Pediatric emergency medicine trisk 1043

current dose or an increased dose of one of their medications may be
appropriate.
The choice of medication(s) should be based on the level of the patient’s
agitation or dangerousness. For mild agitation, antihistamines, alphaadrenergic agents such as clonidine, or benzodiazepines are the first line of
treatment. For moderate to severe agitation, possible medications include
benzodiazepines, alpha-adrenergic agents, typical antipsychotics, and
atypical antipsychotics. The ED physician should choose between these
different agents on the basis of the degree of agitation, the patient’s
willingness to take oral medications, and the medication side-effect profile.
The newer, atypical antipsychotics may have fewer adverse effects than
traditional antipsychotics (e.g., extrapyramidal symptoms [EPS], dystonic
reactions, neuroleptic malignant syndrome [NMS]). However, their use in
the ED may be limited in that ziprasidone, aripiprazole, and olanzapine are
the only atypical antipsychotics that have an immediate release parenteral
form, and there is limited experience using these medications in pediatric
populations. The rapidly dissolving oral forms of olanzapine, aripiprazole,
and risperidone may be an acceptable alternative to physicians and patients.
For patients with severe agitation, rapid tranquilization is the strategy
favored by many experts. In this approach, a dose of a benzodiazepine and
an antipsychotic are given simultaneously. These medications can be given
orally but often will need to be given parenterally. If needed, subsequent
doses can be given 60 and 120 minutes after the initial dose. This approach
may be more effective than a single agent alone and may result in the use of
less total medication. A variation of this approach is to alternate
medications, that is, give a dose of one medication and reassess the patient
30 minutes later. If the patient’s agitation has not sufficiently resolved, a
dose of the other medication is given. The patient is reassessed every 30
minutes and redosed with the appropriate medication as needed.
Both haloperidol and the atypical antipsychotics, ziprasidone to the largest
degree, may cause QTc prolongation. As such, patients receiving these
medications should be closely monitored. There is no consensus regarding

the prophylactic use of benztropine (1 mg oral [PO]/intramuscular [IM]) or
other anticholinergic agents in patients receiving antipsychotics. Some
experts favor giving such medications to all patients receiving


antipsychotics, for the prevention of EPS. Others prefer to use these
medications only if and when EPS develop.
NMS is a rare complication of antipsychotic use. It is more commonly
seen in young, muscular males, although it may occur in patients of any age,
gender, and body habitus. Pre-existing dehydration and chronic
antipsychotic use are other risk factors for developing NMS. Because there
is no test that absolutely confirms it, NMS can be vexing to diagnose. In
addition, the clinical picture of fever, altered mental status, and autonomic
hyperactivity may be difficult to differentiate from meningoencephalitis,
intracranial injury, various toxins, serotonin syndrome, or an underlying
psychiatric condition. It should be strongly considered in any agitated patient
whose condition worsens or does not resolve when given antipsychotic
medication.
Of note, two antipsychotics, thioridazine and droperidol, currently carry
FDA “black box” warnings as they may cause fatal arrhythmias.
Physical Restraint. Any device that restricts a patient’s mobility is a physical
restraint. Theoretically, a bed rail is a form of restraint. In the treatment of
agitated patients, however, physical restraints specifically refer to devices
used with the express purpose of restraining a patient’s limbs. Only such
approved devices should be used for physical restraint.


TABLE 126.8
EMERGENCY AGITATION MEDICATIONS

The Joint Commission analyzed cases of physical restraint and identified
several risk factors associated with patient deaths. Asphyxiation was
associated with excess weight being placed on the back of prone patients, a
towel or sheet being placed over the patient’s head to protect against spitting
or biting, and airway obstruction due to placing the patient’s arm across the
neck area.
A minimum of five trained staff are needed to restrain a patient, one to
control each limb and one for the patient’s head. For extremely violent or
agitated patients, the prone position, although more restrictive, is safer for
both the patient and the care provider. Physically restrained patients need
constant observation by medically trained staff. The Joint Commission
mandates documentation of patient’s vital signs, assessment of behavioral
status, and offering of food, water, and access to bathroom facilities at
regular intervals. These standards also mandate a face-to-face evaluation of


the patient by the ordering physician within 1 hour of the patient being
placed in restraints. Orders for restraint can be renewed, but each order
cannot exceed 1 hour for children younger than 9 years, 2 hours for children
and adolescents between 9 and 17 years, or 4 hours for adults.
Restraints should be removed as soon as possible in an organized manner,
taking into account the severity of the patient’s agitation. The same number
of personnel needed to place the restraints should be present when the
restraints are removed, in case the restraints need to be reapplied. There is no
consensus as to the optimal method; some remove all restraints once the
patient is judged to be safe. Others prefer a stepwise approach, releasing an
arm first, then the opposite leg, and finally the remaining limbs. Between
each step, the patient is informed that if they remain under control, the
removal process will continue. Patients should not be left with only one limb
restrained. They have too much mobility and could injure themselves or

others if they become combative.
Disposition
Patients who are at imminent risk of serious harm to others and who cannot
be safely maintained in lower levels of care require admission to an inpatient
psychiatric facility. Alternatives to inpatient admission include partial
hospitalization programs, acute residential treatment, in-home services,
routine outpatient care, and, in rare circumstances, placement in the juvenile
justice system. Outpatient and in-home services may be of particular use
when family issues are playing a significant role in the unsafe behaviors.
Brief placements in respite care or alternative placements for those in foster
care may also be considered as a diversion from inpatient hospitalization.
Special efforts should be made to avoid inpatient hospitalization in very
young children, children with reactive-attachment disorders, or those with
personality disorders; for these populations in particular, admission may be
countertherapeutic.
Caregivers of those being discharged home should be counseled regarding
means restriction of potential weapons, provided with de-escalation
strategies, and instructed on indications for return. ED physicians may also
use this opportunity to help parents establish, present, and/or reinforce any
pertinent behavioral rules, rewards, consequences, etc. for the child.