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RT AP-Naive — MRCPsych Paper B MCQ

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ModerateSchizophrenia & PsychosisRT AP-NaiveMRCPsych Paper B

A 27-year-old man with a first episode of psychosis becomes severely aggressive and presents an immediate risk to staff. Verbal de-escalation has failed, he will not accept oral medication, and urgent sedation is required. He has never previously received an antipsychotic, has expressed no medication preference, and there is no evidence of intoxication or respiratory compromise. According to NICE guidance, which medication should be used first for rapid tranquillisation?

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Correct answer: E — Intramuscular lorazepam

The correct answer is **B, intramuscular lorazepam**. NICE defines rapid tranquillisation as parenteral medication used when oral medication is not possible or appropriate and urgent sedation is required. For adults, the recommended choices are intramuscular lorazepam alone or intramuscular haloperidol combined with promethazine. However, when the person has not previously taken an antipsychotic, NICE specifically recommends intramuscular lorazepam because of its favourable benefit-to-harm profile. Haloperidol plus promethazine is therefore not the preferred initial choice here, although it may be considered if lorazepam produces no response. Intramuscular olanzapine and aripiprazole are not the NICE NG10 recommended first-line regimens for this situation. Intravenous midazolam is also not a recommended routine psychiatric rapid-tranquillisation option; the intramuscular route is normally used.

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