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NPS Rapid Tranquillisation — MRCPsych Paper B MCQ

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ModerateSubstance MisuseNPS Rapid TranquillisationMRCPsych Paper B

A 28-year-old man presents to the emergency department acutely agitated after smoking “spice”. He is tachycardic and hypertensive and expresses paranoid ideas. Verbal de-escalation fails, he becomes immediately threatening, and he refuses oral medication. There is no respiratory depression or suspected alcohol or opioid co-intoxication. He has not previously received antipsychotic medication, no ECG has yet been obtained, and intravenous access cannot safely be established. Which rapid tranquillisation approach is most appropriate?

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Correct answer: E — IM lorazepam

The correct answer is E, IM lorazepam. NICE recommends IM lorazepam alone as an adult rapid-tranquillisation option and specifically favours it when the patient has not previously received antipsychotics, information is limited, or no ECG is available. Possible intoxication must also inform drug selection. Respiratory status and consciousness require close monitoring after administration. IM aripiprazole is licensed for agitation associated with schizophrenia or bipolar mania, not established synthetic-cannabinoid intoxication. IV diazepam is a possible sedative in other acute settings but is inappropriate when safe IV access cannot be obtained and is not the NICE rapid-tranquillisation choice here. Ketamine and chlorpromazine are not NICE-recommended first-line adult rapid-tranquillisation regimens; chlorpromazine also carries important hypotension and cardiac risks. “Spice” should not simply be described as producing a predictable sympathomimetic toxidrome.

Reference: National Institute for Health and Care Excellence. Violence and aggression: short-term management in mental health, health and community settings (NG10), recommendations 1.4.37–1.4.39. 2015. https://www.nice.org.uk/guidance/ng10/chapter/Recommendations