- Treat in a quiet place and remove dangerous objects
- Ensure your own safety – avoid being trapped in a corner, have other staff or guardians with you
- Give clear, brief, assertive instructions
- Explain your purpose or intention
- Negotiate options and try to understand the reason for their distress
- Avoid verbal and non-verbal threats
- Allow greater body space than normal
- If patient comes while tied do not immediately remove physical restraints until safe to do so
- Identify any signs of a general medical condition
- Identify symptoms of delirium, drug intoxication, psychosis, mania, dementia etc.
Aggressive or Agitated Patient (including Rapid Tranquilisation)
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The vast majority of people with psychiatric disorders are never aggressive or violent. However, if someone presents in this way, it is important to be able to manage the situation safely.
The aim of management is to alleviate suffering and to prevent harm / injury to the patient and the health care staff. It is also to allow investigation and management of the underlying cause of the aggression e.g. delirium, drug intoxication, psychosis, mania, dementia etc.
If trying to calm the person is unsuccessful, offer oral medicine first. You may need to give an antipsychotic and a benzodiazepine if the patient is severely agitated:
Oral Antipsychotic options:
- Haloperidol 2.5 mg OR
- Chlorpromazine 100 mg OR
- Olanzapine 10 mg OR
- Risperidone 2 mg
Oral Benzodiazepine options:
- Diazepam 10 mg OR
- Lorazepam 1–2 mg
Monitor pulse, BP, breathing rate and temperature every 30 minutes. Repeat oral medication up to two more times at 30-minute intervals if still agitated.
If the person refuses oral medicine, only treat against their will if there is an immediate risk of harm to them or to others. Have at least four additional people to handle the patient if rapid tranquilization is needed. Restrain the person in a safe way – one person for each limb avoiding head, neck and chest. You are likely to need an antipsychotic plus one of the other medications listed below:
IM Antipsychotic options:
- Haloperidol 5 mg OR
- Chlorpromazine 25 to 100 mg OR
Other IM option:
- Promethazine 50 mg
IM Benzodiazepine options:
- Lorazepam 1–2 mg, if available
Monitor pulse, BP, breathing rate and temperature every 30 minutes.
Wait for 30 mins. If disturbed behaviour persists, repeat the dose.
Use a large vein – Diazepam 10mg slow push over at least 5 minutes. Repeat after 5-10 min if insufficient effect (up to three times).
Monitor pulse, BP, breathing rate and temperature every 30 minutes.
Note: if giving IV Diazepam, monitor breathing rate VERY closely as it can cause the patient to stop breathing.
Refer patient to hospital urgently if still no response after following the above steps.
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Caution
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