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Each patient will have an individualised treatment plan including:
If IM administration is required the appropriate MHA documentation should be completed if applicable.
When IM sedation is administered, a doctor should be informed and available to attend the patient within 30 minutes if required.
Consider the potential for inadvertent high-dose antipsychotic therapy when prescribing IM antipsychotics.
When prescribing medication for use intramuscularly, write the initial prescription as a once-only dose, do not repeat it until the effect of the initial dose has been reviewed.
If the behavioural disturbance is thought to be related to 'excited delirium' then consider immediate referral to acute care (see RCEM guidance).
Recommended Treatment Choices (NICE Guidance NG10 2015)
Alternatives not recommended by NICE for the purpose of emergency IM treatment in acutely disturbed patients but may be considered where the use of haloperidol is inappropriate e.g. where there is a risk of prolonged QTc interval
Use of lower doses in some patient groups e.g. elderly or debilitated.
Care must be taken in struggling patients to avoid inadvertent IV administration.
Be aware of the total dose of medication administered over the last 24 hours.
Risks with antipsychotics
After IM sedation the ward team monitor the following at least every hour until the patient is ambulatory:
Monitor every 15 minutes if the BNF maximum dose has been exceeded or the patient:
Where full monitoring is impractical, clearly document the reasons why and ensure minimum observation of respiration and level of consciousness.
|Acute dystonias (including oculgyric crisis)||Procyclidine 5-10mg IM|
|Reduced respiratory rate (<10/minute or oxygen saturation <90%||
Give flumazenil if benzodiazepine-induced:
Monitor respiration until rate returns to baseline level.
If induced by other agent patient may require mechanical ventilation–arrange transfer to ITU immediately.
|Reduced respiratory rate (<5/minute)||
Medical Emergency–institute emergency treatment and arrange immediate transfer.
|Tachycardia (>140/min), irregular heart beat or bradycardia (<50/min)||Refer to specialist medical care immediately.|
Lie patient flat, raise legs if possible, monitor closely including blood pressure.
|Fall in blood pressure (systolic <90mmHg or diastolic <50mmHg)||
Urgent medical assessment. Lie patient flat, raise legs if possible.
|Increased temperature (>37.5oC)||Urgent medical assessment. Withhold antipsychotics due to risk of NMS & arrhythmias.|
Last reviewed: 31 May 2019
Next review: 01 March 2021
Approved By: MHS Quality& Clinical Governance Group
Reviewer Name(s): Andrew Walker, Suzanne Burke