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

Discussion

While there was consensus as to general principals of medication use for agitation and some specific agents and strategies as described above, there was not consensus to support the use of one medication or even class of medication for all patients. This reflects both the absence of a strong evidence base, heterogeneity of the patient population, multifactorial nature of agitation, and practice differences between hospitals, regions, training programs, and individuals.

The specific ED setting will also have significant influence on choice of medication for agitation, and even on when medications are indicated. In the situation of an unlocked medical ED containing numerous pieces of equipment with which a child could (purposefully or accidentally) harm himself or herself or others, it may be faster to medicate an agitated child than in a psychiatric ED with specialized staff and an environment designed for safety. Psychiatric EDs, however, rarely have child life support that can be crucial in preventing agitation among young or developmentally-delayed children in a pediatrics ED. Medical or pediatric EDs can administer IV medications compared to psychiatric EDs, which typically use IM medications if PO is not possible. Medical EDs may be more comfortable with potential ADEs such as QT prolongation or respiratory suppression if they have rapid or routine access to telemetry or airway support, but may balk at using unfamiliar psychiatric medications like chlorpromazine. Psychiatric EDs often lack immediate access to pediatric or emergency medicine support, which may complicate assessment and management of delirium or catatonia secondary to physical illness. Hospital formulary, tradition, and milieu preferences will also influence medication choice.

While these consensus guidelines are written largely with psychiatrists and child psychiatrists in mind, they are informed by expert consensus from providers with training in pediatrics and consultation psychiatry. We anticipate these guidelines may also be of use to pediatricians and EPs working in ED settings without immediate access to psychiatry consultation. When available, psychiatric consultants can help elucidate the etiology of agitation. Psychiatric consultation can also assist with the choice of medication and ongoing non-pharmacologic de-escalation strategies. Especially if a first dose of medication for an agitated child was not effective, psychiatry should be consulted to reevaluate the differential diagnosis and the pharmacologic and non-pharmacologic treatment plan. Psychiatry consultation should also be obtained for patients with more complex psychiatric pathology and those who are on complex regimens already, patients with a history of paradoxical reaction to medication, and patients with agitation of mixed etiology. Involvement of other mental health providers, including psychologists and social work, can be helpful in the diagnostic assessment as well as implementation of non-pharmacologic management strategies.

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