# 53 - Rapid tranquillisation (RT) in children and a

# Rapid tranquillisation (RT) in children and adolescents

Prescribing in children and adolescents
CHAPTER 5
Rapid tranquillisation (RT) in children and adolescents
As in adults, a comprehensive assessment and effective treatment plan undertaken by 
staff skilled in the use of de-­escalation techniques and appropriate placement of the 
patient are key to minimising the need for enforced parenteral medication. The 
­differential diagnoses for agitated or challenging behaviour can be broad, but there is 
concern that RT may be disproportionately used in a neurodiverse population where 
other strategies may be more appropriate and the outcome more predictable.1,2
Healthcare professionals undertaking RT and/or restraint in children and adolescents should be trained and competent in undertaking these procedures in this population and should be clear about the legal context for any restrictive practices they employ. 
Be particularly cautious when considering high-­potency antipsychotic medication (e.g. 
haloperidol) especially for those who are neuroleptic naïve, because of the increased 
risk of acute dystonic reactions in this age group.3 Children are particularly prone to 
acute extrapyramidal effects of psychotropic and physical medication.4 In the UK, 
NICE recommends using intramuscular lorazepam (and recommends no other drug).5 
Evidence suggests that lorazepam is effective (at a median dose of 1mg) and rarely 
causes respiratory depression resulting in oxygen desaturation.1 Reviews support the 
use of a range of SGA drugs6 with the most frequently used agent being olanzapine, 
which has evidence of its safety and efficacy.7
A wide dose range is given here for medication used in RT. This is partly a consequence of the wide range of body mass in individuals aged from under 10 to 18 years. 
Caution is required, especially for younger children, but in older adolescents consider 
the use of adult doses, especially in those who are not drug naïve and where doses at 
the lower end of the quoted dose range have proved ineffective.
A summary is given in Table 5.11.
Table 5.11  Recommended drugs for rapid tranquillisation if the oral route is refused or has proven ineffective.
Medication
Dose
Onset of action
Comment
Olanzapine IM8,9
2.­5–­10mg
­15–­30 minutes
Possibly increased risk of respiratory 
depression when administered with 
benzodiazepines, particularly if alcohol has 
been consumed. Separate administration by 
at least 1 hour.
Haloperidol IM10
0.­025–­0.075mg/kg/dose
(max. 2.5mg) IM
 
Adolescents >12 years 
can receive the adult 
dose (2.­5–­5mg)
­20–­30 minutes
Must have parenteral anticholinergics 
present in case of laryngeal spasm or other 
dystonia (young people more vulnerable to 
severe dystonia).
 
Adult data suggest co-­administration of 
promethazine may reduce EPS risk.11
 
ECG is essential
Lorazepam* IM12
<12 years: 0.­5–­1mg;
>12 years: 0.5-­2mg
­20–­40 minutes
Slower onset of action than midazolam
 
Only treatment recommended by NICE
 
Flumazenil is the reversing agent for all 
benzodiazepines.
(Continued )

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The Maudsley® Prescribing Guidelines in Psychiatry
CHAPTER 5
Oral medication should always be offered (and repeated if necessary if the young 
person is willing to take it) before resorting to parenteral treatment. Oral alternatives 
such as buccal midazolam14 and inhaled loxapine20 have not been widely investigated in 
children in RT and have limited availability. Buccal midazolam is commonly used for 
seizures in children.
Monitoring after RT is the same as in adults (see Chapter 3).
Medication
Dose
Onset of action
Comment
Midazolam* IM, 
IV or buccal12
0.­1–­0.15mg/kg IM
 
Buccal midazolam 
­300–­500mcg/kg or ­ 
6–­10 years = 7.5mg;
>10 years = 10mg
­10–­20 min IM
(­1–­3 min IV)
Quicker onset and shorter duration of 
action than lorazepam or diazepam
 
IV administration should only be used (usually 
as a last resort) with extreme caution and 
where resuscitation facilities are available.
 
Quicker onset and shorter duration of 
action than haloperidol
 
When given as buccal liquid, onset of action 
is ­15–­30 minutes.13 There are some 
published data of its use in mental health 
but only in adults;14 buccal liquid is 
unlicensed for this use.
Diazepam* IV
(not for IM 
administration)15
0.1mg/kg/dose by slow 
IV injection
 
Max. 40mg total daily 
dose <12 years and 
60mg >12 years
­1–­3 minutes
Long half-­life that does not correlate with 
length of sedation
 
Possibility of accumulation
 
Never give as IM injection.
Ziprasidone IM16,17
­10–­20mg
­15–­30 minutes IM
Apparently effective
 
QT prolongation is of concern in this patient 
group.
 
ECG is essential.
Aripiprazole IM18,19
9.75mg
­15–­30 minutes
Evidence of effectiveness in adults but no 
clinical trial data for children and adolescents
Promethazine IM
<12 years: ­5–­25mg
(max. 50mg/day)
 
>12 years: ­25–­50mg
(max. 100mg/day)
Up to 60 minutes
An effective sedative, although has a slow 
onset of action. Useful if the cause of 
behavioural disturbance is unknown and 
there is concern about the use of 
antipsychotic medication in a child or young 
person.
*Note that young people are particularly vulnerable to disinhibitory reactions with benzodiazepines. EPS, extrapyramidal symptoms.
Table 5.11  (Continued)