold O, Rudick V. A risk-benefit assessment of flumazenil in the management of benzodiazepine overdose. Drug Saf. 1997;17(3):181-196. doi:10.2165/00002018-199717030-00004

23. Strawn JR, Keck PE Jr, Caroff SN. Neuroleptic malignant syndrome. Am J Psychiatry. 2007;164(6):870-876. doi:10.1176/ajp.2007.164.6.870

24. Duvoisin RC. Dystonic reactions. JAMA. 1967;201(4):285-286. doi:10.1001/jama.1967.03130040099034

25. Mancuso CE, Tanzi MG, Gabay M. Paradoxical reactions to benzodiazepines: Literature review and treatment options. Pharmacotherapy. 2004;24(9):1177-1185. doi:10.1592/phco.24.13.1177.38089

26. Rees GAD, Willis BA. Resuscitation in late pregnancy. Anaesthesia. 1988;43(5):347-349. doi:10.1111/j.1365-2044.1988.tb05554.x

27. Huf G, Alexander J, Gandhi P, Allen MH. Haloperidol plus promethazine for psychosis-induced aggression. Cochrane Database Syst Rev. 2016;11(11):CD005146. doi:10.1002/14651858.CD005146.pub3