Requires specialist advice.
Parenteral medication may occasionally be needed to restrain a violent, psychotic patient when talking, distraction, seclusion and measured physical restraint have failed.
- choice of antipsychotic between chlorpromazine (25-50 mg i.m.) and haloperidol (2-10 mg i.m. repeated hourly if necessary to a maximum of 60 mg over 24 hours)
- acute dystonia is probably least likely with chlorpromazine, but it may cause hypotension and arrhythmias
- preferred antipsychotic agent is often haloperidol; procyclidine (5-10 mg i.m.) can be given prophylactically to prevent dystonic reactions
- use of a benzodiazepine e.g. lorazepam, may rapidly produce drowsiness and reduce anxiety but may depress respiration and so should not be given to a patient with respiratory impairment.
NICE suggest (1):
- oral antipsychotic medication
- offer oral antipsychotic medication to people with an acute exacerbation or recurrence of schizophrenia
- when choosing a drug
- when using antipsychotic medication then consider treatment with antipsychotic medication as an individual therapeutic trial:
- record the indications, expected benefits and risks, and expected time for a change in symptoms and for side effects to occur
- start with a dose at the lower end of the licensed range and titrate upwards slowly within the dose range in the British National Formulary (BNF) or SPC
- justify and record reasons for dosages outside the range specified in the BNF or SPC
- monitor and record the following regularly and systematically throughout treatment, but especially during titration:
- efficacy, including changes in symptoms and behaviour
- side effects of treatment, taking into account overlap with some of the clinical features of schizophrenia
- adherence
- physical health
- the rationale for continuing, changing or stopping medication and the effects of such changes should be recorded
- gake into account the clinical response and side effects of previous and current medication
- consider rapid tranquillisation for people who pose an immediate threat to themselves or others during an acute episode (2):
- oral medication should be offered before parenteral medication as far as possible
- when the behavioural disturbance occurs in a non-psychotic context it is preferable to initially use oral lorazepam alone, or intramuscularly if necessary
- when the behavioural disturbance occurs in the context of psychosis, to achieve early onset of calming/sedation, or to achieve a lower dose of antipsychotic, an oral antipsychotic in combination with oral lorazepam, should be considered in the first instance
- where rapid tranquillisation through oral therapy is refused, is not indicated by previous clinical response, is not a proportionate response, or is ineffective, a combination of an intramuscular antipsychotic and an intramuscular benzodiazepine (i/m haloperidol and i/m lorazepam) is recommended
- in the event of moderate disturbance in service users with psychosis, i/m olanzapine may be considered
- intramuscular lorazepam should not be given within 1 hour of i/m olanzapine. Oral lorazepam should be used with caution
- the following medications are not recommended for rapid tranquillisation:
- intramuscular or oral chlorpromazine or oral (a local irritant if given intramuscularly; risk of cardiovascular complications; causes hypotension due to alpha-adrenergic receptor blocking effects, especially in the doses required for rapid tranquillisation; is erratically absorbed; its effect on QTc intervals suggests that it is unsuitable for use in rapid tranquillisation)
- intramuscular diazepam
- thioridazine
- intramuscular depot antipsychotics
- olanzapine or risperidone should not be used for the management of disturbed/violent behaviour in service users with dementia
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