CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Evaluation and Management of Children and Adolescents With Acute Mental Health or Behavioral Problems. Part I: Common Clinical Challenges of Patients With Mental Health and/or Behavioral Emergencies Thomas H. Chun, MD, MPH, FAAP, Sharon E. Mace, MD, FAAP, FACEP, Emily R. Katz, MD, FAAP, AMERICAN ACADEMY OF PEDIATRICS, COMMITTEE ON PEDIATRIC EMERGENCY , AND AMERICAN COLLEGE OF EMERGENCY PHYSICIANS, PEDIATRIC COMMITTEE

INTRODUCTION This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have Mental health problems are among the leading contributors to the global fi led confl ict of interest statements with the American Academy of Pediatrics. Any confl icts have been resolved through a process 1 burden of disease. Unfortunately, pediatric populations are not spared of approved by the Board of Directors. The American Academy of mental health problems. In the United States, 21% to 23% of children and Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. 2,3 adolescents have a diagnosable mental health or substance use disorder. Clinical reports from the American Academy of Pediatrics benefi t from Among patients of emergency departments (EDs), 70% screen positive for expertise and resources of liaisons and internal (AAP) and external 4 reviewers. However, clinical reports from the American Academy of at least 1 mental health disorder, 23% meet criteria for 2 or more mental Pediatrics may not refl ect the views of the liaisons or the organizations health concerns,5 45% have a mental health problem resulting in impaired or government agencies that they represent. psychosocial functioning,5 and 10% of adolescents endorse significant The guidance in this report does not indicate an exclusive course of 6 treatment or serve as a standard of medical care. Variations, taking levels of psychiatric distress at the time of their ED visit. In pediatric into account individual circumstances, may be appropriate. settings, the reported prevalence of mental health and All clinical reports from the American Academy of Pediatrics behavioral disorders is between 12% to 22% of children and adolescents.7 automatically expire 5 years after publication unless reaffi rmed, revised, or retired at or before that time. Although the American Academy of Pediatrics (AAP) has published a policy DOI: 10.1542/peds.2016-1570 statement on mental health competencies and a Mental Health Toolkit for PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). pediatric primary care providers, no such guidelines or resources exist Copyright © 2016 by the American Academy of Pediatrics 8,9 for clinicians who care for pediatric mental health emergencies. This FINANCIAL DISCLOSURE: The authors have indicated they do clinical report supports the 2006 joint policy statement of the AAP and not have a fi nancial relationship relevant to this article to disclose. American College of Emergency Physicians (ACEP) on pediatric mental FUNDING: No external funding. health emergencies, with the goal of addressing the knowledge gaps in POTENTIAL CONFLICT OF INTEREST: The authors have indicated 10,11 this area. The report is written primarily from the perspective of ED they have no potential confl icts of interest to disclose. clinicians, but it is intended for all clinicians who care for children and adolescents with acute mental health and behavioral problems. To cite: Chun TH, Mace SE, AAP FACEP, Katz ER. Evaluation and Management of Children and Adolescents With Acute Recent epidemiologic studies of mental health visits have revealed a Mental Health or Behavioral Problems. Part I: Common rapid burgeoning of both ED and primary care visits. 12 – 20 An especially Clinical Challenges of Patients With Mental Health and/or Behavioral Emergencies. Pediatrics. 2016;138(3):e20161570 problematic trend is the increase in “boarding” of psychiatric patients in

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 138 , number 3 , September 2016 :e 20161570 FROM THE AMERICAN ACADEMY OF PEDIATRICS the ED and inpatient pediatric beds barriers to caring for their patients medical illnesses or injuries in (ie, extended stays lasting days or with mental health problems. 46, 47 patients presenting with psychiatric even weeks). Although investigation Part I of this clinical report focuses complaints. Concern that medical of boarding practices is still in its on the issues relevant to patients illness may be the underlying cause 21 infancy, the ACEP and the American presenting to the ED with a mental of a psychiatric problem has led 22 Medical Association have both health chief complaint and covers the some to suggest “that emergency expressed concern about it, because following topics: patients with psychiatric complaints it significantly taxes the functioning receive a full medical evaluation.” 48 and efficiency of both the ED and • Medical clearance of pediatric Medical clearance originates from , and mental health services psychiatric patients the perspective that an ED evaluation may not be available in the ED. 23 –26 • Suicidal ideation and suicide of a psychiatric patient may be the only opportunity to diagnose In addition, compared with attempts underlying illnesses or injuries that other pediatric care settings, ED • Involuntary hospitalization could result in morbidity or mortality patients are known to be at higher • Restraint of the agitated patient because resources for diagnosing risk of mental health disorders, and treating medical conditions including depression,27, 28 anxiety, 29 o Verbal restraint may not be readily available in some posttraumatic stress disorder,30 o Chemical restraint psychiatric facilities. In addition, and substance abuse.31 These many psychiatric complaints and mental health conditions may o Physical restraint disorders can be exacerbated or be unrecognized not only by • Coordination with the medical precipitated by medical illness, 49 and treating clinicians but also by the home some psychiatric patients may have child/adolescent and his or her Part II discusses challenging unmet medical needs. 50 –52 parents. 32 –36 A similar phenomenon patients with primarily medical has been described with suicidal or indeterminate presentations, Medical Diseases in ED Psychiatric patients. Individuals who have in which the contribution of an Patients committed suicide frequently underlying mental health condition Previous studies of medical visited a provider in the may be unclear or a complicating conditions in ED psychiatric patients months preceding their death.37, 38 factor, including: have been almost exclusively Although a minority of suicidal conducted with adults and have patients present with some form • Somatic symptom and related had highly variable findings. Past of self-harm, many have vague disorders reports have found underlying somatic complaints (eg, headache, • Adverse effects to psychiatric medical problems in 19% to 63% of gastrointestinal tract distress, ED psychiatric patients. 53 – 55 Studies back pain, concern for a sexually o adverse effects of adults admitted to psychiatric transmitted infection) masking units after an ED medical evaluation their underlying mental health o Neuroleptic malignant syndrome have had similarly disparate results. condition.34 –36 o Serotonin syndrome Some have reported missed medical Despite studies demonstrating • Children with special needs in conditions in up to half of patients, 53,56 moderate agreement between the ED (autism spectrum and including diabetes, uremic and emergency physicians and developmental disorders) hepatic encephalopathy, pneumonia, psychiatrists in the assessment and urinary tract infections, and sepsis, 57 • Mental health screening in the ED management of patients with mental but another found that only 4% health problems, 39, 40 ED clinicians An executive summary of this (12 of 298) needed treatment of a frequently cite lack of training clinical report can be found at www. medical condition within 24 hours and confidence in their abilities as pediatrics. org/ cgi/ doi/ 10. 1542/ of admission to the psychiatric barriers to caring for patients with peds. 2016- 1571. unit. 58 To address these concerns, mental health emergencies. 41 – 44 some have suggested a standardized Another study of emergency evaluation and documentation of medicine and pediatric emergency MEDICAL CLEARANCE OF PEDIATRIC the ED medical evaluation. 59 Major medicine training programs found PSYCHIATRIC PATIENTS limitations of these studies are that formal training in psychiatric that they are from older literature, Background problems is not required nor offered and they did not include children. by most programs. 45 Pediatric Medical clearance can be defined More recent adult and pediatric primary care providers report similar as the process of excluding acute studies, discussed later, suggest that

Downloaded from www.aappublications.org/news by guest on September 28, 2021 e2 FROM THE AMERICAN ACADEMY OF PEDIATRICS significant rates of medical morbidity a comprehensive list of such electrocardiogram (18%). 66 Other in psychiatric patients may be less conditions is beyond the scope of this commonly obtained laboratory likely. article. Table 1 focuses on medical evaluations for medical clearance conditions that can be evaluated include testing for pregnancy and Some authors argue that it is not within the context and time frame sexually transmitted infections. possible to rule out all potential of an ED visit. Examples of medical medical etiologies for psychiatric Recently, the utility of routine conditions requiring ED treatment symptoms and believe that the medical screening tests has been includes suturing, wound or injury role of the ED evaluation is to questioned. In contrast to the older care, and treatment of an overdose. determine whether the patient literature, more contemporary In addition, some psychiatric patients is “medically stable” rather than studies are finding much lower rates may have comorbidities that are not “medically cleared.” 60 Although of unsuspected, clinically emergent, contributing to their behavioral or the concept of “medical stability,” or urgent laboratory abnormalities. psychiatric complaints but would which can be defined as the lack of Two studies of adult ED patients benefit from ED care, such as asthma medical conditions requiring acute with psychiatric complaints found or diabetes. 58 evaluation and/or treatment, is low rates of clinically significant gaining traction, for the purposes of Key elements for detecting abnormalities on routine laboratory this discussion, the term “medical underlying medical condition(s) testing, 55, 67 the majority (94%) of clearance” will be used. A growing include careful assessment of which were clinically suspected on body of adult and pediatric studies abnormal vital signs, a complete the basis of the patient’s history suggest that an ED patient’s history, history and physical examination, and physical examination. 55 Similar physical examination, and vital with particular attention to the results have been reported in signs provide important data for neurologic, cardiac, and respiratory admitted adult psychiatric patients determining the appropriate medical systems. 64 Various screening tools after an ED evaluation. One study evaluation for a psychiatric patient. have been developed to assist in of 250 psychiatric inpatients found These findings support the 2006 the medical clearance of psychiatric a mean of 27.7 tests were ordered ACEP policy statement, which patients in the ED, 60, 65 although these per patient, with only 4% (11 of recommends “focused medical authors also stress the importance 250) having “important” medical assessment” for ED psychiatric of an adequate history and physical problems discovered and less than 1 patients, in which laboratory testing examination and do not mandate test in 50 resulting in any clinically is obtained on the basis of history laboratory or other investigations. 65 useful information. 10 Another study and physical examination rather After medical clearance has been identified only 1 patient of 519 than a predetermined battery of performed, the AAP and ACEP (0.2%) with an abnormal laboratory tests for all patients with psychiatric support the development of transport test result that would have changed complaints. 61 When ED resource protocols to definitive psychiatric ED management or patient utilization and the cost of medical treatment facilities for EDs that disposition.68 screening evaluations for pediatric transfer patients with mental health Similar results have emerged for psychiatric patients are considered, care needs.10, 11 ED pediatric psychiatric patients. additional questions are raised about Several studies have found little to no such evaluations and whether the ED Diagnostic Laboratory Testing and utility for routine urine drug testing. is the optimal site for them. 62, 63 Medical Clearance Shihabuddin et al evaluated such In 1 study of emergency physicians, testing in 547 patients presenting The Goals of Medical Clearance “routine testing” was performed with a psychiatric complaint. A Medical clearance of psychiatric in 35% of respondents, with 16% positive result was found in 20.8% patients focuses on determining of the testing performed because of patients, half of which were whether the patient’s behavioral it was ED protocol and 84% of the suspected on the basis of the patients’ or psychiatric signs and symptoms testing performed at request of the reported substance use history. are caused or exacerbated by an mental health service. Of those with Urine drug testing resulted in no underlying medical condition and protocol testing, the most frequently changes in patient management, and whether there are medical conditions ordered tests were urine toxicology all were medically cleared. 69 Fortu that would benefit from acute screen (86%), serum alcohol (85%), et al examined 652 (385 routine treatment in the ED. Given the vast complete blood cell count (56%), and 267 medically indicated) urine number of medical illnesses that electrolytes (56%), blood urea toxicology screens. 70 For the routine can masquerade as a behavioral nitrogen (45%), creatinine (40%), toxicology screens, only 5% were problem or psychiatric disorder, serum toxicology screen (31%), and positive, and there were no changes

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 138 , number 3 , September 2016 e3 TABLE 1 Medical Disorders That Can Present as a Psychiatric Disorder or Behavioral Problema in management and no significant Neurologic (CNS) Diseases differences in disposition between Stroke/transient ischemic attacks those with positive and negative Hemorrhage: intracerebral, subdural, subarachnoid, epidural toxicology screens. Tenenbein CNS vascular: aneurysms, venous thrombosis, ischemia, vertebrobasilar insuffi ciency reviewed 3 retrospective case studies CNS malignancy/tumors CNS trauma: primary injury, secondary injury or sequelae of head trauma of urine drug testing in children CNS infections: meningitis, encephalitis, abscess (brain, epidural, spinal), HIV, syphilis and concluded, “The emergency Congenital malformations drug screen is unlikely to impact Hydrocephalus significantly upon the management Seizures of the patient in the emergency Headaches including migraines 71 Neurodegenerative disorders: multiple sclerosis, Huntington chorea department.” Tuberous sclerosis Santiago et al prospectively studied Delirium (“ICU psychosis”) Metabolic, Endocrine, and Electrolyte Disturbances 208 children and adolescents Hyponatremia presenting to the ED with Hypocalcemia psychiatric conditions. 62 Half of Hypoglycemia the patients underwent medical Hyperglycemia testing, 26% (55 patients) were Ketoacidosis Uremia medically indicated (ie, because Hyperammonemia of clinical suspicions based on Inborn errors of metabolism: lipid storage diseases, Gaucher disease, Niemann-Pick disease the elicited history and physical Thyroid disease: hyperthyroidism, thyroid storm, hypothyroidism examination), and 24% (54 patients) Adrenal disease: Addison disease, Cushing disease were obtained at the request of Pituitary: hypopituitarism Parathyroid disease: hypoparathyroidism, hyperparathyroidism the mental health consultant. Pheochromocytoma Only 3 patients had laboratory Respiratory abnormalities that required further Hypoxia medical intervention, all of which Hypercarbia/hypercapnia were suspected on the basis of Respiratory failure Medications patient’s presenting history and Drug withdrawal: alcohol, amphetamines, barbiturates, , cocaine, psychiatric physical examination. Among medications patients for whom “routine testing” Drug overdose: was performed, 9% (5 patients) Drugs of abuse: phencyclidine, heroin, cocaine, marijuana, MDMA (3, 4-methylenedioxy- had unsuspected abnormalities, methamphetamine), LSD (lysergic acid diethylamide), alcohol, amphetamines, “bath salts” Prescription drugs: steroids, birth control, antihypertensives, statins, anticonvulsants, none of which altered ED patient barbiturates, benzodiazepines, opioids, anticholinergics, antibiotics, antifungal agents, antiviral management. agents, asthmatic medications, muscle relaxants, gastrointestinal tract drugs, anesthetics, anticholinergics, cardiac medications (such as digoxin), decongestants, antiarrhythmics, Two recent studies of ED pediatric immunosuppressives psychiatric patients have raised Drugs for psychiatric patients: antidepressants, , lithium similar questions about the utility Hematologic/Oncologic of routine medical testing and of Malignancies “medical clearance” evaluations. Tumors Paraneoplastic syndromes Donofrio et al investigated the utility Infl ammatory/Rheumatologic of extensive laboratory testing of Sarcoidosis these patients. 72 Of 1082 eligible Systemic lupus erythematosus patients, more than 68% had multiple Toxins Carbon monoxide laboratory testing, including urine Lead poisoning toxicology, urinalysis, and blood Organophosphates tests for complete blood cell count, Volatile substances electrolytes, hepatic transferases, Other thyroid stimulating hormone, and Fever Child maltreatment syphilis. Of these tested patients, only 7 had a laboratory abnormality that a This is not an exhaustive inclusive list but one that provides examples of the many diseases/conditions and drugs/ medications that can masquerade as a psychiatric/behavioral disorder. resulted in a disposition change. Not only was the number of disposition changing laboratory abnormalities low, only 1 of these abnormalities

Downloaded from www.aappublications.org/news by guest on September 28, 2021 e4 FROM THE AMERICAN ACADEMY OF PEDIATRICS was not suspected from the patient’s in the general population. 76 These Epidemiology and Risk Factors history and physical examination. findings have led some authors to Suicide is the third leading cause of Santillanes et al studied all patients question the utility of routine brain death among people 10 to 24 years 64 referred to their ED for medical CT scans. Given the concerns about of age, accounting for more than screening clearance by a mobile the long-term effects of radiation 4000 deaths per year. 81 Although 63 77–79 psychiatric crisis team. All patients exposure on pediatric patients, only a small percentage of suicide had been placed on an involuntary the utility of routine brain CT in attempts lead to medical attention, 82 psychiatric hold. Among 789 patients, children and adolescents is, at best, they nonetheless account for a 9.1% met criteria for a medical unclear. significant number of ED visits. 83 screening examination (ie, altered Suicidal ideation in the absence of mental status, ingestion, hanging, Summary a suicide attempt is also a common traumatic injury, sexual assault, chief complaint in pediatric EDs. or medical complaints), and only The current body of literature 1.2% (9 patients) were admitted supports focused medical Approximately 16% of teenagers for medical reasons. Of these 9 assessments for ED psychiatric report having seriously considered patients, only 2 did not meet criteria patients, in which laboratory and suicide in the past year, 12.8% report for a medical screening evaluation, radiographic testing is obtained having planned a suicide attempt, although both patients’ conditions on the basis of a patient’s history and 7.8% report having attempted (possible disorientation and urinary and physical examination. Routine suicide in the past year. Females are tract infection in an HIV-positive diagnostic testing generally is low more likely to consider and attempt patient) were suspected on the yield, costly, and unlikely to be suicide, but males are more than 5 basis of a basic history and physical of value or affect the disposition times more likely to die by suicide. examination. or management of ED psychiatric The higher fatality rate among males patients. When patients are clinically is primarily accounted for by their Diagnostic Radiology Testing and stable (ie, alert, cooperative, normal use of more lethal means: males Medical Clearance vital signs, with noncontributory are more likely to attempt suicide All studies of radiographic history and physical examination via firearms and hanging, whereas evaluation of psychiatric patients and psychiatric symptoms), the females are more likely to attempt 82 have been conducted with adults. ACEP states that routine laboratory via overdose. Although central nervous system testing need not be performed American Indian/Alaska Native males (CNS) abnormalities such as as part of the ED assessment. 61 have the highest suicide rates among oligodendroglioma, glioblastoma, If a discrepancy occurs between ethnic groups. Non-Hispanic white meningioma, intracerebral cysts, the ED and clinicians males are also at increased risk.81 and hydrocephalus can present with regarding the appropriate ED Adolescents who have previous primarily psychiatric symptoms,73 medical evaluation of a psychiatric suicide attempts, 84 impulsivity, a mood other studies have found low rates patient, direct communication or disruptive behavior disorder,85 of clinically significant findings on between the ED and psychiatry recent psychiatric hospitalization,86, 87 computed tomography (CT) scan. attending physicians may be helpful. substance abuse, 88 a family history In 1 study of 127 young military For patients with concerning of suicide,89 or a history of sexual recruits with new-onset psychosis, findings on history and/or physical or physical abuse90 ; are homeless/ none had clinically significant examination (eg, altered mental runaway 91; or who identify as lesbian, findings on brain CT scans. 74 In status or unexplained vital signs gay, bisexual, or transgender92 are another analysis of new-onset acute abnormalities) or with new-onset also at higher risk for attempting and/ psychosis in patients admitted to or acute changes in psychiatric or completing suicide. Suicide and a psychiatric unit, only 1.2% had symptoms, a careful evaluation suicide attempts are often precipitated clinically significant findings. 75 A for possible underlying medical by significant psychosocial stressors. larger study of 397 patients with conditions may be important. These can include family conflict, the a psychiatric presentation and no breakup of a romantic relationship, focal neurologic findings detected bullying, academic difficulties, or specific abnormalities in 5%, all SUICIDAL IDEATION AND SUICIDE disciplinary actions/legal troubles. of which had no relevance to the ATTEMPTS Younger patients tend to be triggered patient’s condition. The pretest For an extended discussion on the more often by family conflict, whereas probability of a space occupying assessment and management of older adolescents are more likely to lesion or any relevant abnormality suicidal adolescents, please refer to cite peer or romantic conflicts as a was no greater than finding one the AAP clinical report on suicide. 80 precipitant. 93

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 138 , number 3 , September 2016 e5 Evaluation Mini-Mental Status Examination) 94 continue to work with patients and may be useful. families to promote engagement For patients reporting current or in and adherence to mental health recent suicidal ideation and those Determination of Level of Care treatment. Consensus expert who present after clear or suspected opinion suggests direct contact with intentional self-injury, best practices No validated criteria exist for these outpatient providers, either include an evaluation by a clinician assessing level of risk for subsequent by the mental health consultant or experienced in evaluating pediatric suicide or determining level of care. the ED clinician, documentation of mental health conditions. Whenever However, most experts agree that this contact, and documentation of concern for suicidal ideation or patients who continue to endorse the discharge treatment plan. 95, 96 attempt is present, having the patient a desire to die, remain agitated or undergo a personal and belongings severely hopeless, cannot engage in Discharge Planning search, change into hospital attire, a discussion around safety planning, and be placed in as safe a setting do not have an adequate support Some patients evaluated in the ED as possible (eg, a room without system, cannot be adequately for suicidal ideation or a suicide easy access to medical equipment) monitored or receive follow-up attempt struggle to obtain follow-up with close staff supervision may be care, or had a high-lethality suicide care.97, 98 The ED visit may, therefore, important. attempt or an attempt with clear be a valuable link in obtaining care Interviewing patients and caregivers expectation of death may be at high for these patients. ED physicians both together and separately may risk of suicide, and consideration may stress the importance of be beneficial. Obtaining collateral should be given to admission to an follow-up to both the patient and information from caregivers or inpatient psychiatric facility once the family and attempt to identify 80 other individuals who may have medically cleared. Additional risk and address barriers to subsequent knowledge about the patient’s factors, such as gender, comorbid treatment. Counseling and educating state of mind or the details of substance abuse, and high levels of families about suicide risk and the event in question often has anger or impulsivity, may also be treatment may be beneficial. The significant clinical utility, as considered. greatest risk of reattempting suicide is in the months after an patients frequently minimize the Patients who do not meet initial attempt. In addition, given severity of their symptoms or the criteria for inpatient psychiatric that counseling takes time to work, intention behind their acts. When hospitalization may be candidates emphasizing the importance of interviewing adolescents alone, a for outpatient mental health consistent follow-up may help discussion about the limits of patient treatment and intervention. patients and families. 99 –101 confidentiality may facilitate an Where available, partial hospital open and honest conversation. If programs, intensive outpatient Although having a patient sign a there are significant concerns that services, or in-home treatment/ no-suicide contract has not been the patient may be at high risk of crisis stabilization interventions shown to prevent subsequent harm to himself or herself or others may be considered, especially when suicides,95 a safety-planning (see “Determination of Level of ED clinicians believe that a patient discussion is still an important Care”), the physician may decide to may benefit from more intensive or element of ED care. A safety plan break doctor-patient confidentiality. urgent treatment. Experts suggest typically includes steps such A thorough medical examination with that even patients who are deemed as identification of (1) warning careful evaluation for signs of self- to be at relatively low risk of future signs and potential triggers for injury or toxidromes and a mental suicidal or self-injurious acts recurrence of suicidal ideation; (2) status examination may be helpful. benefit from outpatient follow-up. coping strategies the patient may The mental status examination Whenever possible, a follow-up use if suicidal ideation returns; typically includes assessment of appointment with the medical (3) healthy activities that could the patient’s appearance, behavior, home provider and an outpatient provide distraction or suppression thought process, thought content mental health clinician may be of suicidal thoughts; (4) responsible (including presence or absence of helpful. When outpatient mental social supports to which the patient hallucinations or delusions), mood health services are not readily could turn if suicidal urges recur; (5) and affect, and insight and judgment. accessible or wait times for intake contact information for professional An evaluation for delirium may appointments are considerable, supports, including instructions also be indicated. When suspicion the medical home providers on how and when to reaccess of delirium is high, a number of can play an important bridging emergency services; and (6) means screening tools (eg, the Folstein role. These providers may also restriction. 102

Downloaded from www.aappublications.org/news by guest on September 28, 2021 e6 FROM THE AMERICAN ACADEMY OF PEDIATRICS Studies suggest that means by locking all firearms unloaded in the inability to meet basic physical restriction counseling may be a key a specialized or tamper-proof safe, needs including nourishment, shelter, component of discharge planning separately locking or temporarily safety, and/or basic medical care. 110 discussions. A large percentage of removing ammunition, and State laws differ over whether and, if suicide attempts are impulsive. One restricting access to keys or lock so, at what age, assent for psychiatric study of patients 13 to 34 years of combinations) may be helpful. Given admission must be obtained from age who had near-lethal suicide the high rates of drug and alcohol minors. For more information on attempts found that 24% of patients intoxication among individuals related state laws, contact the AAP went from deciding to attempt who attempt and complete suicide, Division of State Government Affairs suicide to implementing their plan physicians may also want to suggest at [email protected]. within 0 to 5 minutes, 24% took alcohol access restriction and, where 5 to 19 minutes, and 23% took 20 indicated, referral for substance minutes to 1 hour. 103 Several studies abuse counseling and treatment. have demonstrated that patients RESTRAINT OF THE AGITATED PATIENT usually misjudge the lethality of their suicide attempts. 104 – 106 There is also INVOLUNTARY HOSPITALIZATION Restraint typically refers to methods a wide variation in the case-fatality of restricting an individual’s freedom rates of common methods of suicide Under certain circumstances, of movement, physical activity, or attempt, ranging from 85% for physicians may insist on admission normal access to his or her body gunshot wounds to 2% for ingestions to a psychiatric inpatient unit over because of concerns about the and 1% for cutting.107 It follows the objections of patients and/ person harming himself or herself that interventions that decrease or their guardians. This type of or others. Some experts believe access to more lethal means and/ admission is often referred to as that interventions to help control a or increase the amount of time and a “psychiatric hold.” Every state person’s activity and behavior span effort it takes for someone to carry has laws governing involuntary a wide gamut, including verbal and out their suicidal plan and, as a result, admission for inpatient psychiatric behavioral strategies and favor the increase the amount of time they hospitalization. Specific details of term “de-escalation interventions.” have to reconsider or for someone to such laws vary from state to state, Restraints may be used for either intervene may have a positive effect. as do laws regarding confidentiality “medical” or “psychiatric” patients 111 and an adolescent’s right to seek and have been subdivided into verbal, It may be helpful to ask and mental health or substance abuse chemical, and physical restraints. counsel patients and families about treatment without parental consent. Chemical restraint, sometimes called restricting access to potentially As such, ED clinicians may benefit “rapid tranquilization,” is the use lethal means, including access from familiarizing themselves with of pharmacologic means for the to such means in the homes of the relevant laws, statutes, and acute management of an agitated friends or family. Means restriction procedures patient. 112 counseling includes suggestions in the states in which they practice. for securing knives, locking up In general, physicians are able to Four guiding principles for , and removing firearms. admit a patient against his or her will working with agitated patients It is important to note that parents for a brief period of time, typically are as follows: (1) maximizing the often underestimate their children’s up to 72 hours, but ranging from 1 to safety of the patient and treating abilities to locate and access 30 days. After that initial period, the staff; (2) assisting the patient in firearms and that simply having a psychiatric facility works to obtain managing his or her emotions and gun in the home has been shown to a court order for civil commitment maintaining or regaining control of 108, double the risk of youth suicide. for ongoing treatment, if the patient his or her behavior; (3) using the 109 Families who are reluctant to and/or his or her guardian still object least restrictive, age-appropriate permanently remove firearms from to the hospitalization. Criteria for methods of restraint possible; and (4) the home may be open to temporarily involuntary hospitalization typically minimizing coercive interventions relocating them (eg, for safe keeping include the patient having a mental that may exacerbate agitation. 113 with a relative, friend, or local law disorder and being at immediate enforcement) until the child is in a risk of harm to self or others. Some Verbal Restraint better emotional state. If families states also allow for involuntary insist on keeping firearms in the hospitalization if the patient is The general principles of verbal home, counseling them on how to “gravely disabled.” The criteria for restraint can be found across store them as safely as possible (eg, being gravely disabled may include a wide variety of disciplines,

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 138 , number 3 , September 2016 e7 including various psychotherapeutic been conducted with adults. In the are , , and approaches (eg, anger management, literature, different terms have diazepam. Some experts prefer stress reduction), linguistic science, been used to describe the use of lorazepam for the management law enforcement, martial arts, and medications to treat agitation, violent of acute agitation because it has . 113 – 116 Although consensus or aggressive behavior, or excessive fast onset of action, rapid and is that verbal restraint is preferable psychomotor activity (eg, psychosis complete absorption, and no active to chemical or physical restraint, 117 or mania), including pharmacologic metabolites. Midazolam may have reviews of the literature find or chemical restraint 128 and a more rapid onset of action, but it primarily case studies, with a paucity rapid tranquilization. 112 The 3 also has a shorter duration of action. of rigorous studies of verbal restraint, most commonly used classes Diazepam has a longer half-life and little on specific strategies or of drugs for this purpose are and erratic absorption when given efficacy. 113, 118 For example, although the typical antipsychotics, intramuscularly (IM). 134, 135 a study by Jonikas et al found a atypical antipsychotics, and decrease in restraint use, it was benzodiazepines. 124, 125, 129 Less Commonly Used Drugs not clear whether the decrease Other drugs also used for was attributable to staff training in Antipsychotics management of the agitated de-escalation techniques or to crisis patient include the antihistamines Antipsychotics exert their effect intervention training, which occurred diphenhydramine, and primarily as CNS dopamine receptor at the same time. 119 Other protocols hydroxyzine and the α-adrenergic antagonists. 130, 131 “Low-potency” emphasize the importance of agent clonidine. 117, 134, 136, 137 agents (eg, chlorpromazine and prevention in behavior management Diphenhydramine and hydroxyzine thioridazine) are more sedating, with protocols. 115, 120 have sedative effects and are fewer extrapyramidal symptoms commonly used as nighttime sleep than “high-potency” agents (eg, Detailed in Table 2 are Fishkind’s “Ten aids for insomnia. Clonidine is a and droperidol), which Commandments of De-escalation,” presynaptic α -agonist, often used are less sedating but more likely to 2 which incorporate practical, off-label for attention-deficit/ cause extrapyramidal symptoms. 132 commonly used verbal restraint hyperactivity disorder and opiate The second-generation “atypical” strategies.112 – 114,121 – 123 Other withdrawal. Doses are typically given antipsychotics are both serotonin- strategies that may improve the at night because a significant effect dopamine receptor antagonists. 130 chances of successful de-escalation of the is somnolence. Some consider aripiprazole the include a calming physical Although there have been some first “third-generation” environment with decreased sensory controlled trials of diphenhydramine antipsychotic, because it has stimulation, rooms that have been as a sedative, 138, 139 clonidine has partial dopamine receptor agonist “safety-proofed” (ie, removal or been less well studied. 140 activity, distinguishing it from securing of objects that could be used other antipsychotics.130, 132, 133 as weapons) or close monitoring Drug Selection for Chemical Restraint Antipsychotics also have varying if this is not possible,113 modifying Drug selection for chemical restraint ability to block other CNS or eliminating triggers of agitation will depend largely on the specific neurotransmitters, which, combined (eg, an argumentative acquaintance, details of the clinical scenario with their disparate affinity for the friend, or family or staff member, a (Table 3) and collaboration among postsynaptic D receptors, account long ED wait time), 117,124, 125 and 2 ED, psychiatric, and for the side effect profiles of each staff training in behavioral colleagues. The combination of a medication, which are discussed in emergencies.126, 127 A child life and an antipsychotic greater detail below and in part II of specialist may also be an excellent is a regimen frequently suggested this clinical report. 130, 132 resource to help calm an agitated by experts for acutely agitated child. To minimize risk to themselves, patients, including children and Benzodiazepines health care providers may take adolescents124, 134, 141 –147 (Table 4). precautions, such as removing neck Benzodiazepines exert their CNS The route of administration, orally ties, stethoscopes, or securing long hair. depressant effect by binding to or IM, will depend on the patient’s presynaptic γ-aminobutyric acid condition. The choice of medication(s) (GABA) receptors. GABA, the primary also depend(s) on the patient’s Chemical Restraint CNS inhibitory neurotransmitter, current medications. If a patient All controlled trials of medications decreases neuronal excitability. is already on an antipsychotic, an for acute agitation in the ED or Benzodiazepines that have been additional or increased dose of that inpatient psychiatric setting have commonly used to treat agitation medication may be preferred. 61, 145, 147

Downloaded from www.aappublications.org/news by guest on September 28, 2021 e8 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 2 Verbal Restraint Strategies Guiding Principle Strategies, Suggestions, and Examples 1. Respect personal space • Physical environment can make a patient feel • Two arms’ length distance from patient threatened and/or vulnerable • Unobstructed path out of room for both patient and ED staff 2. Minimize provocative behavior • Posture and behavior can make a patient feel • Calm demeanor and facial expressions threatened and/or vulnerable • Concealed hands might imply a hidden weapon • Visible, unclenched hands • Minimize defensive and/or confrontational body language, eg, hands on hips, arms crossed, aggressive posture, directly facing patient (instead, stand at an angle to the patient) 3. Establish verbal contact • Multiple messages and “messengers” may • Ideally, designate 1 or limited staff members to interact with the confuse and agitate the patient patient • Introduce self and staff to patient • Orient patient to ED and what to expect • Reassure patient that you will help him or her 4. Be concise • Agitated patients may be impaired in verbally • Simple language, concise sentences processing information • Repeating the message may be helpful • May be helpful to frequently repeat/reinforce message • Allow the patient adequate time to process information and respond 5. Identify patient’s goals and • Use body language and verbal acknowledgment • “I’d like to know what you hoped or expected would happen here.” expectations to convey • “What helps you at times like this?” • “Even if I can’t provide it, I’d like to know so we can work on it.” 6. Use active listening • Convey to the patient that what he or she said is • “Tell me if I have this right …” heard, understood, and valued • “What I heard is that …” 7. Agree OR agree to disagree • Builds empathy for patient’s situation • (Agree) “What you’re (specifi c example) going through/ experiencing is diffi cult.” • Minimize arguing • (Agree) “I think everyone would want (the same as you).” • (Agree) “That (what patient is complaining about) would upset other people too.” • (Agree to disagree) “People have a lot of different views on (the focus of disagreement).” 8. Clear limits and expectations • Reasonable and respectful limit setting • “We’re here to help, but it’s also important that we’re safe with each other and respect each other.” • Set expectations of mutual respect and dignity, • “Safety comes fi rst. If you’re having a hard time staying safe as well as consequences of unacceptable or controlling your behavior, we will … (clear, nonpunitive behaviors consequence).” • Minimize “bargaining” • “It’ll help me if you (sit, calm yourself, etc). I can better understand you if you calmly tell me your concerns.” • Coach patient on how to maintain control 9. Offer choices and optimism • Realistic choice helps empower the patient, • “Instead of (violence/agitation), what else could you do? Would regain control of himself/herself, and feel like a (offer choice) help?” partner in the process • Link patient’s goals to his or her action • Acts of kindness (eg, food, blanket, magazine, access to a phone or family member) may help • Minimize deception and/or bargaining • “You’d like (desired outcome). How can we work together to accomplish (their goal)?” 10. Debrief patient and staff • If an involuntary intervention is indicated, • Explain why the intervention was necessary debriefi ng may help restore working • Ask patient to explain his or her perspective relationship with the patient and help staff plan • Review options/alternative strategies if the situation arises again for possible future interventions

In situations in which the cause of agitation is unclear, many clinicians TABLE 3 Acute Agitation Medication Considerations prefer a stepwise rather than Suspected Etiology of Symptom Severity combination approach, administering Agitation Mild/Moderate Severe either a benzodiazepine or first- Medical/intoxication Benzodiazepine Benzodiazepine fi rst, consider adding generation antipsychotic. When antipsychotic treating an agitated patient with Psychiatric Benzodiazepine or antipsychotic Antipsychotic a known psychiatric disorder, Unknown Dose of benzodiazepine or antipsychotic; consider a dose of the other either a first- or second-generation medication if the fi rst dose is not effective antipsychotic is generally preferred.

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 138 , number 3 , September 2016 e9 Comments due to other GABAergic due to other GABAergic drugs (eg, barbiturates, benzodiazepine abuse) respiratory compromise acute pediatric agitation animals • Contraindicated for intoxication • Pregnancy class D • Use with caution in patients • Most commonly used drug for • Pregnancy class C • Lowers seizure threshold in Advantages intoxications (eg, cocaine can cause seizures), withdrawal (eg, alcohol) adults for acute agitation • No EPS • Most commonly used drug in c, , c Side Effects (especially younger children and those with developmental disabilities) • Sedation • Paradoxical disinhibition • Respiratory depression • Preferred agent for many • Hypotension • Prolonged QT • NMS • Torsades de pointes • Dysrhythmias • Hypotension • Dystonia/EPS Duration Onset: See individual drugs 20 min PO Peak: 5–15 min IV 15–30 min IM 1 h PO Duration: h 3–4 20–30 min PO Peak: 30 min IV 1 h IM 2 h PO Duration: 2 h IV 6–8 h PO/IM a Dose: Route of Administration Time: Course/Onset Peak/ 0.1 mg/kg PO/IM/IV 0.05–0.1 mg/kg PO/IM/IV Onset: See individual drugs 0.025–0.075 mg/kg IM/PO Onset: Usual dose: Adult: 2 mg/PO/IMMay repeat every 30–60 min 5–10 min IV 10–15 min IM Usual dose: Adult: 2 mg PO/IMMay repeat every 30–60 min 5–10 min IV 15 min IM b Medications for the Acutely Agitated Pediatric Patient antipsychotics” Antipsychotics “typical First-generation, Midazolam PO, IM, IV TABLE 4 Drug: How Supplied Benzodiazepines Lorazepam PO, IM, IV Haloperidol PO, IM

Downloaded from www.aappublications.org/news by guest on September 28, 2021 e10 FROM THE AMERICAN ACADEMY OF PEDIATRICS Comments deaths 3–4 d after appropriate IM dose 3 h after IM injection • FDA investigating 2 unexplained • Pregnancy class C • Consider monitoring for at least Advantages drug in pediatric patients may cause fewer EPS than drugs rst-generation fi dystonia, especially with higher doses and in male and/ or young patients • Second most commonly used • Low addiction potential • High therapeutic index • Lack of tolerance • May have higher risk of Side Effects • Postinjection delirium/sedation • Same as fi rst-generation drugs• Same as fi • May be better tolerated and • Hyperglycemia • Hyperprolactinemia Duration ≤ 60 min Peak: Peak: 6 h PO Onset: 60 min IM 20–30 min IM 45–60 min PO 60 min IM 30–60 min PO Onset: 10–20 min IM 20–30 min PO 15–45 min IM 4–5 h PO 3 h PO Duration: h 4–8 Duration: h 24 Peak: IM 10–20 mg midazolam PO every 60 min tranquilization: 10–20 mg (adults) PO every 30–45 min Dose: Route of Administration Time: Course/Onset Peak/ Usual dose: Usual dose: Haloperidol + lorazepam or Child: 0.5–2 mg Adolescent: 2–5 mg Adult: 5–10 mg May repeat IM every 20–30 min, Usual total dose for May repeat every 2 h PO 6–8 h 0.025–0.050 mg/kg PO/IMUsual dose: Child: 0.25–0.50 mg Onset: Adolescent: 0.5–1 mgMay repeat PO every 60 min 0.1 mg/kg PO/IM 1–2 h PO Usual dose: Child: 2.5 mg Adolescent: 5–10 mg Adult: 10 mg Maximum: 30 mg daily May repeat IM every 20–30 min, Peak: Younger adolescent (12–16 y): 10 mg Older adolescent (>16 y): Maximum: 40 mg daily d Continued tablet, ODT), IM IM benzodiazepine antipsychotics” TABLE 4 Drug: How Supplied Antipsychotic (typical) + Second-generation, “atypical Second-generation, Combinations Ziprasidone PO, IM Risperidone PO (liquid, PO Risperidone Olanzepine PO (tablet, ODT)

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 138 , number 3 , September 2016 e11 125, In other clinical situations, benzodiazepines alone may be the drug of choice. A common scenario is when the agitation is attributable to drug withdrawal or drug intoxication,

Comments especially drugs that decrease seizure threshold (eg, cocaine).117, 123, 143, 145,151 Because of their anticholinergic properties, antipsychotics may worsen the condition of patients who present with intoxication from drugs with anticholinergic properties (eg, hallucinogens) or with an anticholinergic delirium. 123, 124, 143 Advantages Adverse Effects of and Clinical Monitoring During Chemical Restraint Monitoring of patients who have received chemical restraint is similar

but has many of the same adverse effects as other drugs (extrapyramidal/dystonic to patients under physical restraint, 150

126, which are discussed in detail in

118, the subsequent section on physical restraint. 152 – 154 Medications used

Side Effects for chemical restraint may result in myriad adverse effects that benefit from close medical monitoring, including respiratory depression; hypotension; paradoxical behavioral disinhibition from benzodiazepines, especially in younger children and those with developmental disabilities 134,148, 155;

Duration dystonic reactions; orthostatic hypotension; sinus tachycardia; and other dysrhythmias attributable to antipsychotics. 61, 130, 132– 134, 149 Given these concerns, monitoring patients who receive antipsychotics may include close clinical observation, cardiorespiratory monitoring, pulse oximetry, 156 and/or an electrocardiogram, when and if the patient will tolerate them.

midazolam The most feared cardiac adverse Dose: Route of Administration Time: Course/Onset Peak/

Haloperidol + diphenhydramine Risperidone + lorazepam or Risperidone + diphenhydramine effect of antipsychotics is a quinidine-

like QTc prolongation, resulting in dysrhythmias such as torsades de

pointes. QTc prolongation has been noted to occur with therapeutic dosing of antipsychotics and is possible with any antipsychotic Continued 149 medication. Potential risk factors for antihistamine benzodiazepine antihistamine 143, 148, QTc prolongation and dysrhythmia 135, Chlorpromazine, a phenothiazine that can be used to treat nausea/vomiting and intractable hiccups, has also been used with agitated patients Chlorpromazine, a phenothiazine that can be used to treat nausea/vomiting and intractable hiccups, has also been with agitated Studies of the coadministration these drugs have been reported. future. Combinations of a butyrophenone (eg, haloperidol) and benzodiazepine lorazepam) may be given There may be research with other combinations studied in the This table provides suggestions for some of the most commonly used drugs for management of the agitated pediatric patient. Child (prepubertal) ages 6–12 y; adolescent 13 y or older. Adult doses have been used in adolescents with high BMI. (prepubertal) This table provides suggestions for some of the most commonly used drugs management agitated pediatric patient. Child ages 6–12 y; adolescent 13 y or older. EPSs include dystonia and akathisia, which may be treated with diphenhydramine (1.0 mg/kg/dose IV or PO, maximum 50 mg, usual dose in adults is 25 mg or 50 mg) and/or benztropine (1–2 adults). EPSs include dystonia and akathisia, which may be treated with diphenhydramine (1.0 mg/kg/dose IV or PO, maximum 50 mg, usual together for an additive effect and may be administered in the same syringe. Data in some adult studies suggest that coadministration of a butyrophenone with benzodiazepine may be more effective than either medication alone. together for an additive effect and may be administered in the same syringe. Data some adult studies suggest that coadministration b TABLE 4 Drug: How Supplied Antipsychotic (typical) + Antipsychotic (atypical) + Antipsychotic (atypical) + www. antipsychotics listed in the table are class C (last accessed December 2, 2013). EPS, extrapyramidal symptom; rst- and second-generation c drug in the class are given in the row for drug class. Pregnancy class is based on limited data, but according to Lexicomp (http:// ), the benzodiazepines are class D and fi pharmacy/ Side effects for all drugs in the class are given row drug class. a specifi community- online/ lexicomp- com/ wolterskluwercdi. oral administration. oral disintegrating tablet; PO, intravenous; NMS, neuroleptic malignant syndrome; ODT, FDA, US Food and Drug Administration; IV, a 129, c d symptoms, neuroleptic malignant syndrome) as well as anticholinergic side effects and a decrease in the seizure threshold, without having any major advantages over the other drugs. side effects and a decrease in the seizure threshold, without symptoms, neuroleptic malignant syndrome) as well anticholinergic include coadministration with

Downloaded from www.aappublications.org/news by guest on September 28, 2021 e12 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 5 QT-Interval-Prolonging Medications in Pediatrics mydriasis, delirium, and conduction Antiemetics Cardiac Antidepressants abnormalities. Clonidine can result in • Ondansetron • Adenosine • Fluoxetine hypotension and sedation. 136, 137 • Dolasetron • Dopamine • Sertraline Macrolides • Epinephrine • Paroxetine • Azithromycin • Dobutamine • Venlafaxine Physical Restraint • Clarithromycin • Quinidine • Amitriptyline • Erythromycin • Procainamide • Desipramine Physical restraint involves the use Fluoroquinolones • Flecainide • Imipramine of mechanical restrictive devices • Ciprofl oxacin • Amiodarone Mood-stabilizing agents to limit physical activity. Some • Levofl oxacin • Bretylium • Lithium differentiate physical restraint from • Moxifl oxacin • Nicardipine Antipsychotics “therapeutic holding,” a method Other Antibiotics • Sotalol • Please see Table 4 at www. pediatrics. org/ cgi/ doi/ 10. 1542/ in which health care providers peds.2016- 1573 or caregivers hold the individual • Amantadine Antihistamines Other medications to contain the agitated behavior. • Trimethoprim-sulfamethoxazole • Diphenhydramine • Cisapride Therapeutic holding is most often Antimalarials • Hydroxyzine • Octreotide used in patients of younger ages as • Quinine • Loratadine • Pentamidine • Chloroquine • Astemizole • Tacrolimus a method to help patients regain Neurologic • Terfenadine • Vasopressin control of their behavior. 169 In • fos-Phenytoin Respiratory tract 1 study, restraint was achieved • Sumatriptan • Albuterol with a mean of 3.5 people per • Zolmitriptan • Terbutaline patient, with patients held for an • Chloral hydrate • Phenylephrine 170 • Pseudoephedrine average of 21 minutes. Another This is an incomplete list of QT-interval-prolonging medications, limited to those that are commonly used in pediatrics. For technique is seclusion, which refers a more comprehensive list, please refer to the cited references Haddad et al, Olsen et al, and Yap et al.159 – 161 to the placement of an individual in isolation in an enclosed space. 171 other drugs that prolong the QTc; warning, the use of droperidol has The prevalence of the use of physical administration of high doses of declined exponentially.114, 117, 125, 157 restraints among ED adult psychiatric 157,158 haloperidol ; and underlying Acute dystonia usually presents as patients varies widely, ranging from medical illness (eg, electrolyte involuntary motor tics or spasms 8% to 59%.172 – 177 There are much abnormalities, hepatic or renal usually involving the face, neck, back, fewer data on the use of restraint impairment, heart failure, elderly, and limb muscles and may occur among pediatric patients. 62, 144 congenital long QT syndromes). after antipsychotic administration. Complications of Physical Restraints Among the typical and atypical Oculogyric crisis is a specific form antipsychotics, thioridazine and of acute dystonia, characterized by Over the past 2 decades, there has ziprasidone, respectively, are continuous rotatory eye movements. been increasing concern regarding associated with the greatest degrees A rare, life-threatening form of adverse events, including deaths, of QTc prolongation. 130, 134, 145, 159 dystonia is laryngeal dystonia, which associated with the use of physical Many other commonly used presents as a choking sensation, restraints in psychiatric facilities. 111 pediatric medications may prolong difficulty breathing, or stridor. Acute The New York State Commission dystonia is commonly treated with on Quality of Care in 1994 reported the QTc, including antiemetics (eg, ondansetron), antibiotics such as diphenhydramine or benztropine 111 deaths over a 10-year period in macrolides, fluoroquinolones, and administered intravenously or New York facilities that were linked 178 antifungal agents (eg, ketoconazole), IM. Additional doses of these to the use of physical restraints. antiarrhythmics, and other psychiatric medications may be indicated, given Four years later, the Hartford Courant medications (Table 5).160 –162 US Food that their half-life is shorter than detailed 142 mortalities nationwide and Drug Administration “black antipsychotics. attributed to physical restraint use, with children disproportionately box” warnings have been issued for Among the less commonly used represented among the deaths. 179 both droperidol and thioridazine chemical restraint medications, Among child and adolescent because of this risk, although the antihistamines, such as psychiatric facilities, between 1993 actual clinical risk of and dangers diphenhydramine and hydroxyzine, and 2003, 45 deaths were ascribed to from antipsychotic-induced cardiac can cause anticholinergic adverse the use of restraints. 180 dysrhythmias is unclear and is being effects including dry mouth, vigorously debated. 61, 134, 149, 163 – 168 dry skin, urinary retention, There is also significant morbidity However, since the black box constipation, flushing, dizziness, associated with the use of physical

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 138 , number 3 , September 2016 e13 restraints. The most common ‘medical treatment’ that should only aspiration. If a female patient is being complication is skin breakdown at be used as ‘last resort measure.’” 186 restrained, having at least 1 female the site of the restraint, with the Adding to the complexity of this issue, on the restraint team may be helpful. possibility of neurovascular damage it is important to keep in mind the In some cases, a “sandwiching” also occurring. 123 Rhabdomyolysis potential liability for failure to restrain technique between 2 mattresses has may occur, especially in patients who a patient who loses control and injures been used, with careful monitoring continue to struggle, which can lead someone and/or destroys property, for risk for asphyxia. 122 to kidney failure. Other reported which may be greater than the liability Although definitive studies evaluating complications include accidental for appropriately restraining an the best and safest restraint practices strangulation from vest restraints, aggressive/violent patient.114 are lacking, experts suggest the use of brachial plexus injuries, electrolyte age-appropriate or leather restraints. abnormalities, hyperthermia, deep Indications for the Use of Physical Restraints made of softer, makeshift, vein thrombosis, pulmonary injury/ Restraints or other materials may be less effective diseases, and asphyxia. 171 There are specific indications for and more likely to result in patient the use of restraints: when the injury. After their review of deaths of Physical Restraint Policies and patient is an acute danger to patients who were being physically Regulations harm himself/herself or restrained, The Joint Commission made 111,123, 124, 176, 187 others, to prevent the following suggestions 188: Because of increasing awareness significant disruption of the treatment of the potential complications and plan including considerable disruption • Proper staff training on dangers of physical restraint, federal of property, and when other less alternatives to and proper agencies and hospital accreditation restrictive measures have failed or application of physical restraints organizations have developed formal are not possible options.61, 129, 182, 185 • regulations regarding physical Continuous monitoring of It is unethical to use restraints for restrained patients restraint. In 2006, the Centers for convenience or punishment and when • Medicare and Medicaid Services prohibited by law or regulation or by Supine positioning, with published its most recent guidelines untrained personnel.185 o the head of the bed elevated, and on patients’ rights regarding the use of restraints and seclusion. 152 Techniques for Application of Physical o free cervical range of motion, to The US General Accounting Restraints decrease aspiration risk Office and The Joint Commission If other less restrictive measures • Prone positioning may be used if (formerly, The Joint Commission have failed, nursing staff may other measures have failed or are for the Accreditation of Health Care initiate restraint use in extenuating not possible. Deaths have been Organizations) have published circumstances, with a physician associated with its use. If used, similar policies and regulations. 153, 181 or other licensed independent helpful strategies include the Medical professional organizations, practitioner performing a face-to- following: including the AAP, 182 the ACEP, 183 face evaluation and reviewing and the American Academy of Child and o monitoring for airway approving the order within 1 hour. 123 Adolescent Psychiatry, 115 and the obstruction, Sometimes, the mere show of force American Medical Association, 184 by a cohort of trained professionals o minimizing or eliminating pressure all have policies supporting these may induce the agitated/violent on the neck and back, and regulations, the principles of the individual to deescalate, rendering o discontinuing as soon as possible humane and least restrictive possible restraint unnecessary. When use of restraint, and the need for • Minimize covering of the patient’s possible, 5 or more individuals further research in this area. face or head may be included in the application The use of restraints remains of physical restraints. One person • Minimize the use of high vests, controversial. Although restraints can supports the head, and 4 other waist restraints, and beds with be a component of patient treatment individuals secure each limb. Experts unprotected, split side rails 61,182, 185 in certain situations, the use suggest applying restraints securely • Remove smoking materials from of restraints and seclusion has been to each extremity, then to the bed the patient questioned by some. According to the frame rather than the side rails. • National Association of State Mental Maximizing patient safety includes Minimize restraint of medically Health Program Directors, “Seclusion allowing the patient’s head to rotate compromised or unstable patients and restraint should be considered freely, elevating the head of the bed, • In cases of agitation because a security measure, not a form of if possible, to decrease the risk of of suspected illicit stimulant

Downloaded from www.aappublications.org/news by guest on September 28, 2021 e14 FROM THE AMERICAN ACADEMY OF PEDIATRICS use, chemical restraint may be TABLE 6 The Joint Commission Requirements for Evaluating and Ordering Restraint preferable, as a rapid increase Age in serum potassium secondary <9 y 9–17 y >18 y to rhabdomyolysis may result in LIP in-person evaluation to order restraint Within 1 h of Within 1 h of Within 1 h of cardiac arrest. placement of placement of placement of The Joint Commission guidelines restraints restraints restraints also include a schedule for the Renew restraint order by qualifi ed staff Every 1 h Every 2 h Every 4 h LIP in-person evaluation to renew Every 4 h Every 4 h Every 8 h evaluation of the need for and restraint order ordering of restraints, as well as Assessments every 15 min (all ages) • Vital signs patient monitoring and assistance, by • Signs of injury due to restraint or seclusion a licensed independent practitioner • Nutrition/hydration (licensed independent practitioner; • Extremities circulation and range of motion • Hygiene and elimination (bowel/bladder) eg, physician, nurse practitioner, • Physical and psychological status/comfort physician assistant) and the staff • Readiness to members who apply or monitor the discontinue restrained patient ( Table 6). 153 restraint LIP, licensed independent practitioner. Techniques for Removal of Restraints Before removal of restraints, it may opportunities to engage children and mortality are increased in adults with be helpful to inform the patient of families in mental health care without psychiatric illness. In fact, studies what behavior is expected to minimize stigma.” 191 Unfortunately, nearly suggest that the life expectancy of the chance that restraints will be half of adolescents lack a medical adults with severe psychiatric illness reapplied. The same number of staff home, with those with mental health is between 13 and 35 years lower members that was used to apply the problems being even less likely to than their peers without psychiatric restraints may be present when the have the benefit of a medical home.192 illness. 193 Pediatric studies have restraints are removed. A common Whenever possible, best practices demonstrated increased rates of strategy is removing 1 restraint at a include consulting primary care obesity and worse self-reported time, usually starting with 1 lower pediatricians regarding level-of-care health in adolescents with mental extremity, next the other leg, then 1 determination, follow-up planning, illness. 194 Youth with attention- of the upper extremities, and then the other arm, to monitor the patient’s and referrals. When referral to an deficit/hyperactivity disorder and response. If the patient becomes outpatient mental health specialist is developmental disabilities, such as violent or disruptive, then the limb indicated, providers who are either autism spectrum disorders, have restraint(s) may be reapplied; if the colocated within or have established been found to have elevated rates patient is cooperative, the restraint collaborations with the medical home of medical conditions including removal process may continue. may be strongly considered. The asthma, frequent ear infections, medical home provider can follow severe headaches or migraines, up with the family to help facilitate and seizures. They also have COORDINATION WITH THE MEDICAL and encourage adequate aftercare. increased utilization of specialists HOME In circumstances when a referral to and higher unmet health needs, Experts strongly endorse the benefits a mental health specialist or higher including delays in care and of a “medical home”—patient- level of psychiatric care is either not inability to afford prescriptions. 150 centered care that is coordinated indicated or unavailable, encouraging Therefore, emergency physicians and integrated by the patient’s patients to seek follow-up treatment may have a significant effect on personal physician, especially for through their medical home may be children presenting with mental high-risk and/or high-utilization beneficial. health concerns by referring and 189,190 patients. The AAP also supports encouraging them to participate in the integration of mental health There are likely additional health coordinated care through a suitable treatment within the medical home benefits to involving a child’s medical medical home. so that youth can “benefit from the home in the aftercare plan. Although strength and skills of the primary data in children are limited, there LEAD AUTHORS care clinician in establishing rapport is a body of data demonstrating Thomas H. Chun, MD, MPH, FAAP with the child and family, using that access to primary care may Sharon E. Mace, MD, FAAP, FACEP the primary care clinicians’ unique be problematic and morbidity and Emily R. Katz, MD, FAAP

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 138 , number 3 , September 2016 e15 AMERICAN ACADEMY OF PEDIATRICS, Ann Marie Dietrich, MD, FACEP disorders in U.S. adolescents: results COMMITTEE ON PEDIATRIC EMERGENCY Paul J. Eakin, MD from the National Comorbidity Survey MEDICINE, 2015-2016 Marianne Gausche-Hill, MD, FACEP, FAAP Replication—Adolescent Supplement Michael Gerardi, MD, FACEP, FAAP Joan E. Shook, MD, MBA, FAAP, Chairperson (NCS-A). J Am Acad Child Adolesc Charles J. Graham, MD, FACEP Psychiatry. 2010;49(10):980–989 James M. Callahan, MD, FAAP Doug K. Holtzman, MD, FACEP Thomas H. Chun, MD, MPH, FAAP Jeffrey Hom, MD, FACEP 3. National Institute of Mental Health, Gregory P. Conners, MD, MPH, MBA, FAAP Paul Ishimine, MD, FACEP Substance Abuse and Mental Health Edward E. Conway Jr, MD, MS, FAAP Hasmig Jinivizian, MD Services Administration, Department Nanette C. Dudley, MD, FAAP Madeline Joseph, MD, FACEP of Health and Human Services. Mental Toni K. Gross, MD, MPH, FAAP Sanjay Mehta, MD, Med, FACEP Health: A Report of the Surgeon Natalie E. Lane, MD, FAAP Aderonke Ojo, MD, MBBS Charles G. Macias, MD, MPH, FAAP Audrey Z. Paul, MD, PhD General. Executive Summary. Rockville, Nathan L. Timm, MD, FAAP Denis R. Pauze, MD, FACEP MD: US Department of Health and Nadia M. Pearson, DO Human Services; 1999 LIAISONS Brett Rosen, MD 4. Grupp-Phelan J, Delgado SV, Kelleher KJ. W. Scott Russell, MD, FACEP Kim Bullock, MD – American Academy of Family Failure of psychiatric referrals from the Physicians Mohsen Saidinejad, MD Harold A. Sloas, DO pediatric emergency department. BMC Elizabeth Edgerton, MD, MPH, FAAP – Maternal Emerg Med. 2007;7:12 and Child Health Bureau Gerald R. Schwartz, MD, FACEP Orel Swenson, MD Tamar Magarik Haro – AAP Department of 5. Grupp-Phelan J, Wade TJ, Pickup T, et Federal Affairs Jonathan H. Valente, MD, FACEP Muhammad Waseem, MD, MS al. Mental health problems in children Madeline Joseph, MD, FACEP, FAAP – American Paula J. Whiteman, MD, FACEP and caregivers in the emergency College of Emergency Physicians Dale Woolridge, MD, PhD, FACEP department setting. J Dev Behav Angela Mickalide, PhD, MCHES – EMSC National Pediatr. 2007;28(1):16–21 Resource Center FORMER COMMITTEE MEMBERS Brian R. Moore, MD, FAAP – Natonal Association of 6. Fein JA, Pailler ME, Barg FK, et al. EMS Physicians Carrie DeMoor, MD Feasibility and effects of a Web- Katherine E. Remick, MD, FAAP – National James M. Dy, MD based adolescent psychiatric Association of Emergency Medical Technicians Sean Fox, MD assessment administered by clinical Sally K. Snow, RN, BSN, CPEN, FAEN – Emergency Robert J. Hoffman, MD, FACEP staff in the pediatric emergency Nurses Association Mark Hostetler, MD, FACEP department. Arch Pediatr Adolesc Med. David W. Tuggle, MD, FAAP – American College of David Markenson, MD, MBA, FACEP Surgeons Annalise Sorrentino, MD, FACEP 2010;164(12):1112–1117 Cynthia Wright-Johnson, MSN, RNC – National Michael Witt, MD, MPH, FACEP 7. Sheldrick RC, Merchant S, Perrin Association of State EMS Offi cials STAFF EC. Identifi cation of developmental- behavioral problems in primary Dan Sullivan care: a systematic review. Pediatrics. FORMER MEMBERS AND LIAISONS, Stephanie Wauson 2013–2015 2011;128(2):356–363 Alice D. Ackerman, MD, MBA, FAAP 8. Committee on Psychosocial Aspects of Lee Benjamin, MD, FACEP, FAAP - American College ABBREVIATIONS Child and Family Health and Task Force of Physicians AAP: American Academy of on Mental Health. Policy statement— Susan M. Fuchs, MD, FAAP Pediatrics The future of pediatrics: mental health Marc H. Gorelick, MD, MSCE, FAAP ACEP: American College of competencies for pediatric primary Paul Sirbaugh, DO, MBA, FAAP - National care. 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Downloaded from www.aappublications.org/news by guest on September 28, 2021 e22 FROM THE AMERICAN ACADEMY OF PEDIATRICS Evaluation and Management of Children and Adolescents With Acute Mental Health or Behavioral Problems. Part I: Common Clinical Challenges of Patients With Mental Health and/or Behavioral Emergencies Thomas H. Chun, Sharon E. Mace, FACEP, Emily R. Katz, AMERICAN ACADEMY OF PEDIATRICS, COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE, AND AMERICAN COLLEGE OF EMERGENCY PHYSICIANS and PEDIATRIC EMERGENCY MEDICINE COMMITTEE Pediatrics originally published online August 22, 2016;

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2016/08/18/peds.2 016-1570 References This article cites 167 articles, 16 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2016/08/18/peds.2 016-1570#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Emergency Medicine http://www.aappublications.org/cgi/collection/emergency_medicine_ sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 28, 2021 Evaluation and Management of Children and Adolescents With Acute Mental Health or Behavioral Problems. Part I: Common Clinical Challenges of Patients With Mental Health and/or Behavioral Emergencies Thomas H. Chun, Sharon E. Mace, FACEP, Emily R. Katz, AMERICAN ACADEMY OF PEDIATRICS, COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE, AND AMERICAN COLLEGE OF EMERGENCY PHYSICIANS and PEDIATRIC EMERGENCY MEDICINE COMMITTEE Pediatrics originally published online August 22, 2016;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/early/2016/08/18/peds.2016-1570

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2016 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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