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Dib JE, Yaacoub HE, Ikdais WH, Atallah E, Merheb TJ, Ajaltouni J, Akkari M, Mourad M, Nasr ME, Hachem D, Kazour F, Tahan F, Haddad G, Azar J, Zoghbi M, Haddad C, Hallit S, Adams CE. 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. Psychol Med 2022; 52:2751-2759. [PMID: 33402230 DOI: 10.1017/s0033291720004869] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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.
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Affiliation(s)
- Joseph E Dib
- Division of Psychiatry & Applied Psychology, Institute of Mental Health, School of Medicine, University of Nottingham, Nottingham, Nottinghamshire, NG1 1NU, UK
| | - Hiba Edward Yaacoub
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
- School of Medicine, Lebanese American University, Beirut, Lebanon
| | - Werner Henry Ikdais
- 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
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
- Faculty of Medical Sciences, Lebanese University of Beirut, Beirut, Lebanon
| | - Tony Jean Merheb
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
- School of Medicine, Lebanese American University, Beirut, Lebanon
| | - Jean Ajaltouni
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
- Division of Psychiatry, School of Medicine, Lebanese American University, Beirut, Lebanon
| | - Myriam Akkari
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
| | - Marc Mourad
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
- Faculty of Medicine, St Joseph's University, Beirut, Lebanon
| | - Maria Elias Nasr
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
- Faculty of Medical Sciences, Lebanese University of Beirut, Beirut, Lebanon
| | - Dory Hachem
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
| | - Francois Kazour
- 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
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
| | - Georges Haddad
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
- School of Medicine, Lebanese American University, Beirut, Lebanon
| | - Jocelyn Azar
- 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
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
- Faculty of Medicine, St Joseph's University, Beirut, Lebanon
| | - Chadia Haddad
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
| | - Souheil Hallit
- 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
- Institute of Mental Health, University of Nottingham, Nottingham, Nottinghamshire, UK
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Dib JE, Adams CE, Ikdais WH, Atallah E, Yaacoub HE, Merheb TJ, Kazour F, Tahan F, Haddad G, Zoghbi M, Azar J, Haddad C, Hallit S. Study protocol for a randomised controlled trial of haloperidol plus promethazine plus chlorpromazine versus haloperidol plus promethazine for rapid tranquilisation for agitated psychiatric patients in the emergency setting (TREC-Lebanon). F1000Res 2019; 8:1442. [PMID: 32528650 PMCID: PMC7262571 DOI: 10.12688/f1000research.19933.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2019] [Indexed: 01/10/2023] Open
Abstract
Background: Agitated and aggressive behaviours are common in the psychiatric setting and rapid tranquilisation is sometimes unavoidable. A survey of Lebanese practice has shown that an intramuscular haloperidol, promethazine and chlorpromazine combination is a preferred form of treatment but there are no randomised trials of this triple therapy. Methods: This is a pragmatic randomised trial. Setting - the psychiatric wards of the Psychiatric Hospital of the Cross, Jal Eddib, Lebanon. Participants - any adult patient in the hospital who displays an aggressive episode for whom rapid tranquilisation is unavoidable, who has not been randomised before, for whom there are no known contraindications. Randomisation - stratified (by ward) randomisation and concealed in closed opaque envelope by independent parties. Procedure - if the clinical situation arises requiring rapid tranquilisation, medical residents overseeing the patient will open a TREC-Lebanon envelope in which will be notification of which group of treatments should be preferred [Haloperidol + Promethazine + Chlorpromazine (HPC) or Haloperidol + Promethazine (HP)], along with forms for primary, secondary and serious adverse effects. Treatment is not given blindly. Outcome - primary outcome is calm or tranquil at 20 minutes post intervention. Secondary outcomes are calm/tranquil at 40, 60 and 120 minutes post intervention, asleep, adverse effects, use of straitjacket and leaving the ward. Follow-up will be up to two weeks post randomisation. Discussion: Findings from this study will compare the HPC versus HP combination used in Lebanon's psychiatry emergency routine practice. Trial registration: ClinicalTrials.gov NCT03639558. Registration date, August 21, 2018.
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Affiliation(s)
- Joseph E. Dib
- Institute of Mental Health, University of Nottingham, Nottingham, Nottinghamshire, NG1 1NU, UK
| | - Clive E. Adams
- Institution of Mental Health, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Werner Henry Ikdais
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
- Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Beirut, Lebanon
| | - Elie Atallah
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
- Faculty of Sciences, Lebanese University of Beirut, Beirut, Lebanon
| | - Hiba Edward Yaacoub
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
- School of Medicine, Lebanese American University, Beirut, Lebanon
| | - Tony Jean Merheb
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
- School of Medicine, Lebanese American University, Beirut, Lebanon
| | - Francois Kazour
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
- Faculty of Sciences, Lebanese University of Beirut, Beirut, Lebanon
- Department of Psychology, Holy Spirit University of Kaslik, Beirut, Lebanon
- Faculty of Medicine, St Joseph's University, Beirut, Lebanon
- INSERM U930, équipe 4 “Troubles affectifs”, Université François-Rabelais de Tours, Tours, France
| | - Fouad Tahan
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
| | - Georges Haddad
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
- School of Medicine, Lebanese American University, Beirut, Lebanon
| | - Marouan Zoghbi
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
- Faculty of Medicine, St Joseph's University, Beirut, Lebanon
| | - Jocelyn Azar
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
- Faculty of Sciences, Lebanese University of Beirut, Beirut, Lebanon
- School of Medicine, Lebanese American University, Beirut, Lebanon
| | - Chadia Haddad
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
| | - Souheil Hallit
- Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Beirut, Lebanon
- INSPECT-LB: Institut National de Sante Publique, Epidemiologie Clinique et Toxicologie, Beirut, Lebanon
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