Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department

Consensus Statement of the American Association for Emergency Psychiatry

Ruth Gerson, MD; Nasuh Malas, MD, MPH; Vera Feuer, MD; Gabrielle H. Silver, MD; Raghuram Prasad, MD; Megan M. Mroczkowski, MD; Pediatric BETA Consensus Guideline Working Group

Disclosures

Western J Emerg Med. 2019;20(2):409-418. 

In This Article

Abstract and Introduction

Abstract

Introduction: Agitation in children and adolescents in the emergency department (ED) can be dangerous and distressing for patients, family and staff. We present consensus guidelines for management of agitation among pediatric patients in the ED, including non-pharmacologic methods and the use of immediate and as-needed medications.

Methods: Using the Delphi method of consensus, a workgroup comprised of 17 experts in emergency child and adolescent psychiatry and psychopharmacology from the the American Association for Emergency Psychiatry and the American Academy of Child and Adolescent Psychiatry Emergency Child Psychiatry Committee sought to create consensus guidelines for the management of acute agitation in children and adolescents in the ED.

Results: Consensus found that there should be a multimodal approach to managing agitation in the ED, and that etiology of agitation should drive choice of treatment. We describe general and specific recommendations for medication use.

Conclusion: These guidelines describing child and adolescent psychiatry expert consensus for the management of agitation in the ED may be of use to pediatricians and emergency physicians who are without immediate access to psychiatry consultation.

Introduction

Background. Agitation and aggression in children and adolescents in the emergency department (ED) can be dangerous and distressing for patients, families and staff.[1] Agitation and aggression can disrupt care, cause injury, or necessitate use of physical restraint. Of youth presenting to the ED for psychiatric care, 6–10% require restraint.[2–3] At least 30 children in the United States (U.S.) have died in restraint-related incidents, which has led to regulations limiting the use of restraint to emergencies where least restrictive options have been exhausted.[4–5] There is little guidance or standardization toward use of less restrictive options, especially medications, to manage agitation and avoid restraint.

There are no randomized controlled trials, expert consensus guidelines, or comparative studies of medication efficacy or safety in the ED setting. A survey of emergency physicians (EP) regarding pro re nata (as needed) (hereafter referred to as STAT/PRN) medications commonly used for agitation, and review papers providing recommendations for medication use, all emphasize use of first- and second-generation neuroleptics, benzodiazepines, and mood stabilizers.[2,6–9] These are largely inspired by consensus guidelines for treatment of agitated adults or pediatric outpatients with chronic aggression.[10–12] Symptoms and triggers that underlie agitation in the ED may be different from those that underlie chronic aggression among outpatients.[13]

A small number of studies have examined the use of STAT/PRN medications for acute agitation in psychiatrically hospitalized youth. There is only one randomized, placebo-controlled study of STAT/PRN medication for acute agitation, which found no difference between diphenhydramine vs placebo.[14] Intramuscular (IM) administration (of either diphenhydramine or placebo) was significantly more effective than by mouth (PO) administration. A retrospective study of STAT/PRN medications in 49 psychiatrically hospitalized youth reported antihistamines were used most commonly, followed by neuroleptics and sedative-hypnotics.[15] Only 32% of all PRNs were clearly effective on chart review. Benzodiazepines and neuroleptics were equally efficacious, and IM administration was significantly more effective than PO administration across medication classes.

A retrospective study of STAT/PRN medications among psychiatrically hospitalized youth found that olanzapine was more likely than lorazepam or chlorpromazine to produce a "settling effect" within 30 minutes or less; all were generally well tolerated, although the authors noted that a small number of youth experienced paradoxical agitation with lorazepam.[16] Two case-controlled, retrospective, chart-review studies have assessed the relative efficacy of IM ziprasidone, compared to other IM neuroleptics, in psychiatrically hospitalized adolescents. The first compared IM ziprasidone to IM olanzapine; there was no significant difference in efficacy, although ziprasidone subjects received significantly more emergency medications.[17] A second compared the combination of IM haloperidol with IM lorazepam and IM ziprasidone. There was no significant difference found in restraint duration, use of STAT/PRN medications, or vital sign changes.[18]

Importance. These studies have limited generalizability to STAT/PRN use of these medications for acute agitation or aggression in ED settings. Without evidence-based or expert consensus guidelines to direct decision-making, physicians in the ED setting typically use medications with which they are most comfortable, although these may not be the most effective or safest choice with significant variance in practice.[2,6]

Goals of Investigation. We aim to present consensus guidelines for management of agitation among pediatric patients in the ED, including use of STAT (for immediate administration) or STAT/PRN medications, in follow up to the Consensus Statement of the American Association for Emergency Psychiatry (AAEP) Project BETA Psychopharmacology Workgroup guidelines for agitation in adults.[10]

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