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Pediatric Agitation Pathway in the Emergency Department

Pediatric Agitation Pathway in the Emergency Department

Adapted from the 2019 Consensus Statement of the American Association for Pediatric Agitation Pathway in the Emergency Department The following information is intended as a guildeline for the acute management of children and adolescents with acute agitation in the emergency department (including GNSH and BHED). Management of your patient may require a more individualized approach.

Agitation is a symptom, like pain, with many potential etiologies and often multiple contributing in the moment. Even if a child has a known psychiatric/developmental disorder history, comorbid physical disease, anxiety, or other acute triggers should still be ruled out and a broad differential mantained. Non-pharmacologic approaches used for de-escalation should be employed early with a preventative, proactive approach. The goal for pharmacotherapy is twofold: 1) Target the underlying cause of distress; and 2) calm the patient sufficiently for rapid assessment and treatment. Pharmacologic strategies should be used in concert with non-pharmacologic de-escalation efforts continuing during and after medication administration

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- Attempt behavioral interventions Still severely - Consider extra dose of patient's regular standing - Assess pain, hunger, other physical needs, agitated and needs medication () Yes and what usually soothes the patient medication - Avoid benzodiazepines or due to risk Is the patient developmentally delayed or autistic? - Utilize sensory tools of disinhibition - Ask about prior medication responses - : (Risperdal), (especially to benazodiazepines and (Thorazine), (Zyprexa) )

No ADHD or Oppositional defiant disorder or (Catapres) or - If on standing antipsychotic give extra Conduct Disorder (Benadryl) or Risperidone (Risperdal) dose Does the patient have a clear psychiatric Yes Chlorpromazine (Thorazine) or - Risperidone (Risperdal) or diagnosis? (Ativan) or Olanzapine Chlorpromazine (Thorazine) or Anxiety, trauma, or PTSD (Zyprexa) or Risperidone Olanzapine (Zyprexa) or Haloperidol Lorazepam (Ativan) or Clonidine (Catapres) (Risperdal) (Haldol) +/- Lorazepam (Ativan) No

- Address unerlying medical etiology Still severely agitated Is it ? - Risperidone (Risperdal) or Clonidine (Catapres) or - Assess pain and needs medication Acute onset/fluctuating course plus inattention plus Olanzapine (Zyprexa) or Chlorpromazine Yes - Avoid benzodiazepines (BZD) and disorganized thinking or altered level of (Thorazine) or Haloperidol (Haldol) +/- Lorazepam which may worsen consciousness? (Ativan) if there are seizure concerns or catatonia delirium

No Unknown Substance EtOH/Bzd withdrawal or intoxication Lorazepam (Ativan), with or without Lorazepam (Ativan) + Haloperidol (Haldol) if Utox Negative Haloperidol (Haldol) severe agitation or hallicunating Suspect synthetic Is it substance intoxication or withdrawal? Yes or ; Lorazepam Opiate withdrawal EtOH/Bzd intoxication (Ativan) +/- Haloperidol (Haldol) Clonidine (Catapres) +/- opiate replacement Haloperidol (Haldol) or Chlorpromazine or Chlorpromazine (Thorazine) Add supportive meds as needed (Thorazine)

No Unknown etiology with moderate Unknown etiology with severe agitation Unknown etiology with mild agitation agitation or against objects or aggression to self/others or verbal aggression Yes Unknown etiology of agitation? Diphenhydramine (Benadryl) or Haloperidol (Haldol) +/- Lorazepam Utilize behavioral and environmental Lorazepam (Ativan) or Olanzapine (Ativan) or Chlorpromazine (Thorazine) strategies to deescalate (Zyprexa) or Olanzapine (Zyprexa)

Last revision 10/4/19. Contact Dr. Daniel Park ([email protected]) for questions regarding this document Medications for Acute Agitation Medication Dose Peak effect Max daily dose Notes/monitoring

PO/IM: 12.5-50mg Diphenhydramine 1 mg/kg/dose Child: 50-100 mg [Benadryl] PO: 2 hours Avoid in delirium TID-QID PRN Adolescent: 100-200 mg (antihistaminic) (50 mg max per dose)

PO/IM/IV:0.5 mg-2 mg Child: 4 mg Avoid in delirium. Do not give with olanzapine Lorazepam [Ativan] Q4-8hrs PRN I V : 10 mins Adolescent: 6-8 mg (especially IM due to risk of respiratory (benzodiazepine) (2 mg max per dose) P O / I M : 1 - 2 h o u r s Depending on weight/prior suppression). 0.05 mg-0.1 mg/kg/dose medication exposure

27-40.5 kg: 0.2 mg/day M o n it o r f o r h y p o tension and bradycardia Clonidine [Catapres] PO: 0.05 mg- 0.1 mg PO: 30-60 mins 40.5-45 kg: 0.3 mg/day A v o i d g i v i n g w i t h benzodiazepines (BZD) or (alpha 2 ) Q8 hrs PRN >45 kg: 0.4 mg/day atypical antipsychotics due to risk

Chlorpromazine PO/IM: 12.5-60 mg PO: 30-60 mins C hild <5 years: 40 mg/day M o n i t o r hypotension [Thorazine] Q6-8hrs PRN IM: 15 mins Child >5 years: 75 mg/day Monitor for QT prolongation (antipsychotic) 0.55 mg/kg/dose

Monitor hypotension Consider EKG or cardiac PO/IM: 0.5 mg- 5 mg 15-40 kg: 6mg m o n it o r in g f o r Q T p r o lo n gation, especially for IV Haloperidol [Haldol] 0.05-0.1 mg/kg/dose PO: 2 hours >40 kg: 15 mg a d m i n istration. (antipsychotic) Q6hr PRN I M : 2 0 mins Depending on prior antipsychotic Note EPS risk with major depressive disorder (5 mg max per dose) exposure (MDD) > 3 mg/day, with IV dosing having very high EPS risk.

PO/ODT or IM: P O: 5 hours 10-20 mg Olanzapine [Zyprexa] Age 4 to <6: 1.25 mg once (range 1-8 Do not give IM with or within 1 hour of any Depending on antipsychotic (antipsychotic) Age 6-12 years: 2.5 mg once h o u r s ) BZD given risk for respiratory suppression exposure Age >12: 2-5-5 mg once IM: 15-45 mins

Child: 1-2 mg Risperidone [Risperdal] PO/ODT: 0.25-1mg Adolescent: 2-3 mg C a n c a u s e a k a t h is ia (restlessness/agitation) in PO: 1 hour (antipsychotic) 0.005-0.01 mg/kg/dose Depending on antipsychotic higher doses exposure

For any dosing or formulation questions call the pharmacy Psych ED Pharmacy: 4-4097 ED Pharmacy: 4-3765 Peds Pharmacy (7a-10p): 4-6679 Central Pharmacy (10p-7a): 4-8761

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