Rapid tranquilisation

recommended agents

  • IM ketamine - 4mg/kg IM
  • IM droperidol 5-10mg
  • IM midazolam 5-10mg
  • IM lorazepam 4mg
  • IM haloperidol 5mg with IM promethazine

This comes with

  • hourly obs until no concerns
  • 15 minute obs if dose > BNF dose, or patient appears sedated

RCEM/NICE recommendations...

"Consider rapid tranquillisation or seclusion as alternatives to prolonged manual restraint (longer than 10 minutes)."
"Use either intramuscular lorazepam on its own or intramuscular haloperidol combined with intramuscular promethazine for rapid tranquillisation in adults"

to tube or not to tube?

RCEM guidance suggests if

  • A-E problems, i.e. airway protection, inadequate ventilation, metabolic derangement, hyperthermia

  • unmanageable aggression with maximal safe sedative doses

  • other investigations or interventions need to be done

  • Cardiostable induction - literally they use "physiologically fragile"

  • Consider ventilating throughout RSI! - keeping up with their compensation for metab acidosis

  • Recall histamine release with morphine, and potential Serotonin syndrome with fentanyl

#sedation

https://www.nice.org.uk/guidance/ng10/chapter/Recommendations#managing-violence-and-aggression-in-emergency-departments-2
https://www.rcemlearning.co.uk/reference/violent-behaviour-in-the-ed/#1637581918442-546417a9-a4d5