# 66 - Practical measures

# Practical measures

Schizophrenia and related psychoses
CHAPTER 1
positive or negative effects and while adding a benzodiazepine to another drug may not 
be clearly advantageous it may lead to unnecessary adverse effects.49
With respect to those who are behaviourally disturbed secondary to acute intoxication 
with alcohol or illicit drugs, there are fewer data to guide practice. A large observational study of IV sedation in patients intoxicated with alcohol found that combination 
treatment (most commonly haloperidol 5mg and lorazepam 2mg) was more effective 
and reduced the need for subsequent sedation than either drug given alone.50 A case 
series (n = 59) of patients who received modest doses of oral, IM or IV haloperidol to 
manage behavioural disturbance in the context of phencyclidine consumption showed 
that haloperidol was effective and well tolerated (one case each of mild hypotension 
and mild hypoxia).51 A section on the treatment of behavioural disturbance caused by 
substance misuse is included in Chapter 9.
Ketamine is widely used for agitation in hospital emergency departments. In a 
­systematic review of 18 studies of ketamine,52 a mean dose of 315mg IM ketamine 
achieved adequate sedation in an average of 7.2 minutes. Over 30% of 650 patients 
were eventually intubated and more than 1% experienced laryngospasm. Ketamine is 
not suitable for RT where facilities for intubation are not available, although it may be 
the most effective treatment.3
Overall, the current broad consensus is that midazolam and droperidol are the 
fastest-­acting single-drug, intramuscular treatments53 and that haloperidol alone should 
be avoided and perhaps abandoned completely even in combination.54 Second-­line 
treatments are combinations of benzodiazepines and antipsychotics and third line 
would probably be intravenous benzodiazepines and then ketamine (2–5mg/kg IM), 
assuming intubation facilities are available.
Practical measures
Plans for the management of individual patients should ideally be made in advance. The 
aim is to prevent disturbed behaviour and reduce risk of violence. Nursing interventions (de-­escalation, time out, seclusion),55 increased nursing levels, transfer of the 
patient to a psychiatric intensive care unit and pharmacological management are 
options that may be employed. Care should be taken to avoid combinations and high 
cumulative doses of antipsychotic drugs. The monitoring of routine physical observations after RT is essential. RT is often, of course, viewed as punitive by patients. There 
is little research into the patient experience of RT. The aims of RT are threefold:
■
■To reduce suffering for the patient: psychological or physical (through self-­harm or 
accidents).
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■To reduce risk of harm to others by maintaining a safe environment.
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■To do no harm (by prescribing safe regimens and monitoring physical health).
Note: Despite the need for rapid and effective treatment, concomitant use of two or 
more antipsychotics (antipsychotic polypharmacy) should be avoided on the basis of 
risk associated with QT prolongation (common to almost all antipsychotics). This is a 
particularly important consideration in RT, where the patient’s physical state predisposes to cardiac arrhythmia.