Pediatric emergency medicine trisk 1042

Assessment and frequent reassessment signs and symptoms for violence
and danger to others are important ( Tables 126.5 and 126.6 ). Patients
should be asked if they currently have any violent or homicidal thoughts, if
they have specific plans or thoughts, if they have access to firearms or other
weapons. Unfortunately, no single sign, symptom, or set of criteria
successfully identifies all patients with significant risks for violence.
Management
Verbal De-Escalation. Studies have shown that when hospital staff are
trained in verbal de-escalation techniques, there is significant decrease in the
use of medications and physical restraint in the care of psychiatric patients.
Ideally, all ED staff participating in the care of psychiatric patients should
have training in verbal de-escalation techniques ( Table 126.7 ).
All verbal de-escalation techniques share common features. Strategies
include approaching the patient with a calm, nonjudgmental manner, and
being empathetic. The simple act of listening can have a powerful effect.
The patient should be reassured that the ED staff is there to help and work
with them. Frequent updates about the care plan can help the patient stay
calm.


TABLE 126.6
PREDICTORS OF DANGEROUSNESS TO OTHERS
High degree of intent to harm
Presence of a victim
Frequent and open threats
Concrete plan
Access to instruments of violence
History of loss of control
Chronic anger, hostility, or resentment
Enjoyment in watching or inflicting harm
Lack of compassion

Self-view as victim
Resentful of authority
Childhood brutality or deprivation
Decreased warmth and affection in home
Early loss of parent
Fire setting, bed-wetting, and cruelty to animals
Prior violent acts
Reckless driving
Adapted with permission from Sadock BJ, Sadock VA, eds. Kaplan & Sadock’s Synopsis of Psychiatry
. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003.

Patients should be given as much autonomy as possible; try to present a
few reasonable treatment options and allow them to choose. Patients often
feel empowered and are better able to control themselves. It is equally
important to set clear limits with the patient to maintain safety. Limit setting,
done in a nonpunitive manner, may include discussing acceptable and
unacceptable behaviors as well as consequences for these behaviors. With
few exceptions, one should avoid “bargaining” with patients as this may
encourage limit testing. Feeling threatened or punished may exacerbate a
patient’s agitation and/or behavior.


TABLE 126.7
VERBAL DE-ESCALATION/CALMING TECHNIQUES
Clearly introduce yourself
Use simplified language, a soft voice, and slow movements
Explain what will happen in the ED
Reduce environmental stimulation, if possible (less noise or light, fewer
people)
Remove access to breakable objects/equipment

Allow room for pacing, if possible
Offer food or drink, which is inherently calming
Reassure child that you are there to keep him or her safe, that this is your
job
Listen and empathize (a treatment cornerstone)
Tell child how you plan to honor his or her reasonable requests
Clarify the child’s goal and then try to link his or her cooperation to that
goal
Find things for the child to control, like choice of drinks
Engage available consultants: security, social work, psychiatry
Offer distracting toys/sensory modalities
Remain engaged; perceived ignoring may encourage escalations
Remember not to take their anger personally
ED, emergency department.
Reprinted from Hilt RJ, Woodward TA. Agitation treatment for pediatric emergency patients. J Am
Acad Child Adolesc Psychiatry 2008;47(2):132–138. Copyright © 2008 The American Academy of
Child and Adolescent Psychiatry. With permission.

Medical and Physical Strategies for the Emergency Treatment of Agitation.
Medical and physical methods may be necessary to contain the patient’s
violent behavior. However, controversy exists regarding in what situations
and when such treatment is indicated. While their use can prevent significant
and potentially life-threatening violent outbursts and can help an out-ofcontrol patient calm down, restraint also has the potential to be physically
and psychologically harmful and traumatizing to the patient, the family, and
the staff. Adverse reactions to medications, physical harm and death due to


physical restraint, as well as psychological harm (e.g., feelings of shame
and/or of being personally violated, frank symptoms of posttraumatic stress
disorder [PTSD]) have all been reported. Both the Centers for Medicare and

Medicaid Services (CMS) and The Joint Commission mandate that
healthcare institutions monitor their use of these methods, and develop and
maintain protocols in which patients are treated in the least restrictive
manner possible. ED physicians and staff thus need to be familiar with their
institution’s restraint policies, practices, and guidelines.
Emergency Agitation Medications. Medications can be a useful tool in
helping to manage unsafe behaviors in the pediatric emergency setting and
can be used to treat agitation related to the patient’s underlying condition.
This is distinct from the concept of chemical restraint, which CMS defines
as “a medication used to control behavior or to restrict a patient’s freedom of
movement and not standard treatment for the patient’s medical or psychiatric
condition.” Although medications are extensively used to treat agitation and
there are numerous published studies of their use in the adult ED and
psychiatric settings, there is scant literature on their use in pediatric
populations. In addition, as is the case with many medications and pediatric
populations, few of the medications have FDA-approved indications for
treating agitation associated with pediatric mental health conditions, and
none are approved for the purpose of emergent treatment of agitation in
children and adolescents. Any medication used for emergency agitation is
thus an “off-label” use of the medication. Although there are multiple
published studies using the oral forms of the newer, atypical antipsychotics
in children and adolescents, there is scant published evidence regarding the
parenteral forms of these medications. These limitations aside, it is widely
held by experienced psychiatric and pediatric emergency physicians that
these medications are both safe and efficacious. Adverse reactions to these
medications in the acute setting are rare and usually easily managed when
they arise.
Medications that are commonly used for agitation and the appropriate
initial dose of these medications are listed in Table 126.8 . It is acceptable to
round the dose to the nearest half or whole milligram or the nearest whole

pill dose. Alternatively, for patients already on psychiatric medications, their