The 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