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.

The "Goal of Calmness"

• Success: The patient is rousable, able to communicate, but not aggressive.
• Failure: The patient is unconscious (GCS < 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 property - though property alone is rarely legal justification for IM meds).
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)?

Before reaching for a syringe, every clinician must master verbal de-escalation. It fails often, but it must be attempted.

Top 10 De-escalation Tactics

1. Modify the Environment: Remove the audience. "Can we step into this quieter room?" (Reduces the 'performance' aspect of aggression).
2. Respect Personal Space: Stand 2 arm-lengths away. Stand at a 45-degree angle (less confrontational than head-on).
3. Open Body Language: Hands visible (not in pockets, not crossed). No sudden movements.
4. One Voice: Only ONE professional should speak. Others stand back to support physically if needed but stay silent. "Command and Control".
5. Use Their Name: "Dave, I can see you are upset. I want to help you."
6. Validation: Acknowledge the anger. "It must be frustrating waiting this long." (Doesn't mean you agree, just validates the emotion).
7. Simple Choice: Give control back. "Would you prefer water or juice?" "Would you like to sit here or there?"
8. The "Broken Record": Repeat the boundary calmly. "I want to help, but I cannot do that while you are shouting."
9. Avoid "No": Instead of "You can't go out", say "We can talk about going out once the doctor has seen you."
10. Know When to Stop: If violence is imminent (clenched fists, target locking, weapon), stop talking and initiate safety protocols (Code Black/Security).

The Neurobiology of Aggression ("The Hijacked Brain")

Understanding why a patient is aggressive helps maintain empathy.

1. The Amygdala (The Alarm):
   • Scans for threat. In psychosis/PTSD, it is hyperactive. It perceives neutral stimuli (e.g., a nurse walking past) as a life threat.
   • Triggers the "Fight or Flight" response (Sympathetic surge).
2. The Prefrontal Cortex (The Brakes):
   • Responsible for impulse control and rationing.
   • In acute arousal, the connection between the Cortex and Amygdala is severed ("Cortical Shutdown").
   • 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...").
3. Neurotransmitters:
   • Dopamine: Excess drives paranoia and goal-directed aggression (Schizophrenia/Mania). -> Target for Antipsychotics.
   • GABA: The inhibitory "calming" neurotransmitter. -> Target for Benzodiazepines.
   • Noradrenaline: Drives the physical arousal (High HR, sweating). -> Target for Beta-blockers (rarely used in acute phase).

Prevention is better than cure. The Safewards model identifies triggers.

1. Flashpoints: Rules, waiting times, bad news.
2. Patient Modifiers: Intoxication, delusions.
3. Staff Modifiers: inconsistent limits, lack of empathy, "Us vs Them" attitude.
4. Interventions:
   • Soft Words: Using non-confrontational language.
   • Mutual Help Meeting: Start the day discussing how to support each other.
   • Discharge Messages: Notes from past patients on the wall ("I got better, you can too").

In a crisis, our brains freeze. Memorise these scripts.

1. The "Safety Statement" (First Contact)

• Goal: Establish non-threat.
• Script: "My name is [Name]. I am the [Role]. I am here to help you feel safe. I can see you are distressed, but I need you to put the chair down so we can talk."

2. The "Broken Record" (Setting Limits)

• Goal: Maintain boundary without engaging in an argument.
• Patient: "You don't care! I'm leaving!"
• Clinician: "I hear that you are angry, but I cannot let you leave while you are unwell."
• Patient: "F*** you, let me out!"
• Clinician: "I understand you are frustrated, but I cannot let you leave while you are unwell." (Same tone, same words).

3. The "Pseudo-Choice" (Giving Control)

• Goal: Force a choice between two acceptable options, avoiding "Yes/No".
• Script: "We need to give you medication to help you calm down. Would you prefer a tablet, or do we need to use an injection? I would much prefer the tablet."

4. The "Explanation of Restraint" (During Restraint)

• Goal: Reassurance during high stress.
• Script: "We are holding you to keep you safe. We are not hurting you. As soon as you stop fighting and relax, we will release the pressure on your arms. Can you take a deep breath for me?"

5. Alternative Strategies: Sensory Modulation

Before drugs, try sensory input (if the patient is amenable).

• Weighted Blanket: Provides proprioceptive input/calming ('deep pressure').
• Low Stimulus Area: Dim lights, reduce noise.
• Ice: Holding an ice cube (grounding technique for emotional dysregulation/Borderline Personality Disorder).
• Music: Patient's own playlist.

Agitation is a symptom, not a diagnosis. "Organic" causes have high mortality if sedated without treatment.

1. The "Fatal Six" (Must Exclude)

1. Hypoxia:
   • Pathophysiology: Low O2 to frontal cortex -> Disinhibition and confusion (The "Air Hunger" panic).
   • Clue: Cyanosis, COPD history, "Gasping".
   • Action: Pulse Oximetry is non-negotiable.
2. Hypoglycaemia (< 4.0 mmol/L):
   • Pathophysiology: Neuroglycopenia triggers massive adrenaline surge (Sympathetic overdrive).
   • Clue: Sweaty (diaphoretic), History of Diabetes, Sudden onset.
   • Action: Finger prick glucose. Give Glucogel/IM Glucagon before sedation.
3. Sepsis (Delirium):
   • Pathophysiology: Cytokines (IL-1, TNF) cross BBB -> Neuroinflammation -> Acetylcholine disruption.
   • Clue: Fever (hot), Tachycardia, Hypotension, UTI symptoms (smell), Pneumonia (cough).
   • Action: CHECK TEMP.
4. Intracranial Event (Bleed/Tumour):
   • Pathophysiology: Raised ICP compresses Reticular Activating System.
   • Clue: Headache, Vomiting, Focal Neurology (one pupil fixed, one arm weak), History of fall/trauma.
   • Action: Neuro obs (Pupils). CT Head.
5. Post-Ictal State:
   • Pathophysiology: chaotic neuronal discharge followed by exhaustion/confusion.
   • Clue: History of Epilepsy, Incontinence, Tongue biting.
   • Action: Observe. Do not sedate unless Status Epilepticus develops.
6. Serotonin Syndrome / NMS:
   • Pathophysiology: Drug induced hyper-reflexia or rigidity.
   • Clue: Current meds (SSRIs, Antipsychotics), Clonus, Tremor, Rigidity.
   • Action: Stop meds. Cooling.

2. Substance-Related Agitation

• Alcohol Withdrawal (Delirium Tremens):
  • Signs: Coarse tremor, visual hallucinations ("Liliputian" - small animals), Formication (tactile bugs).
  • Risk: Seizures.
  • Management: Benzodiazepines are curative (Chlordiazepoxide/Lorazepam). Avoiding them is dangerous.
• Stimulant Toxicity (Cocaine/Meth):
  • Signs: Dilated pupils (Mydriasis), Grinding teeth (Bruxism), paranoid delusions, super-strength.
  • Risk: Arrhythmias, MI.
  • Management: Benzodiazepines to blunt sympathetic drive.

3. Primary Psychiatric Causes

Once organic causes excluded:

• Mania: Grandiose, flight of ideas, sexual disinhibition, high energy.
• Schizophrenia: Paranoid delusions ("You are the CIA"), Auditory hallucinations (Command voices).
• Personality Disorder (EUPD): High arousal due to emotional dysregulation/abandonment fear. Often high risk of self-harm during restraint.
• Acute Psychosis: Schizophrenia/Mania (Paranoid delusions driving aggression).
• Intoxication: Alcohol, Stimulants (Cocaine/Meth), or Hallucinogens.
• Delirium: Hypoxia, Sepsis, Head Injury ("Combative medical patient"). Caution: RT can kill these patients.
  • Section 5(2): Holding power for inpatients.
  • Section 2/3: Detention for assessment/treatment.
  • Note: RT is "treatment for mental disorder" and is covered under Part 4 (T3 form not needed for first 3 months).
• Mental Capacity Act (MCA):
  • Used for Organic Delirium or Intoxication where the patient lacks capacity to decide on treatment for their agitation.
  • Do not use MHA for pure alcohol intoxication if no mental disorder is present.
• Common Law (Necessity):
  • Used in dire emergencies to prevent immediate life-threatening harm, even if status is unknown. "Doctrine of Necessity".

"Chemical Restraint" vs RT

• RT: Acute, emergency, goal is diagnosis/safety.
• Chemical Restraint: Use of medication to restrict freedom of movement (often chronic/sub-acute). This is legally distinct and ethically controversial (Deprivation of Liberty Safeguards - DoLS).

Risk assessment is dynamic. Use structured judgment.

1. The B-A-R Assessment

• B - Background: Diagnosis? Forensics (History of violence)? Drugs?
• A - Affect: Angry? Threatening? Suspicious? Fearful?
• R - Risk: To Self (Head banging)? To Others (Weapons)? From Others (Vulnerable)?

2. The Brøset Violence Checklist (BVC)

A validated tool to predict imminent violence in the next 24 hours. Score 1 for presence of each.

• Confusion: Disoriented.
• Irritability: Easily annoyed.
• Boisterousness: Loud, shouting.
• Physical Threats: Raising fists, posturing.
• Verbal Threats: "I'm going to kill you".
• Attacks on Objects: Kicking doors, throwing chairs.
• Interpretation:
  • Score 0: Low Risk.
  • Score 1-2: Moderate Risk (De-escalation required).
  • Score > 2: High Risk (Preventative measures / PRN medication indicated).

3. Medical Assessment (Exclude "Mimics")

Before assuming "Psychiatric Behaviour", exclude:

• Hypoxia: Check Sats. (Hypoxia causes agitation).
• Hypoglycaemia: Check BM/Gluco. (Neuroglycopenia causes aggression).
• Sepsis: Delirium.
• Head Injury: Frontal lobe disinhibition.
• Post-Ictal: Confusion after seizure.
• Serotonin Syndrome: If on SSRIs.

4. Baseline Physical Health

If safe to approach, check:

• Pulse & BP: Baseline tachycardia/hypertension?
• QTc Interval: If history of cardiac issues or taking multiple antispychotics. Note: In an emergency, do not delay RT for an ECG, but prioritize ECG immediately post-sedation.

• ECG: Baseline QTc interval (Antipsychotics prolong QT).

Step 1: Oral Medication (The "Offer")

Always offer oral medication first. It preserves dignity and is safer.

• Benzodiazepines:
  • Lorazepam (1-2mg): Gold standard. Rapid onset (30 mins). Short half-life (12h). No active metabolites (safer in liver disease).
• Antipsychotics:
  • Haloperidol (5mg): Classic typical. Risk of EPSEs.
  • Olanzapine (10mg): ODT (Oro-dispersible) wafers dissolve on tongue (harder to "cheek").
  • Promethazine (25-50mg): Sedating antihistamine. Useful adjunct.

Step 2: Intramuscular (IM) Options - "The Fork in the Road"

If immediate danger persists, proceed to IM.

Option A: The "Benzodiazepine Monotherapy" (safest)

• Drug: Lorazepam 1-2mg IM.
• Onset: 45-60 mins (Peak).
• Pros: Safe cardiac profile. Reversible (Flumazenil).
• Cons: Respiratory depression (especially if drunk). Paradoxical agitation (rare).

Option B: The "Combined Approach" (Standard)

• Regimen: Haloperidol 5mg IM + Promethazine 25-50mg IM.
• Rationale: Promethazine provides sedation and protects against Haloperidol-induced dystonia.
• Pros: Known efficacy. "Clean" sedation.
• Cons: QT prolongation (Haloperidol).

Option C: The "Modern Atypical"

• Drug: Olanzapine 10mg IM.
• Pros: Less EPSEs. Good sedation.
• Critical Warning: NEVER combine IM Olanzapine with IM Benzodiazepines.
  • Why? FDA Black Box Warning. Interaction causes profound bradycardia and hypotension (fatalities occurred). Leave a gap of at least 1-2 hours between them.

Option D: Emergency Medicine (ABD Protocol)

• Setting: ED Resus ONLY (Full monitoring available).
• Drug: Droperidol (5-10mg IM) or Ketamine (4-5mg/kg IM).
• Rationale: For "Excited Delirium" where the patient fights against restraints to the point of metabolic acidosis/cardiac arrest. Ketamine provides "dissociative anaesthesia" instantly (3-5 mins).
• Requirement: Requires immediate intubation readiness.

Pharmacokinetic Comparison Table

Special Agent: Zuclopenthixol Acetate (Acuphase)

• What is it?: An intermediately active depot (oil-based).
• Duration: Lasts 2-3 days.
• Indication: NOT for immediate RT. Used for patients who require repeated RT injections over days.
• Caution: If you give it, you "own" the sedation for 3 days. Do not give if the patient is neuroleptic naïve.

1. Lorazepam (Ativan)

• Class: Benzodiazepine (Short-acting).
• Indication: First-line for RT in all settings.
• Dose:
  • Oral: 1-2mg.
  • IM: 1-2mg.
  • Max Daily: 4mg (BNF). (Though higher used in specialist units).
• Pharmacokinetics:
  • Onset: 30 mins (IM).
  • Peak: 60-90 mins.
  • Half-life: 12-16 hours. (No active metabolites = safer in liver failure).
• Cautions: Respiratory depression (Synergy with Alcohol/Opioids). Paradoxical agitation.
• Antidote: Flumazenil.

2. Haloperidol (Haldol)

• Class: Typical Antipsychotic (Butyrophenone).
• Indication: Second-line or Combined with Promethazine.
• Dose:
  • Oral: 5mg.
  • IM: 5mg.
  • Max Daily: 20mg (BNF).
• Pharmacokinetics:
  • Onset: 20-40 mins (IM).
  • Half-life: 24 hours.
• Cautions:
  • EPSEs: High risk of Dystonia/Akathisia (give Procyclidine).
  • Cardiac: QTc Prolongation (Baseline ECG if possible).
  • NMS: Risk factor.

3. Promethazine (Phenergan)

• Class: Sedating Antihistamine (Phenothiazine derivative).
• Indication: Adjunct to Haloperidol (increases sedation, reduces dystonia).
• Dose:
  • IM: 25-50mg.
• Mechanism: H1 antagonist + Muscarinic antagonist.
• Cautions: Anticholinergic burden (Delirium in elderly). Lower seizure threshold. Painful injection.

4. Olanzapine (Zyprexa)

• Class: Atypical Antipsychotic.
• Indication: Agitation in Schizophrenia/Mania.
• Dose:
  • Oral: 10mg (ODT wafer/Velotab).
  • IM: 10mg.
• Pharmacokinetics:
  • Onset: 15-30 mins.
  • Peak: 45 mins.
  • Half-life: 30 hours.
• Critical Safety: Contraindicated within 1 hour of parenteral Benzodiazepines. (Fatal bradycardia/hypotension).

5. Midazolam

• Class: Benzodiazepine (Ultra-short acting).
• Indication: General Medical/ED settings (NOT standard Psych usage due to respiratory risk).
• Dose:
  • IM: 2.5 - 7.5mg.
• Pros: Very fast onset (5 mins).
• Cons: High risk of apnea. Requires immediate airway skills.

6. Ketamine

• Class: Dissociative Anaesthetic (NMDA Antagonist).
• Indication: "Excited Delirium" / Profound agitation with metabolic risk (Code Black).
• Dose:
  • IM: 4-5mg/kg (~300-400mg).
• Mechanism: Dissociation of Thalamocortical tracts.
• Pros: Preserves respiratory drive/reflexes. Instant onset.
• Cons: Laryngospasm (rare), Hypersalivation, Emergence phenomenon. Requires Anaesthetist present.

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

The NEWS2 Protocol (Monitoring Frequency)

• Time 0 - 60 mins: Every 15 minutes (ACVPU, RR, SaO2, HR).
• Hour 1 - 4: Every 30 minutes.
• Hour 4+: Every hour until awake and ambulatory.

What to Watch For

1. Positional Asphyxia:
   • Cause: Being held prone (face down) compresses the diaphragm. The patient struggles -> demand for O2 increases -> supply decreases -> Cardiac Arrest.
   • Action: Turn to Supine or Lateral immediately after injection. Ensure airway is patent.
2. Respiratory Depression:
   • Sign: RR < 10 or SaO2 < 90%.
   • Action: Shake and shout. Apply High-flow O2 (15L). Bag-Valve-Mask if needed. Give Flumazenil (if Benzo used).
3. Hyperthermia:
   • Sign: Temp > 38°C + Rigidity.
   • Cause: Neuroleptic Malignant Syndrome (NMS) or Serotonin Syndrome.
   • Action: Rapid cooling. Transfer to ICU.

Rapid Tranquillisation does not end with the injection. The hours following are critical for safety and recovery.

1. Observation & Engagement

• Level of Observation: Increase to Level 3 (Controls & Restraint) or Level 4 (Close Obs) - i.e., within eyesight or arms length.
• Rationale: Risk of airway compromise is highest in the first hour.
• Action:
  • One nurse dedicated solely to the patient.
  • Do not leave the patient alone in a room if they are heavily sedated.

2. Physical Health Care

• Hydration:
  • Patients often dehydrated from mania/agitation.
  • Offer Oral Fluids as soon as patient can swallow.
• Skin Integrity:
  • Check for restraint injuries (wrists, shoulders).
  • Check injection site for haematoma.
• Toileting:
  • Ensure patient can access toilet (avoid incontinence which degrades dignity).
  • Caution: Fall risk is high due to sedation. Assist them.

3. Psychological Support & Dignity

• Re-orientation: "You are safe. You are in hospital. Use their name."
• Privacy:
  • If clothes were torn during restraint, provide clean pyjamas immediately.
  • Screen the bed area.
• Information:
  • Provide a "Understanding Rapid Tranquillisation" leaflet when they wake up.

4. Falls Prevention

• Risk: Benzodiazepines cause ataxia. Orthostatic hypotension from Antipsychotics.
• Action: Bed rails up? Low bed? Non-slip socks. Supervised mobilisation.

RT carries significant mortality risk. Complications must be treated as medical emergencies.

1. Neuroleptic Malignant Syndrome (NMS)

A rare but fatal reaction to antipsychotics.

• Signs: "Lead-pipe" rigidity, Hyperpyrexia (>39°C), Autonomic instability (BP swings), Confusion.
• Labs: CK > 1000 (often 10,000+), Leukocytosis.
• Action:
  1. STOP all antipsychotics immediately.
  2. Cool: Aggressive cooling (Ice packs, Fans).
  3. Hydrate: IV fluids to prevent renal failure (Rhabdomyolysis).
  4. Drugs: Dantrolene (Muscle relaxant) or Bromocriptine (Dopamine agonist).
  5. Transfer: ICU admission is usually required.

2. Acute Dystonia (Oculogyric Crisis)

Terrifying for the patient but easily treatable.

• Signs: Eyes rolling upwards (Oculogyric crisis), Torticollis (Neck spasm), Trismus (Lockjaw).
• Risk: High with Haloperidol (especially young males). Low with Olanzapine.
• Management:
  • Procyclidine 5-10mg IM or IV (Relief in 20 mins).
  • Benztropine 1-2mg IM.
  • Pearl: If giving Haloperidol to a young male, consider prophylactic Procyclidine.

3. Respiratory Depression (Benzodiazepine Toxicity)

• Risk Factors: High dose Lorazepam, concurrent Alcohol/Opioids, COPD, OSA (Obesity).
• Signs: RR < 10, SpO2 < 90%, "Snoring" respiration (Airway obstruction).
• Management:
  1. Airway: Head-tilt chin-lift. Insert Guedel airway.
  2. Breathing: Bag-Valve-Mask ventilation with 15L Oxygen.
  3. Antidote: Flumazenil 200mcg IV over 15 secs. Repeat if needed.
  4. Caution: Flumazenil lowers seizure threshold. Do not use if patient is epileptic or took Tricyclic overdose.

4. QT Prolongation & Torsades de Pointes

• Mechanism: Antipsychotics block K+ channels, repolarization delays.
• Risk: Haloperidol > Olanzapine > Aripiprazole.
• Threshold: QTc > 500ms is alarming.
• Action:
  • Monitor ECG.
  • Correct electrolytes (K+, Mg++).
  • Magnesium Sulphate 2g IV for Torsades.

5. Paradoxical Agitation

• Sign: Patient becomes more aggressive after Benzodiazepines.
• Cause: Disinhibition (like getting drunk). Common in head injury or learning disability.
• Action: Switch class. Stop Benzos. Use Antipsychotic (e.g., Olanzapine).

Principles of Safe Restraint

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

1. The Team Roles

• Team Leader (No. 1): Manages the Head. Dedicated airway officer. Does NOT get involved in limb restraint.
• Limb Handlers (No. 2-5): One for each limb. Secure large joints (shoulders/knees), not wrists/ankles (prevents fractures).

2. Positioning (The Controversy)

• Prone (Face Down):
  • Pros: Easier to administer IM injection in gluteal region. Easier to control limbs.
  • Cons: High risk of Positional Asphyxia. Compresses chest. Patient cannot breathe.
  • Rule: Never keep prone for > 2 minutes. Turn immediately after injection.
• Supine (Face Up):
  • Pros: Airway is visible. Chest can expand.
  • Cons: Risk of aspiration if vomiting.
  • Rule: Head must be supported. Suction must be nearby.
• Lateral (Recovery Position): The goal. Get them here as soon as possible.

3. "Positional Asphyxia" The most common cause of death in custody/care.

• Mechanism:
  • Prone position + Pressure on back + Agitation (High O2 demand).
  • -> Diaphragm cannot descend.
  • -> Hypoxia and Acidosis.
  • -> Cardiac Arrhythmia (PEA Arrest).
• Warning Signs: Patient stops struggling and goes limp. This is NOT compliance; this is cardiac arrest. Check Pulse immediately.

4. Duration

• Restraint should be minutes, not hours.
• Prolonged struggle risks Rhabdomyolysis (Muscle breakdown -> Renal Failure).

1. Pregnancy

• Risk: Medication affects the fetus (Respiratory depression, Floppy infant).
• First Line: Verbal de-escalation is paramount.
• Drug Choice:
  • Haloperidol: Category C. Generally considered safest antipsychotic in emergency.
  • Promethazine: Safe.
  • Lorazepam: Avoid if possible (Floppy infant syndrome), but safe for single emergency dose.
  • Avoid: Valproate (Teratogenic), Olanzapine (less data).
• Restraint: Left Lateral Tilt is mandatory to prevent Aortocaval Compression (Gravid uterus compressing Vena Cava). NEVER restraint Prone.

2. Elderly / Frail / Dementia

• Risk: Falls, Delirium, Over-sedation, CVA (Stroke risk with antipsychotics).
• Dose Reduction: "Start low, go slow". Use 50% or 25% of adult dose.
  • Lorazepam: 0.5mg IM (Max 1mg).
  • Haloperidol: 0.5 - 1mg IM. (Monitor QTc closely).
• Avoid:
  • Olanzapine: Higher risk of stroke/mortality in dementia.
  • Promethazine: Anticholinergic burden worsens delirium.

3. Children & Adolescents (CAMHS)

• Rule: Specialist advice if possible.
• Differences:
  • Higher metabolic rate but paradoxical reactions common.
  • Dystonia risk higher in teenagers.
• Protocol (Example):
  • Lorazepam: 0.5 - 1mg (based on age/weight).
  • Olanzapine: Not licensed but often used (5mg).
  • Haloperidol: Generally avoided in children due to EPSEs.

4. Patients with Cardiac History

• History: Long QT syndrome, Previous MI, Heart Failure.
• Avoid: Haloperidol, Droperidol.
• Preferred:
  • Lorazepam (Neutral cardiac profile).
  • Aripiprazole (if antipsychotic needed).
  • Promethazine (Caution: Tachycardia).

5. Intoxication (Alcohol/Drugs)

• Alcohol: Potentiates Benzodiazepines. Risk of apnea.
  • Strategy: Reduced dose of Lorazepam (0.5-1mg) OR Use Haloperidol (does not suppress respiratory drive as much).
• Stimulants (Cocaine/Meth): High Dopamine surge.
  • Strategy: Benzodiazepines are first line (blunt the sympathetic surge). Antipsychotics second line. Avoid Beta-blockers (unopposed Alpha action).

Justification under the Mental Health Act (UK)

RT is a serious intervention interfering with human rights (Article 8 ECHR).

1. Section 5(2): Doctors holding power (72 hrs). Allows RT if urgently needed.
2. Section 5(4): Nurses holding power (6 hrs).
3. 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.
4. Community Treatment Order (CTO): Does NOT authorise forced medication in the community. Recall to hospital is usually required.

Mental Capacity Act (MCA) 2005

• Used when the primary cause is physical (e.g., Sepsis, Head Injury, Hypoglycaemia) or Intoxication, and the patient lacks capacity to consent to treatment.
• Best Interests: You must document why RT is in their best interest (e.g., to prevent life-threatening exhaustion or injury).
• Proportionality: The force used must be proportional to the risk.

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

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

1. De-escalation: What was tried? Why did it fail? (e.g., "Patient threw chair at nurse").
2. Capacity/MHA Status: "Detained under S2".
3. Drug/Dose/Route: "Lorazepam 2mg IM into L Gluteal".
4. Restraint Details: "Prone for 90 seconds, then supine. Head supported by Nurse A."
5. Monitoring: "NEWS2 chart started. 15-min obs ongoing."

Key Case Law (UK)

Legal precedents shape how RT is viewed by the courts.

1. R (Munjaz) v Mersey Care NHS Trust [2005]:
   • Issue: Can hospitals have policies that depart from the Code of Practice on seclusion/RT?
   • Ruling: Hospitals must have "cogent reasons" to depart from the Code. You cannot just ignore NICE guidelines because "we do it differently here".
2. Keenan v UK [2001] (ECHR):
   • Issue: Inhumane treatment of a mentally ill prisoner.
   • Ruling: Poor record keeping and lack of medical monitoring during segregation/restraint can amount to a violation of Article 3 ECHR (Prohibition of Torture/Inhumane Treatment).
3. MS v UK [2012]:
   • Issue: Police detention of a mentally ill man with agitation.
   • Implication: Prolonged restraint in a non-medical setting (police cell) without medical supervision is a violation of human rights.

Ethical Principles

1. Autonomy vs Paternalism:
   • RT overrides autonomy. It is the ultimate act of Paternalism.
   • Justification: The "harm principle" (prevention of harm to others) or "soft paternalism" (preserving the patient's future self).
2. The "Trauma-Informed" Approach:
   • Many psychiatric patients have histories of abuse (sexual/physical).
   • Being pinned down by 5 men replicates past trauma.
   • Mitigation: Use female staff where possible? Explain constantly. Debrief quickly.
3. Moral Distress in Staff:
   • Nurses often feel guilty or "like jailers" after RT.
   • Action: Staff Supervision groups.

A critical step often missed.

1. Immediate (Hot Debrief):
   • Are the staff injured?
   • Is the patient safe?
   • Who is doing the monitoring?
2. Patient Debrief (Cold Debrief - 24h later):
   • "Why did we have to do that?"
   • "I felt scared."
   • Repair the therapeutic relationship. Apologise for the distress, explaining the safety necessity.
3. Team Reflection:
   • Could we have de-escalated earlier?
   • Did the restraints work well?

All units using RT must audit their practice against these standards (NICE QS14).

Key Guidelines

1. NICE NG10 (2015): The gold standard. Emphasises de-escalation and safety monitoring.
2. BAP (British Association for Psychopharmacology): Consensus guidelines on high-dose antipsychotics.
3. Maudsley Prescribing Guidelines (14th Ed): Detailed drug dosages and interactions.

The TREC-Rio Trial (2003)

• Comparison: Midazolam vs Haloperidol/Promethazine for RT in emergency departments.
• Result: Midazolam was faster (mean 15 mins) than Haloperidol/Promethazine (mean 28 mins), but caused more respiratory depression.
• Conclusion: Benzodiazepines are faster but riskier.

Case 1: "The Manic Crisis"

History: 30M with Bipolar I. Stopped Lithium. Brought by police (S136). Singing loudly, pacing, sexually intrusive towards staff. De-escalation: Offered oral Lorazepam ("To help you relax"). Spat it out. Pushed a nurse. Action: Restraint team called (5 person). Drug: Haloperidol 5mg + Promethazine 50mg IM (Combined for maximum sedation). Outcome: Asleep in 20 mins. Monitoring showed HR 110, SaO2 98%. Woke up 6 hours later, calmer. restart Oral meds. Learning: Combination therapy is effective for high arousal states.

Case 2: "The Fragile Elderly"

History: 82F with Vascular Dementia. UTI. Agitated, hitting out with walking stick. Screaming "Get out!". Risk: Falls, Fracture, Stroke. Action: Oral failed. Drug: Lorazepam 0.5mg IM. (Haloperidol avoided due to vascular risk/Lewy Body risk). Outcome: Calmed in 45 mins. Did not sleep but stopped hitting. Learning: "Start Low, Go Slow". 0.5mg is often enough.

Case 3: "Excited Delirium" (Code Black)

History: 24M. Cocaine use. Sweating profusely, taking clothes off, fighting 4 policemen. Impervious to pain. Taser ineffective. Red Flags: Hyperthermia, Super-human strength. Medical Emergency. Action: Anesthetist called. Drug: Ketamine 4mg/kg IM. Outcome: Dissociated in 3 mins. Intubated in ED. Cooling initiated. CK was 50,000. Learning: Standard RT (Lorazepam/Haloperidol) is too slow for Excited Delirium. Ketamine saves lives here.

OSCE Station: The Aggressive Patient

Scenario: You are the Foundation Doctor on call. A 25-year-old male (Schizophrenia) is in the assessment room. He is throwing chairs and shouting that the staff are "poisoning him". He has punched a security guard. Task: Assess the patient, de-escalate if possible, and manage the immediate risk.

Mark Scheme:

1. Safety First:
   • Do not enter the room alone.
   • Check for weapons.
   • Activate alarm/Identify exit route.
2. De-escalation:
   • Use calm, low tone. "My name is Dr X. I want to help."
   • Validation: "You seem very angry."
   • Offer oral meds: "Can we give you a tablet?"
3. Command:
   • Instruct restraint team clearly: "Team Leader, please secure the head. Limb team, secure limbs."
4. Drug Choice:
   • "I am prescribing Lorazepam 2mg IM." (Safe first line).
   • Alternative: "Haloperidol 5mg + Promethazine 50mg".
   • Check: "Does he have allergies? Any cardiac history?"
5. Post-Sedation:
   • "Please move him to recovery position."
   • "Start NEWS2 obs every 15 mins."
   • "Check Pulse and O2 Sats immediately."

Viva Questions

1. "Why do we avoid IM Olanzapine and Benzodiazepines?"
   • Answer: Synergy causes profound hypotension and bradycardia. FDA Black Box warning requires 2 hour gap.
2. "What is the antidote for Benzodiazepine toxicity?"
   • Answer: Flumazenil (200mcg). Caveat: Risk of seizures in mixed overdose or epilepsy.
3. "What are the signs of Neuroleptic Malignant Syndrome?"
   • Answer: Rigidity ("Lead pipe"), Hyperthermia, Autonomic Instability, Confusion + Raised CK.
4. "Why is Haloperidol risky in the elderly?"
   • Answer: Increased risk of Stroke, Falls, QTc prolongation, and Pneumonia.
5. "What is Positional Asphyxia?"
   • Answer: Death caused by body position (usually prone) preventing chest expansion/diaphragm descent, worsened by agitation (high O2 demand).

MCQ Bank

Q1: A 19-year-old male with First Episode Psychosis is agitated. He accepts oral medication. Which is the most appropriate first line? A. Haloperidol 10mg B. Lorazepam 2mg C. Clozapine 12.5mg D. Acuphase (Zuclopenthixol Acetate) 50mg E. Promethazine 25mg

• Correct: B (Lorazepam). Benzodiazepines are first line for oral tranquilisation due to safety and rapid effect. Haloperidol has higher EPSE risk in drug-naive patients.

Q2: You have administered Haloperidol 5mg IM. 20 minutes later, the patient's eyes roll upwards and he looks distressed. His neck is twisted. Diagnosis? A. Seizure B. Behavioural acting out C. Acute Dystonic Reaction D. Tardive Dyskinesia E. Tetanus

• Correct: C (Acute Dystonia). Oculogyric crisis and Torticollis are classic. Treat with Procyclidine.

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

• Correct: C (SpO2). Respiratory depression is the primary lethal mechanism.

Q4: A patient has been restrained in the Prone position. What is the maximum recommended duration for this position? A. 2 minutes B. 10 minutes C. 30 minutes D. Until asleep E. No limit

• Correct: A (2 minutes). Guidelines state turn to supine/lateral as soon as possible, ideally < 2 mins.

Q5: A patient taking Clozapine becomes aggressive. Which drug should be avoided if possible? A. Lorazepam B. Promethazine C. Haloperidol D. Paracetamol E. Hyoscine

• Correct: B (Promethazine). Clozapine is highly anticholinergic and sedating. Adding Promethazine increases risk of Ileus/Agranulocytosis/Sedation. (Though Haloperidol also carries risks, anticholinergic load is often the subtle killer).

What just happened?

Rapid Tranquillisation is used when you are so distressed that you are in danger of hurting yourself or others. The nurses gave you an injection to help your brain slow down and give you a break from the overwhelming feelings.

"I felt pinned down"

We understand that being held down is frightening. We only do this when there is absolutely no other choice to keep everyone safe. We train to do it as quickly and safely as possible. We stopped as soon as the medication started working.

"What are the side effects?"

You might feel groggy, have a dry mouth, or feel stiffness in your muscles. These will wear off. The nurses are checking your blood pressure and breathing every 15 minutes to make sure you are safe while you sleep it off.