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 hour of the patient being placed in restraints Orders for restraint can be renewed, but each order cannot exceed hour for children younger than years, hours for children and adolescents between and 17 years, or 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  ... 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