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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 ... 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... 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... 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