DRUG TREATMENT OF ACUTE BEHAVIOURAL DISTURBANCE

IN GENERAL ADULT (18 65YRS) PSYCHIATRIC IN-PATIENTS

This algorithm is a good practice guideline developed by multidisciplinary staff in NHS Lothian. You are strongly
encouraged to adhere to it, circumstances permitting. This algorithm does not cover the treatment of patients over the age
of 65. For these patients please refer to the individual management plan or discuss with the responsible/duty
consultant.
Preventative skilled management (e.g. de-escalation techniques) is obviously preferable to the use of medication. Medication
prescribed in an emergency should be reviewed at least daily to prevent subsequent inappropriate escalation of dose.
Continued use of medication after the acute disturbance may require review of Mental Health Act or Consent to Treatment
status (T2/T3).

Rationale for Choice of Regimens for Algorithm

Haloperidol and lorazepam/midazolam is the treatment choice in acute behavioural disturbance and must be considered
first line for all patients.
This combination of haloperidol and a benzodiazepine is desirable to avoid very high antipsychotic doses when the
immediate aim is sedation.
Olanzapine is the second treatment choice and may only be considered for:
- patients who have had severe dystonic reactions to haloperidol previously
- patients with less extreme agitation who are refusing oral therapy but who are showing escalating levels of hostility
IM Olanzapine must not be administered with a benzodiazepine.

Potential Risks associated with Rapid Tranquillisation

Acute hypotension; seizures (caution with antipsychotics in alcohol withdrawal as they lower seizure threshold);
cardiovascular complications; respiratory complications; extrapyramidal symptoms, especially acute dystonia; CNS
depression; Neuroleptic Malignant Syndrome - a medical emergency - stop antipsychotics and seek advice from Consultant or
Specialist Registrar.

Flumazenil reverses respiratory depression and sedation caused by benzodiazepines. Treating clinicians should note that as
flumazenil has a short half-life as compared to the benzodiazepines, over-sedation and consequent respiratory depression can
re-emerge.
The SPC for haloperidol recommends a baseline ECG prior to treatment in all patients, especially with a positive
personal or family history of cardiac disease or abnormal findings on cardiac clinical examination.
It is recognised this may not always be practical in the context of rapid tranquilisation. However each prescriber must
make his/her own decisions based on the risk-benefit when prescribing haloperidol.

NOTES
Resuscitation facilities must be available as per local guidelines.
Use the minimum effective doses to achieve tranquillisation.
Question aetiology if no response to repeated doses. Consider referring to other guidelines, e.g. Alcohol
Detoxification.
If patient loses consciousness because of administration of benzodiazepines, monitor as for a full anaesthetic
procedure. Give flumazenil if respiratory rate drops below 10 per minute. Flumazenil should be given by
IV injection, 200 micrograms over 15 seconds, then 100 micrograms at 60 second intervals if required; usual
dose range 300-600 micrograms; maximum total dose 1mg.
Procyclidine can be given for acute dystonia by IM injection, 5-10mg repeated if necessary after 20 minutes;
maximum 20mg daily; by IV injection, 5mg usually effective after 5 minutes; occasionally 10mg may be needed.
PRN oral and IM doses of the same medication should be written separately on the prescription sheet as
bioavailability of oral versus IM routes can vary widely.
Repeated prn doses may increase total antipsychotic daily dose above BNF maximum. Consider need for
monitoring according to High Dose Antipsychotic Guidelines.
The IV route of administration for rapid tranquilisation is no longer recommended in inpatient psychiatric setting.
There is no evidence of additional benefit from increasing doses of medication. Seek further advice. Consider
further non-pharmacological interventions. Consider increasing security.

Acute Behavioural Disturbance 2011

 GENERAL ADULT (18 65YRS) PSYCHIATRIC IN-PATIENTS
ALGORITHM FOR DRUG TREATMENT OF ACUTE BEHAVIOURAL DISTURBANCE
NB TO BE USED IN CONJUNCTION WITH THE NOTES OVERLEAF
Assess situation fully including collateral history, review of past notes, etc.
Try to make a diagnosis; consider concurrent medication, drug misuse, etc.
Consider non-drug measures: talking down, distraction and change of environment.
Having taken age, weight, cardiac status and previous exposure to antipsychotics into account a decision is made
on which treatment route to use following guidance from Consultant and MDT.
Try ORAL therapy:

SECOND CHOICE
FIRST CHOICE OR
(Ensure patient meets criteria listed over)

HALOPERIDOL 5mg oral AND

LORAZEPAM 2mg oral
OLANZAPINE 5 - 10mg oral

NO RESPONSE AFTER 30mins

or PATIENT REFUSES
(consider medico-legal issues)

HALOPERIDOL 5mg IM
AND
OLANZAPINE 10mg IM
LORAZEPAM 2mg IM OR
Do not administer with benzodiazepine.
MIDAZOLAM 2mg IM
5mg recommended in renal/hepatic impairment.
Do not mix in same syringe
2.5 - 5mg recommended in patients over 60 years of age
Dilute lorazepam with equal volume of
water for injection or 0.9% sodium chloride.

Monitor physical observations

every 5-10 minutes as clinical condition warrants

Remember maximum doses in 24 hours:

Haloperidol 30mg oral
OR Haloperidol 18mg IM Remember maximum dose in 24 hours:
TOTAL BENZODIAZEPINE 8mg oral/IM Olanzapine 20mg oral/IM
(ie total Lorazepam + Midazolam 8mg)
(maximum 4mg for elderly)

NO RESPONSE NO RESPONSE
AFTER 30mins AFTER 2 hours

Repeat the above and wait 30 minutes. Repeat with olanzapine 5 - 10mg and wait 2 hours.
May repeat again using IM route 3 times up to May repeat again using IM route up to
maximum doses (if no oral benzodiazepines maximum of 3 injections in 24 hours.
given within 24 hours). Maximum duration of IM treatment is 3 days.
Remember to account for ORAL DOSES. Remember to account for ORAL DOSES.

NO RESPONSE NO RESPONSE

Seek further advice from Consultant or Seek further advice from Consultant or
Specialist Registrar. Specialist Registrar.

Give ZUCLOPENTHIXOL ACETATE (CLOPIXOL ACUPHASE), but only to patients with previous exposure to antipsychotics.
This should only be used if the patient is likely to refuse to take oral medication and should not be considered as the first option.
Dose = 50 150mg by deep IM injection (maximum 100mg for elderly)
Sedative effects not apparent for at least 2 hrs.
Peak effect at 24 36 hrs, effective for 72 hrs; repeat if necessary after 2 3 days one additional dose may be needed after 24 hours.
Acuphase is NOT intended for long term use. Duration of treatment, e.g. a course, should not be greater than 2 weeks. Maximum
cumulative dose in this 2-week period is 400mg. However, maximum of 4 injections allowed in 2-week period.

Produced: June 2011 Review date: February 2012

Acute Behavioural Disturbance 2011