Emergency Sedation Guidelines for Use in the Community NHS Highland Warning – Document uncontrolled when printed Policy Reference: id1309 Date of Issue: August 2012 Prepared by: Emergency Sedation Working Group Date of Review: August 2014 Lead Reviewer: Arun Sharma Version: 1 Authorised by: Policies, Procedures and Guidelines Date: August 2012 Subgroup of ADTC Distribution All GPs Mairi MacDonald, Oban, Lorn and Isles Medical Director CMHT Team Leader Nursing Director Dianne Langley, Cowal and Bute CMHT Director of Pharmacy Team Leader Head of Specialist Pharmaceutical Services Donald MacKinnon, Helensburgh CMHT Head of Community Pharmaceutical Services Team Leader Community Hospitals CHP Lead Pharmacists Teresa Green, Caithness CMHT Manager CHP Clinical Leads Neil Turner, Skye CMHT Manager CHP Lead Nurses Gill MacNeill, Inverness CMHT Manager Steven Gorman, Area Service Manager, Richard Pearson, Badenoch & Strathspey CMHT Scottish Ambulance Service Manager Pam Gowie, Lead Resuscitation Officer Douglas Philand, Mid-Argyll, Kintyre and Islay Glenda Critchley, Resuscitation Team CMHT Team Leader Method CD Rom E-mail Paper Intranet Warning – Document uncontrolled when printed Policy Reference: id1309 Date of Issue: August 2012 Prepared by: Emergency Sedation Working Group Date of Review: August 2014 Lead Reviewer: Arun Sharma Version: 1 Authorised by: Policies, Procedures and Guidelines Subgroup of ADTC Page 1 of 22 INTRODUCTION The purpose of this guideline is to provide GPs, and members of the Community Mental Health Team (CMHT), with guidance on the treatment of patients who require to be medicated in order to keep the patient, and others, safe in a community hospital, domestic or public area setting. In addition, guidance is also provided in order to achieve the safe transfer of a patient to the nearest place of safety or local psychiatric hospital. Emergency sedation should be seen in the context of the need to give treatment urgently to a seriously disturbed patient in order to prevent serious harm to that patient or to others. Strictly speaking such medication is being administered under the premise enshrined in common law, as effectively, Section 243 of the Mental Health Act does not come in to operation until the patient is actually in hospital. Clearly there are times when emergency sedation is required prior to admission to hospital. GPs who administer or prescribe medication under these circumstances should nevertheless adhere to the recommendations outlined under Section 243 http://www.legislation.gov.uk/asp/2003/13/section/243. The professional administering the medication should keep a detailed note of the reasons behind their decision. It should be stressed that these are only intended as guidelines and GPs may wish to use alternative medications with which they are familiar. This guideline updates a previous guideline on The Safe Transfer of Patients to New Craigs Hospital (2002), and takes into account the recent changes made to the Specialist Emergency Sedation Policy Specialist Emergency Sedation Policy and the inclusion of Argyll and Bute into NHS Highland. SAFE TRANSFER OF PATIENTS Escort teams are, by necessity, pulled together at short notice with staff, equipment and vehicular transport that is available at the place of safety/psychiatric hospital base, at that moment in time. For patients who have been detained, the escort team, when available, will arrive with a supply of the medicines recommended for use in emergency sedation. It may however be a period of time before the escort team arrives. As a consequence the GP should be prepared to medicate, if necessary, beforehand. The doses of drugs recommended are for the average adult patient and may need to be varied depending on age, body build, physical health, etc. Information on dosage for older adults and young people (12 to 15 years) is also provided. The escort team will not include a doctor and therefore the GP should administer and/or prescribe medication to be administered. In anticipation of this occasional event it would be useful for GPs to have ready access to key documents, including a pre-printed Kardex. For this purpose the policy and the key documents are available from the intranet under “shared clinical guidelines”. Note that an “at a glance” summary is available which is designed to be printed off, laminated and to be kept within the escort box or Out of Hours (OOH) Bag. This documentation is particularly useful where there may be practical difficulties in the GP and escort team being able to rendezvous. As a back up plan, the escort team will continue to be in a position to provide a Kardex to the GP. The practice in Northern Highland is for the GP who has assessed the patient to prescribe. In Argyll and Bute a different system operates. In Argyll and Bute, nursing staff on escort can be provided with authority to administer emergency sedation via completion of the “Emergency Sedation Prescription for Escort”. This is completed by the psychiatric hospital based doctor after discussion with the referring doctor who has assessed the patient. If GPs have any doubts or concerns about the patient’s safe transfer, please make contact with the hospital doctor involved with co-ordinating the admission, or the duty consultant at New Craigs – telephone 01463 704000 or Argyll and Bute Psychiatric Hospital - telephone 01546 602323. Warning – Document uncontrolled when printed Policy Reference: id1309 Date of Issue: August 2012 Prepared by: Emergency Sedation Working Group Date of Review: August 2014 Lead Reviewer: Arun Sharma Version: 1 Authorised by: Policies, Procedures and Guidelines Subgroup of ADTC Page 2 of 22 GENERAL PRINCIPLES OF EMERGENCY SEDATION Early intervention is desirable as disturbed behaviour should be brought under control as soon as possible. Initially attempts should be made to provide verbal reassurance rather than resort to medication. Although no hard and fast rules can be made as each situation is unique, certain general principles apply. Route Use oral medication if at all possible, if not use IM medication. The IV route should not be used. Choice In patients who have previously been exposed to antipsychotics or are clearly psychotic, haloperidol is a suitable drug to use for emergency sedation. If there is doubt as to the diagnosis, a benzodiazepine is probably more appropriate in the first instance. It is important to consider the risk of inducing a seizure especially in patients who may be withdrawing from alcohol or have a history of illicit substance misuse. In such cases it is advisable to use a benzodiazepine rather than an antipsychotic as the latter reduces the seizure threshold in a potentially compromised patient. Avoid lorazepam in patients with compromised respiratory function. Avoid haloperidol in patients with clinically significant cardiac disorders. There is a risk of dystonia with haloperidol, especially in young males. Consider prescribing prophylactic procyclidine oral or IM for this group. Dose Use the minimum dose to achieve calm, bearing in mind that there is a marked inter individual response to such drugs. The bioavailability of drugs can vary depending on the route of administration, and dosages must take this into account. The usual adult dosage of lorazepam would normally be in the range of 1 to 2mg. Consider 4mg only in exceptional circumstances. Avoid Do not mix lorazepam and haloperidol in the same syringe. The use of IM chlorpromazine is not recommended as it is pro-arrythmogenic, crystallizes in tissues and can cause profound hypotension. Ensure Flumazenil is readily available. Places of safety and escort teams have the necessary equipment available to enable cannulation for the administration on flumazenil. Adrenaline is available in escort boxes and places of safety. Warning – Document uncontrolled when printed Policy Reference: id1309 Date of Issue: August 2012 Prepared by: Emergency Sedation Working Group Date of Review: August 2014 Lead Reviewer: Arun Sharma Version: 1 Authorised by: Policies, Procedures and Guidelines Subgroup of ADTC Page 3 of 22 Parenteral procyclidine is readily available. The dilution of lorazepam IM with an equal volume of water for injection. This is important as the undiluted injection can be quite viscous and hence painful on injection. On occasion, the UK licensed product is not available, and an unlicensed product may be used as an alternative. This unlicensed product should also be diluted with an equal volume of water for injection. That if all lorazepam injection supplies are exhausted, the recommended alternative, midazolam injection, is available. Please note the increased risks associated with the use of midazolam IM referred to within this policy document. That patients who have been administered emergency sedation are monitored and the results recorded on a SEWS chart (appendix 1e and 1f). SPECIFIC ISSUES Safety procedures in place – IM Benzodiazepine risk of Respiratory Depression Use of flumazenil Flumazenil (Anexate®) is used to reverse the respiratory depression caused by parenteral benzodiazepines. It is anticipated that IM administration of benzodiazepines is unlikely to produce this effect. However the use of IM midazolam does increase this risk due to potential drug interactions involving midazolam but not lorazepam. If required, flumazenil should be given by IV injection, 200 micrograms over 15 seconds, then 100 micrograms at 60 second intervals if required. Usual dose range 300 to 600 micrograms.