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RT in Antipsychotic-Naïve — MRCPsych Paper B MCQ

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ModerateSchizophrenia & PsychosisRT in Antipsychotic-NaïveMRCPsych Paper B

A 40-year-old woman with schizophrenia becomes acutely violent on an inpatient ward. De-escalation has failed, oral medication is not possible and urgent sedation is required. She has never previously taken antipsychotic medication. There is no suspected intoxication or contraindication to benzodiazepines. According to NICE NG10, which intramuscular medication should be used initially for rapid tranquillisation?

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Correct answer: A — IM lorazepam

The correct answer is A, IM lorazepam. NICE NG10 recommends either IM lorazepam alone or IM haloperidol with IM promethazine for adult rapid tranquillisation, but recommendation 1.4.38 specifically directs clinicians to use IM lorazepam when the person has not previously taken antipsychotic medication or when insufficient treatment history is available. IM haloperidol plus promethazine is therefore not the preferred initial regimen in this antipsychotic-naive patient; it may be considered subsequently if lorazepam produces no response. It should also be avoided where cardiovascular disease, QT prolongation or the absence of an ECG creates concern. IM olanzapine, aripiprazole and chlorpromazine are not among the adult rapid-tranquillisation regimens recommended by NG10.

Reference: National Institute for Health and Care Excellence. Violence and aggression: short-term management in mental health, health and community settings (NG10), recommendations 1.4.37–1.4.38. 2015. https://www.nice.org.uk/guidance/ng10/chapter/Recommendations