Agitation

Chemical RestraintThe world can be a scary and dangerous place, but few things are as dangerous as an acutely agitated patient in your emergency department.  While violent adults in the ED seem nearly commonplace (although still deserve provider’s vigilance), the agitated and dangerous child is also becoming more prevalent in our EDs.  The management of acute agitation in children can be challenging, so let’s spend a minute considering our options.

 

Agitation: What is it?

  • This seems like a silly question, but the literature does not use a consistent definition. [Sonnier, 2011]
  • Most definitions include behavior that may lead to harm to the patient or healthcare providers if no intervention is taken.

 

Agitation: Common?

  • Estimated that 10-20% of children and adolescents have mental disorders and/or substance abuse.
  • ED visits for psychiatric conditions in children continue to increase. [Pittsenbarger, 2014]
  • The resources required to care for pediatric patients needing psychiatric care in the ED continues to increase also. [Sheridan, 2015]
  • During psychiatric evaluation, about 1 out 15 of kids required restraint. [Dorfman, 2006]

 

Agitation: What is it due to?

  • This question is incredibly important to address.
    • Similar to the trauma patient, do not get distracted by the obvious injury and overlook the more substantial, occult one.
    • Violent behavior may be why the patient is in the ED, but think of it as a symptom rather than the diagnosis.
    • The acutely agitated patient is not a “psychiatric patient” until you’ve consider the other emergent medical conditions.
  • Undifferentiated agitation (abridged) Ddx:
    • Broad Categories:
      • Medical Conditions
      • Substance Use
      • Psychiatric illness
    • AEIOU TIPS (yes… this is the one for Altered Mental Status… I’m not smart enough to remember more than one acronym)
      • Alcohol – while often a sedative, ETOH can cause agitation
      • Electrolyte derangements (ex, hyponatremia, hypercalcemia)
      • Insulin (got hypoglycemia??)
      • Opiates and Other Drugs (got a toxidrome? anticholinergic vs sympathomimetic? NMS? Serotonin syndrome?)
      • Uremia
      • Trauma – Look closely for signs of trauma
      • Infection – Meningitis/encephalitis?
      • Psychiatric disorder – really should be the last one considered
      • Space occupying lesion
    • While each year a new set of “designer” intoxicants may be added to the list, don’t become enamored with them and forget more “boring” entities (ex, hypoglycemia!).

 

Agitation: Management?

  • Primary Goal = keep patient and staff safe while allowing continued evaluation.
    • The least restrictive method that attains this goal should be used. [Adimando, 2010]
    • Unfortunately, how to safely restrain pediatric patients is not often taught. [Dorfman, 2004]
  • If not immediately dangerous, attempt simple, nonrestrictive strategies: [Adimando, 2010]
    • Verbal de-escalation
    • Reduction of environmental stimuli (a quite room is much better than a loud hallway)
    • Offer basic needs (ex, food, warm blanket)
  • If simple tactics don’t work, or the patient is initially dangerous, move onward to restraint.
  • Ideally, before selecting a medication, the etiology would be known so risk could be minimized…
  • In reality, evaluation and management occur concurrently, so some Rx options may be less desirable in the undifferentiated acutely agitated patient.
  • “Chemical Restraint”

    • Oral vs Intramuscular
      • If the patient is cooperative, offer oral medications first.
        • May give the patient sense of some control.
        • Avoid trauma of being physically restrained for IM shot
        • Many medications are equally effective in oral form
      • If patient is not cooperative, the oral route is not going to be an option.
    • There is no perfect medication option for every scenario, and the true efficacy of the various options is unknown in children, so be conservative and keep a few options in mind: [Carubia, 2016]
      • Benzodiazepines
        • Lorazepam – 0.05-0.1 mg/kg/dose (PO/IM/IV)
        • Midazolam – 0.25-0.5 mg/kg/dose PO; 0.2-0.3 mg/kg IN; 0.1-0.15 mg/kg/dose IM
      • First Generation Antipsychotics
        • Haloperidol – 0.5-5 mg PO; 0.05-0.15 mg/kg IM (up to 5 mg/dose)
        • Droperidol – 0.03-0.07 mg/kg/dose (IM/IV)
          • Has become scarce in the USA after FDA black-box warning regarding QT prolongation — which other antipsychotics cause as well (some even more so)
          • Has been shown to be safe and effective for acute agitation in pediatric patients in ED setting. [Szwak, 2010]
        • Chlorpromazine – 0.55 mg/kg/dose (PO/IM)
      • Second Generation Antipsychotics
        • Risperidone – 0.25-2 mg PO/ODT
        • Olanzapine – 2.5-5 mg PO/ODT
      • Others:
        • Diphenhydramine – 1 mg/kg/dose (PO/IM)
        • Ketamine (ok, so I’m biased, but this is awesome!) [Kowalski, 2015]
          • Rapid onset due to high bioavailability (even when given IM)
          • No QT prolongation issues
          • Safe even in overdose (important when you aren’t sure of patient weight)
          • No respiratory depression (rarely, may see laryngospasm)
          • Should likely avoid in patient with known schizophrenia
  • Physical Restraints

    • Can be dangerous (i.e., Rhabdomyolysis and Airway compromise), but there are safe methods to use.
    • Use as last option
    • Remove as soon as no longer needed

 

Moral of the Morsel

  • Acutely agitated patients can be hazardous to themselves and the entire ED; anticipate how you will deal with them (because eventually one will be requiring your acute attention).
  • Acute agitation is a symptom — look for the cause while keeping everyone safe.
  • Consider non-restrictive means to controlling the situation first, if possible.
  • There is no perfect medication that is good for every scenario and patient — keep several in your tool belt.

 

References

Carubia B1,2, Becker A3,4, Levine BH5. Child Psychiatric Emergencies: Updates on Trends, Clinical Care, and Practice Challenges. Curr Psychiatry Rep. 2016 Apr;18(4):41. PMID: 26932516. [PubMed] [Read by QxMD]

Sheridan DC1, Spiro DM, Fu R, Johnson KP, Sheridan JS, Oue AA, Wang W, Van Nes R, Hansen ML. Mental Health Utilization in a Pediatric Emergency Department. Pediatr Emerg Care. 2015 Aug;31(8):555-9. PMID: 25834957. [PubMed] [Read by QxMD]

Kowalski JM1, Kopec KT, Lavelle J, Osterhoudt K. A Novel Agent for Management of Agitated Delirium: A Case Series of Ketamine Utilization in the Pediatric Emergency Department. Pediatr Emerg Care. 2015 Oct 13. PMID: 26466151. [PubMed] [Read by QxMD]

Pittsenbarger ZE1, Mannix R. Trends in pediatric visits to the emergency department for psychiatric illnesses. Acad Emerg Med. 2014 Jan;21(1):25-30. PMID: 24552521. [PubMed] [Read by QxMD]

Sonnier L1, Barzman D. Pharmacologic management of acutely agitated pediatric patients. Paediatr Drugs. 2011 Feb 1;13(1):1-10. PMID: 21162596. [PubMed] [Read by QxMD]

Adimando AJ1, Poncin YB, Baum CR. Pharmacological management of the agitated pediatric patient. Pediatr Emerg Care. 2010 Nov;26(11):856-60; quiz 861-3. PMID: 21057285. [PubMed] [Read by QxMD]

Szwak K1, Sacchetti A. Droperidol use in pediatric emergency department patients. Pediatr Emerg Care. 2010 Apr;26(4):248-50. PMID: 20401969. [PubMed] [Read by QxMD]

Barzman DH1, DelBello MP, Forrester JJ, Keck PE Jr, Strakowski SM. A retrospective chart review of intramuscular ziprasidone for agitation in children and adolescents on psychiatric units: prospective studies are needed. J Child Adolesc Psychopharmacol. 2007 Aug;17(4):503-9. PMID: 17822344. [PubMed] [Read by QxMD]

Dorfman DH1, Kastner B. The use of restraint for pediatric psychiatric patients in emergency departments. Pediatr Emerg Care. 2004 Mar;20(3):151-6. PMID: 15094571. [PubMed] [Read by QxMD]

Sorrentino A1. Chemical restraints for the agitated, violent, or psychotic pediatric patient in the emergency department: controversies and recommendations. Curr Opin Pediatr. 2004 Apr;16(2):201-5. PMID: 15021203. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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2 Responses

  1. Seth Brown says:

    Hi Sean — Thanks for the wonderful review! I noticed that Ziprasidone (Geodon) was not included on your list. What are your thoughts on this med? My limited experience with it is that although it takes a few minutes to reconstitute (tough in acute situations), it has less QTc prolongation that the 1st gen antipsychotics. Thanks for fielding the question!

    • Sean Fox says:

      Seth, great question! I personally like to use it in adults, but the literature for children and ziprasidone is not that supportive. This is why I left it off. In time, this information may change.
      Hope you are well!
      Have a great day,
      Sean

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