Treatment of consumers with acute behavioural arousal can be a complex clinical challenge to medical and nursing staff. This includes behavioural management strategies, sensory modulation and pharmacological options. This protocol guides the medication choices when considering pharmacological options to manage agitation.

To provide effective and safe pharmacological interventions in the management of the agitated patient.

The goal of Rapid Tranquilisation (RT) is to achieve a state of calmness without sedation, sleep or unconsciousness, thereby reducing the risk to self and/or others while maintaining the ability of the patient to respond to communication (NICE, 2015).

RT is defined as the use of medication by the parenteral route (usually intramuscular or, exceptionally intravenous) if oral medication is not possible or appropriate and urgent sedation with medication is required(NICE, 2015).

The clinical practice of RT is used when appropriate psychological and behavioural approaches have failed to deescalate acutely disturbed behaviour.

The Aims of RT:

• To reduce suffering for the patient: psychological or physical (through self harm or accidents).

• To reduce risk of harm to others by maintaining a safe environment.

• To do no harm (by prescribing safe regimes and monitoring physical health).

 This protocol is not to be used for Drug withdrawal management 

• Lower dose should be considered in elderly, low body weight, dehydrated and drug naive patients.

• Monitor BP for any postural drop post antipsychotics and ECG if higher dose of antipsychotics used.

• Extrapyramidal side effects should be monitored even with atypical antipsychotics.

• Benztropine 2mg IM may be required for acute dystonia (Max= 6mg/24hrs).

• Benztropine 1-2mg bd may be used orally for parkinsonian symptoms.

• Haloperidol alone- high risk of dystonia but better in delirium at 0.5-5mg IM.

• Avoid promethazine if delirium or medically unstable.

• Benzodiazepines are not recommended for use in elderly due to the high risk of delirium, sedation and falls risk.

Note:

• Parenteral sedation should only be administered under conditions in which monitoring of vital signs is possible, persons are trained in cardiopulmonary resuscitation equipment is immediately available.

• Minimum equipment requirement include an oxygen supply, suction, a BP monitor, with a fully equipped resuscitation trolley with ECG monitor and pulse oximetry.

• To be read in conjunction with the behavioral management policy in Emergency department. The use of the appropriate guideline is the clinical discretion of the Emergency department physician.

Prior to the administration of a pharmacological intervention to manage agitation:

• attempt to establish underlying diagnosis including assessment of alcohol and drug intoxication and/or withdrawal prior to making any treatment decision.

• explain treatment options to the patient that is agitated, and;

• if possible obtain an informed consent and document it in the clinical file.

Behavioural Management:

Behavioural strategies that are useful in the management of agitation:

• Clear, calm and quiet communication with the patient.

• Staff should actively increase the personal space they afford the patient better to decrease any perceived threat.

• Aggression should be understood as an expression of a need for the patient. Identifying and resolving that need may help avert violence.

• Fear or shame may underlie overt  aggression. Reassuring the patient that they are safe, respected, valued  that nobody will harm them, can be critical.

• Talk with the patient with respect and dignity and ensure appropriate privacy.

• Create an opportunity for patient to ventilate their anxiety, fear and frustrations.

• Discuss with the patient options available to alleviate the agitation.

• Take a non-confrontational approach, e.g. do not challenge delusions.

Acute Arousal flow chart located at Appendix A