Rapid Tranquilisation Algorithm
Recommended Medications
| Medication | Dose | Onset of Action | Peak Effect | Max. Daily Dose | Notes |
|---|---|---|---|---|---|
| Promethazine [Phenergan] (anti-histaminic) |
PO: Age <12 years: 5-10 mg Age >12 years: 10-25 mg IM: Age <12 years: 6.25-12.5 mg Age >12 years: 10-25 mg |
PO: 15-30 minutes IM: 20 minutes |
PO: 2-3 hours IM: 2-3 hours |
<12 years: 50 mg >12 years: 100 mg |
Use with caution in children with epilepsy (significant anti-muscarinic activity). Requires ECG as soon as possible. May prolong QTc interval. |
| Clonidine (alpha-2-agonist) |
PO: 1-4 micrograms/kg Recommended starting dose is 2 micrograms/kg or 50 micrograms-100 micrograms (6 hourly) |
30-60 minutes | PO: 3-5 hours | 300 mcg | Monitor for hypotension and bradycardia, particularly when combined with a benzodiazepine or atypical antipsychotic. Can cause rebound reaction and agitation in 6-8 hours. |
| Midazolam (benzodiazepine) |
Buccal: 5-9 years: 7.5 mg 10-18 years: 10 mg Intranasal (see Emed): 0.3-0.5 mg/kg, max dose 10 mg |
Buccal: 15-30 minutes Intranasal: 3-5 minutes |
Buccal: 15-30 minutes Intranasal: 10 minutes |
Buccal, 5-9 years: 15 mg Buccal, 10-18 years: 20 mg Intranasal: 20 mg |
Monitor respiratory rate and SpO2. For IN administration, use an atomiser with IV formulation and see Emed Protocol (https://emed.ie/Analgesia/IN_Protocol.php). |
| Lorazepam (benzodiazepine) |
PO: Age <12 years/<40 kg: 0.5-1 mg Age >12 years/>40 kg: 1-2 mg 4-8 hourly IM: Age <12 years/<40 kg: 0.5-1 mg13 Age >12 years/>40 kg: 0.5-2 mg13 |
PO: 15-30 minutes IM: 20-40 minutes |
PO/IM: 2 hours | PO/IM: 4 mg | Slower onset of action and half-life than Midazolam. Avoid in delirium. Do not give with olanzapine due to risk of respiratory depression. |
| Olanzapine (atypical antipsychotic) |
Orodispersible route preferred PO/IM: Age 4 to <6: 1.25 mg for one dose Age 6-12 years: 2.5 mg-5 mg for one dose Age >12 years: 5 mg-10 mg for one dose |
PO: 2-4 hours IM: 15-30 mins |
PO: 5-8 hours IM: 15-45 mins |
10-20 mg depending on antipsychotic exposure Contact Psychiatry/Paediatric consultant if using ≥ 10 mg |
Do not give PO within 1-2 hours of any BZD due to risk of respiratory depression. Requires ECG as soon as possible. May prolong QTc interval. |
| Risperidone (atypical antipsychotic) |
PO: 5-12 years/<40kg: 0.25 mg-0.5 mg >12 years/≥ 40 kg: 0.5 mg-1 mg |
1 hour | PO: 1-2 hours | <50 kg: 1 mg >50 kg: 2 mg |
Can cause restlessness/agitation in higher doses. Requires ECG as soon as possible. May prolong QTc interval. |
| Procyclidine (anti-cholinergic) |
IM/IV: <2 years: 0.5-2 mg for one dose 2-10 years: 2-5 mg for one dose 10-18 years: 5-10 mg for one dose |
5-20 minutes | IM/IV: 1-2 hours |
Discuss with Senior Clinicians | Psychotic episodes may be precipitated. Anti-cholinergic side effects. |
| Benzatropine (anti-cholinergic) |
IM/IV: ≥3-12 years: 20-50 micrograms/kg (max single dose 2 mg) bolus over 1-2 minutes ≥12 years: 1-2 mg bolus over 2 minutes |
5-20 minutes | Limited evidence | Discuss with Senior Clinicians | Anti-cholinergic side effects. Contra-indicated in children < 3 years of age. Avoid in GI obstruction, myasthenia gravis, narrow-angle glaucoma. |
| Flumazenil (benzodiazepine antagonist) | IV: 10 micrograms/kg repeated at one minute intervals as required up to five doses with anaesthetic support (Max. single dose 200 micrograms) | 1-2 minutes | IV: 6-10 minutes | 50 micrograms/kg per course to max of 1 mg | Contraindicated in life threatening conditions (e.g. raised intracranial pressure, status epilepticus) controlled by benzodiazepines. Monitor for re-sedation. |
Adverse Effects:
- Airway Obstruction
- Respiratory Depression - Benzodiazepines, Olanzapine)
- Extrapyramidal reactions/dystonic reactions - Risperidone, Olanzapine
- Neuroleptic Malignant Syndrome - Risperidone, Olanzapine
- Paradoxical Reactions (increased agitation, hyperactivity, etc) - Benzodiazepines
Emergency resuscitation equipment, procyclidine injection & flumazenil injection should be available before treatment
Monitoring of the patient must be performed & recorded by nursing staff after any injection is given. Pulse, RR, BP, Temp every 5-10 minutes for one hour post-injection; then half-hourly until ambulatory
Pharmacy Contact Details (8am to 5pm)
- ED Pharmacist (General) - 087 2040676
- ED Pharmacist (Paediatric) - 087 1818059
- Paediatric Pharmacist - 086 1747994 / 087 1622045
- Central Pharmacy - 021 4922146 / 021 4922542