An agitated and violent patient on an acute ward needs rapid tranquillisation after de-escalation has failed. He is not antipsychotic-naive. Which is a NICE-recommended option?

Answer and explanation

Correct answer: A. Intramuscular lorazepam, or intramuscular haloperidol combined with promethazine

  1. Step 1: NICE NG10 sets out rapid tranquillisation choices.
  2. Step 2: Oral medication is offered first where possible; if IM treatment is needed, NICE lists IM lorazepam alone or IM haloperidol combined with IM promethazine, with physical health monitored.
Answer
Intramuscular lorazepam, or intramuscular haloperidol combined with promethazine.
Why not the others: Oral caffeine tablets to improve his concentration and help de-escalation: Caffeine would worsen agitation. Intravenous diazepam into a peripheral vein, given as a rapid bolus: IV diazepam is not recommended in this setting. Intramuscular haloperidol alone, with no monitoring of physical observations: Haloperidol alone raises the risk of acute dystonia and needs monitoring.

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