Occasionally patients in the community setting will require rapid tranquilisation. This may take place in a variety of scenarios, such as at the patient’s home, at a nursing home, or during transport. The assessing senior doctor/GP is responsible for recommending rapid tranquilisation and prescribing this on the kardex if indicated.
At the time of initial assessment it may be that rapid tranquilisation is not considered necessary.
If the patient's mental health subsequently deteriorates then the senior doctor/GP should return to reassess and, if indicted, prescribe rapid tranquilisation. In exceptional circumstances, when this is not possible, the advice of the senior doctor/GP should be sought. They can advise on the prescribing of rapid tranquilisation by a junior doctor or non-medical prescriber who has reviewed the patient.
There is a risk with lorazepam of respiratory depression. This should be managed with attention to airway and breathing, with oxygen if required, and can be reversed with IV flumazenil.
IV flumazenil should be prescribed as an “as required” medication alongside IM lorazepam. (see 'specific issues').
If there are no signs of deteriorating consciousness or respiratory depression an hour following rapid tranquilisation, the risk of developing this is considered low.
If IM lorazepam is administered at the patient’s home, the clinician should remain on site for an hour, or until replaced by ambulance crew or nursing staff. Emphasis is on early identification of deteriorating respiratory function by monitoring closely (see 'observation and monitoring' section) and responding to a deterioration in respiratory function by calling an ambulance and supporting and maintaining an airway until an ambulance arrives.
The manufacturer does not guarantee stability out of the fridge for longer than a period of 30 minutes. Beyond that its use would be "off licence". However, data indicates that lorazepam injection remains stable for a period of up to 6 months at ambient temperatures (fluctuating between 10 to 30 degrees centigrade).
Escort or place of safety teams should establish that appropriate medication has been prescribed.
An ambulance with oxygen and airway/breathing adjuncts is required for transport due to the possible risk of respiratory depression in patients who have had, or may require, rapid tranquilisation.
In the event of respiratory depression the crew should manage the patient’s airway and oxygenation, and seek the quickest way for the patient to receive IV flumazenil (carried by the escort team along with equipment for cannulation). This would be via a GP or local A&E department.
The likelihood of being able to arrange an ECG for patients in the community is low. This highlights the risks associated with the prescription of antipsychotics discussed in the body of this guideline. Therefore any prescription should be carefully considered and the rationale for treatment clearly documented.
Medical, escort or place of safety bags should have available all the equipment required for safe administration and monitoring of rapid tranquilisation. This includes:
|Medication (inc. Flumazenil)
|Equipment for IM injection
|Equipment for cannulation
|Kardex and NEWS chart