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Management of Acutely Disturbed Behaviour

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Management of Acutely Disturbed Behaviour Formulary and Prescribing Guidelines SECTION 8: MANAGEMENT OF ACUTELY DISTURBED BEHAVIOUR 8. Rapid Tranquillisation 8.1 Management of acutely disturbed ADULTS Before considering pharmacological measures: (see CLG52 for more information) Consider de-escalation, using non drug approaches: seclusion/moving to a low stimulus area, talking down, time out, distraction If possible, do a mental state examination and physical state examination, take a history including drug/alcohol status, drug sensitivities, concurrent medication Check for intercurrent illness and recent illicit substance use Establish a working diagnosis Check for any advance directive in relation to medicines NON-PHARMACOLOGICAL MEASURES UNSUCCESSFUL OR INAPPROPRIATE L E V E L 1 L E V E L 2 Disturbed BUT accepting oral medication Disturbed AND refusing oral medication nurse in a quiet area Review all medication prescribed within last ongoing verbal de-escalation 24hours (BNF limits, side effects etc) food and fluid to be provided Consultant opinion may have to be sought review current medication PARENTERAL interventions (IM) decide whether additional medication required ORAL interventions (PO) Lorazepam IM (1-2mg; max 4mg/24H) Sedation in 30-45 mins; peaks 1-3 hours; Lorazepam (1-2mg; max 4mg/24H) Lasts 4-6 hours, dose should be reduced by 50% Can be repeated after 1 hour in patients taking sodium valproate Dose should be reduced by 50% in patients OR taking sodium valproate OR Promethazine IM (50mg; 100 mg/24H) Can be repeated in 1-2 hours, may be used in Haloperidol (5-10mg; max 20mg/24H) benzodiazepine-tolerant patients Can be repeated after 1 hour Promethazine is the first line alternative during Ensure cardiac status of patient is known, shortages of lorazepam preferably with previous ECG AND/OR OR Chlorpromazine 50-100mg (Max 300mg/24H Haloperidol IM (5mg; max 12mg/24H) Use alone or in combination with lorazepam, Can be repeated after 1 Hour sedation in 10 mins, peaks in 15-60 mins, half life 10-36 hours, Risperidone (2mg) Orodispersible tablets may be considered if the Ensure cardiac status of patient is known, patient is likely to spit out the tablets preferably with previous ECG Can be repeated after 2 hours OR OR Olanzapine IM as monotherapy (5-10mg; max Olanzapine (10mg) 20mg/24H) Peaks in 15-45 mins Do not repeat within 2 hours Orodispersible tablets may be considered if the patient is likely to spit out the tablet Do not use lorazepam within one hour of administering olanzapine IM Can be repeated after 2 hours L E V E L 3 Consultant’s direct involvement mandatory Promethazine 50mg IM Consult on-call pharmacist OR Second opinion of another consultant Diazepam 10mg IV over at least 5 minutes. Avoid Diazepam if ECT is being considered Can be repeated up to 3 times if insufficient effect. 2 Approved by Medicines Management Group October 2016 8. Rapid Tranquillisation 8.2 Management of acutely disturbed OLDER ADULTS Before considering pharmacological measures: (see CLG52 for more information) Consider de-escalation, using non drug approaches: seclusion/moving to a low stimulus area, talking down, time out, distraction If possible, do a mental state examination and physical state examination, taking into account frailty, drug/alcohol status, drug sensitivities, concurrent medication, dementia Check for intercurrent illness and recent illicit substance use Establish a working diagnosis Check for any advance directive in relation to medicines NON-PHARMACOLOGICAL MEASURES UNSUCCESSFUL OR INAPPROPRIATE L E V E L 1 L E V E L 2 Disturbed BUT accepting oral Disturbed AND refusing oral medication medication nurse in a quiet area Review all medication prescribed within last ongoing verbal de-escalation 24hours (BNF limits, side effects etc) food and fluid to be provided Consultant opinion may have to be sought review current medication decide whether additional medication required PARENTERAL interventions (IM) ORAL interventions (PO) Lorazepam IM (0.5 -1mg; max 2mg/24H) Lorazepam (0.5-1mg; max 2mg/24H) Sedation in 30-45 mins; peaks 1-3 hours; Can be repeated after 1 hour Lasts 4-6 hours, dose should be reduced by 50% Dose should be reduced by 50% in patients in patients taking sodium valproate taking sodium valproate. Worsens confusion in Do not use lorazepam within one hour of BPSD administering olanzapine IM OR OR Haloperidol (1-3mg; max 10mg/24H) Promethazine IM (25mg; 50mg/24H) Can be repeated after 1 hour Can be repeated in 1-2 hours, may be used in Ensure cardiac status of patient is known, benzodiazepine-tolerant patients preferably with previous ECG Promethazine is the first line alternative during OR shortages of lorazepam AND/OR Risperidone (0.5-1mg) Orodispersible tablets may be considered if the Haloperidol IM (1-2mg; max 10mg/24H) patient is likely to spit out the tablets Use alone or in combination with lorazepam, Can be repeated after 2 hours sedation in 10 mins, peaks in 15-60 mins, half Preferred option in BPSD life 10-36 hours, OR Ensure cardiac status of patient is known (ECG) OR Olanzapine (2.5-5mg) Orodispersible tablets may be considered if the Olanzapine IM as monotherapy (5-10mg; max patient is likely to spit out the tablet 20mg/24H) Peaks in 15-45 mins Can be repeated after 2 hours Do not repeat within 2 hours L E V E L 3 Refer to consultant Refer to consultant 3 Approved by Medicines Management Group October 2016 8. Rapid Tranquillisation 8.3 Management of acutely disturbed CHILDREN & ADOLESCENTS Before considering pharmacological measures: (see CLG52 for more information) Consider de-escalation, using non drug approaches: seclusion/moving to a low stimulus area, talking down, time out, distraction If possible, do a mental state examination and physical state examination, take a history including drug/alcohol status, drug sensitivities, concurrent medication Check for intercurrent illness and recent illicit substance use Establish a working diagnosis Check for any advance directive in relation to medicines NON-PHARMACOLOGICAL MEASURES UNSUCCESSFUL OR INAPPROPRIATE L E V E L 1 L E V E L 2 Disturbed BUT accepting oral medication Disturbed AND refusing oral medication nurse in a quiet area Review all medication prescribed within last ongoing verbal de-escalation 24hours (BNF limits, side effects etc) food and fluid to be provided Consultant opinion may have to be sought review current medication decide whether additional medication required PARENTERAL interventions (IM) If patient is unknown to services initially treat with Lorazepam IM (≥12 yrs 1-2mg, max 4mg/24H; Lorazepam and avoid antipsychotics if possible <12 yrs 0.5-1mg, max 2mg/24H) ORAL interventions (PO) Sedation in 30-45 mins; peaks 1-3 hours; lasts 4-6 hours Lorazepam (≥12 yrs 1-2mg, max 4mg/24H; Dose should be reduced by 50% in patients <12 yrs 0.5-1mg, max 2mg/24H) taking sodium valproate Can be repeated after 1 hour OR Reduce dose by 50% in patients taking sodium valproate Promethazine IM (≥12 yrs 25-50mg; <12 yrs OR 10-25mg) Promethazine is the first line alternative during Promethazine (≥12 yrs 25-50mg; <12 yrs 10- shortages of lorazepam 25mg) OR Can be repeated after 1 hour OR Haloperidol IM (≥12 yrs 1-5mg, max 10mg/24H; <12 yrs 0.5-3mg, max 5mg/24H) Haloperidol (≥12 yrs 1-5mg, max 10mg/24H; Sedation in 10 mins; peaks in 15-60 mins; half- <12 yrs 0.5-3mg, max 5mg/24H) life 10-36 hours Can be repeated after 1 hour Use alone or in combination with Lorazepam Ensure cardiac status of patient is known, Ensure cardiac status of patient is known, preferably with previous ECG preferably with previous ECG OR OR Risperidone (≥12 yrs 1-2mg; <12 yrs 0.5- Olanzapine IM as monotherapy (≥12 yrs 5- 1mg) 10mg, max 3 injections/24H) Orodispersible tablets may be considered if Peaks in 15-45 mins the patient is likely to spit out the tablets Do not repeat within 2 hours Can be repeated after 2 hours OR Do not use lorazepam within one hour of administering olanzapine IM Olanzapine (≥12 yrs 10mg) Orodispersible tablets may be considered if the patient is likely to spit out the tablet Can be repeated after 2 hours OR Quetiapine (≥12 yrs 25-50mg; <12 yrs 12.5- 25mg) Can be repeated after 2 hours 4 Approved by Medicines Management Group October 2016 8. Rapid Tranquillisation 8.4 Drugs approved for management of acute disturbed behaviour See latest BNF for licensed indications. Time to max. Half life Drug and form Comments plasma Conc. Haloperidol IM injection 15-60 mins 10-36 hours Haloperidol solution 3-6 hours 10-36 hours Haloperidol tab 3-6 hours 10-36 hours Lorazepam IM injection 60-90 mins 12-16 hours The FDA has warned of a serious risk of death when benzodiazepines are used in combination with Opioid Lorazepam tabs 2 hours 12 hours analgesic or cough preparations.6 Olanzapine dispersible tab. 5-8 hours 32-50 hours IM olanzapine may produce a 5-fold Olanzapine injection 15-45 mins 32-50 hours increase in plasma conc. vs. the same dose given orally Olanzapine tab 5-8 hours 32-50 hours Promethazine IM injection 2-3 hours 5-14 hours Risperidone dispersible tab. 1-2 hours 24 hours Risperidone liquid 1-2 hours 24 hours Risperidone tab 1-2 hours 24 hours 8.5 Guidelines for the use of Flumazenil Indications for use Respiratory rate < 10/minute after administration of benzodiazepines Contra-indications Patients with epilepsy who have been receiving long-term benzodiazepines Cautions Dose should be carefully titrated in hepatic impairment Dose & route of administration Initially: 200 mcg intravenously over 15 seconds (in adults) Time before the dose 60 seconds can be repeated Subsequent dose: 100 mcg over 10 seconds as required (up to 8 doses) Maximum dose: 1 mg in 24 hours (one initial dose and eight subsequent doses) Patients may become agitated, anxious, or fearful on awakening.
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