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Rapid tranquillisation in a psychiatric emergency hospital in Lebanon: TREC-Lebanon – a pragmatic randomised controlled trial of intramuscular haloperidol and promethazine v. intramuscular haloperidol, promethazine and chlorpromazine

Published online by Cambridge University Press:  06 January 2021

Joseph E. Dib*
Affiliation:
Division of Psychiatry & Applied Psychology, Institute of Mental Health, School of Medicine, University of Nottingham, Nottingham, Nottinghamshire, NG1 1NU, UK
Hiba Edward Yaacoub
Affiliation:
Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon School of Medicine, Lebanese American University, Beirut, Lebanon
Werner Henry Ikdais
Affiliation:
Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon Faculty of Medicine and MedicalSciences, Holy Spirit University of Kaslik (USEK), Beirut, Lebanon
Elie Atallah
Affiliation:
Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon Faculty of Medical Sciences, Lebanese University of Beirut, Beirut, Lebanon
Tony Jean Merheb
Affiliation:
Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon School of Medicine, Lebanese American University, Beirut, Lebanon
Jean Ajaltouni
Affiliation:
Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon Division of Psychiatry, School of Medicine, Lebanese American University, Beirut, Lebanon
Myriam Akkari
Affiliation:
Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
Marc Mourad
Affiliation:
Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon Faculty of Medicine, St Joseph's University, Beirut, Lebanon
Maria Elias Nasr
Affiliation:
Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon Faculty of Medical Sciences, Lebanese University of Beirut, Beirut, Lebanon
Dory Hachem
Affiliation:
Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
Francois Kazour
Affiliation:
Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon Faculty of Medical Sciences, Lebanese University of Beirut, Beirut, Lebanon Faculty of Medicine, St Joseph's University, Beirut, Lebanon Department of Psychology, Faculty of Arts and Sciences, Holy Spirit University of Kaslik (USEK), Beirut, Lebanon INSERM U930, équipe 4 “Troubles affectifs”, Université François-Rabelais de Tours, Tours, France
Fouad Tahan
Affiliation:
Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
Georges Haddad
Affiliation:
Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon School of Medicine, Lebanese American University, Beirut, Lebanon
Jocelyn Azar
Affiliation:
Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon School of Medicine, Lebanese American University, Beirut, Lebanon Faculty of Medical Sciences, Lebanese University of Beirut, Beirut, Lebanon
Marouan Zoghbi
Affiliation:
Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon Faculty of Medicine, St Joseph's University, Beirut, Lebanon
Chadia Haddad
Affiliation:
Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
Souheil Hallit
Affiliation:
Faculty of Medicine and MedicalSciences, Holy Spirit University of Kaslik (USEK), Beirut, Lebanon INSPECT-LB: Institut National de Sante Publique, Epidemiologie Clinique et Toxicologie, Beirut, Lebanon
Clive E. Adams
Affiliation:
Institute of Mental Health, University of Nottingham, Nottingham, Nottinghamshire, UK.
*
Author for correspondence: Joseph E. Dib, E-mail: joseph.elie.dib@gmail.com

Abstract

Background

Agitated patients constitute 10% of all emergency psychiatric treatment. Management guidelines, the preferred treatment of clinicians differ in opinion and practice. In Lebanon, the use of the triple therapy haloperidol plus promethazine plus chlorpromazine (HPC) is frequently used but no studies involving this combination exists.

Method

A pragmatic randomised open trial (September 2018–July 2019) in the Lebanese Psychiatric Hospital of the Cross in Beirut Lebanon involving 100 people requiring urgent intramuscular sedation due to aggressive behaviour were given intramuscular chlorpromazine 100 mg plus haloperidol 5 mg plus promethazine 25 mg (HPC) or intramuscular haloperidol 5 mg plus promethazine 25 mg

Results

Primary outcome data were available for 94 (94%) people. People allocated to the haloperidol plus promethazine (HP) group showed no clear difference at 20 min compared with patients allocated to the HPC group [relative risk (RR) 0.84, 95% confidence interval (CI) 0.47–1.50].

Conclusions

Neither intervention consistently impacted the outcome of ‘calm’, or ‘asleep’ and had no discernible effect on the use of restraints, use of additional drugs or recurrence. If clinicians are faced with uncertainty on which of the two intervention combinations to use, the simpler HP is much more widely tested and the addition of chlorpromazine adds no clear benefit with a risk of additional adverse effects.

Type
Original Article
Copyright
Copyright © The Author(s), 2020. Published by Cambridge University Press

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Footnotes

*

Souheil Hallit and Clive E Adams are last coauthors.

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