Pharmacologic management of the agitated child

Treatment of Aggressive Behavior and Agitation in an 11-Year-Old Boy with Co-Occurring Autism and ADHD: A Case Report and Literature Review on the Use of Intravenous Valproate in Emergency Psychiatry

Background: Autism spectrum disorder (ASD) is a persistent neurodevelopmental disorder frequently co-occurring with attention-deficit/hyperactivity disorder (ADHD) and behavior-related disorders. While behavioral therapy is the first-line option to manage the core symptoms of ASD, pharmacological therapy is sometimes needed to treat acute problems, such as agitation and aggressive behaviors. Recent guidelines recommend the use of neuroleptics to reduce psychomotor agitation in patients with ASD. However, as children with ASD are often drug-resistant, alternative treatments are often justified. Reports from the literature have indicated that intravenous valproate (IV-VPA) can be effective in reducing agitation in psychiatric patients, with a lower frequency of adverse events compared to conventional treatments. However, as the related findings are occasionally inconsistent, IV-VPA is not yet an approved option in the context of clinical psychiatry. We aim to improve knowledge of the IV-VPA treatment option for emergency psychiatric treatment in pediatric patients. Methods: We report the case of an 11-year-old boy suffering from a complex neurodevelopmental condition who experienced a psychotic episode with severe aggressive and disruptive behaviors and was successfully treated with IV-VPA. Furthermore, we provide an updated literature review on this topic. Conclusion: In our case, first-line therapies proved to be ineffective. To the contrary, IV-VPA led to safe and prompt clinical success, which is in line with other reports. Based on our literature review, IV-VPA can be highly effective and reduces the risk of adverse events that frequently occur with the use of high-dose standard medications in emergency psychiatry.

Emergency department management of acute agitation in the reproductive age female and pregnancy

BACKGROUND

Agitation is a common presentation within emergent departments (EDs). Agitation during pregnancy should be treated as an obstetric emergency, as the distress may jeopardize both the patient and fetus. The safety of psychotropic medications in the reproductive age female has not been well established. This review aimed to explore a summary of general agitation recommendations with an emphasis on ED management of agitation during pregnancy.

METHODS

A literature review was conducted to explore the pathophysiology of acute agitation and devise a preferred treatment plan for ED management of acute agitation in the reproductive age or pregnant female.

RESULTS

While nonpharmacological management is preferred, ED visits for agitation often require medical management. Medication should be selected based on the etiology of agitation and the clinical setting to avoid major adverse effects. Adverse effects are common in pregnant females. For mild to moderate agitation in pregnancy, diphenhydramine is an effective sedating agent with minimal adverse effects. In moderate to severe agitation, high-potency typical psychotropics are preferred due to their neutral effects on hemodynamics. Haloperidol has become the most frequently utilized psychotropic for agitation during pregnancy. Second generation psychotropics are often utilized as second-line therapy, including risperidone. Benzodiazepines and ketamine have demonstrated adverse fetal outcomes.

CONCLUSION

While randomized control studies cannot be ethically conducted on pregnant patients requiring sedation, animal models and epidemiologic studies have demonstrated the effects of psychotropic medication exposure in utero. As the fetal risk associated with multiple doses of psychotropic medications remains unknown, weighing the risks and benefits of each agent, while utilizing the lowest effective dose remains critical in the treatment of acute agitation within the EDs.

The Use of Chemical Control Within Coercive Controlling Intimate Partner Violence and Abuse

This paper explores the use of chemical control by perpetrators as part of coercive controlling intimate partner violence and abuse, defined as the nonconsenting use of prescribed and nonprescribed medication (including vaccines), and/or other substances to coerce or control, reducing the victim-survivor's capacity for independence, freedom, and health. Based on testimonies of 37 victims-survivors and nine domestic abuse practitioners in the UK we identify varying tactics used to chemically coerce and control, deepening our understanding about the continually changing forms of domestic violence and abuse and enhancing the potential for a more robust response through better informed policy and practice.

De-escalation Techniques for the Agitated Pediatric Patient

ABSTRACT

The emergency department can be a particularly challenging environment for the care of pediatric patients presenting with acute agitation. Agitation is a behavioral emergency requiring prompt intervention. Timely recognition of agitation and proactive implementation of de-escalation strategies are critical for safe and effective management of agitation, as well as prevention of recurrent episodes. This article reviews the definition of agitation, explores the domains of verbal de-escalation, and considers multidisciplinary management strategies for children with acute agitation.

Prehospital Use of Ketamine versus Benzodiazepines for Sedation among Pediatric Patients with Behavioral Emergencies

INTRODUCTION

Ketamine is an emerging alternative sedation agent for prehospital management of agitation, yet research is limited regarding its use for children. Our objective was to compare the effectiveness and safety of ketamine and benzodiazepines when used for emergent prehospital sedation of pediatric patients with behavioral emergencies.

METHODS

We performed a retrospective review of 9-1-1 EMS records from the 2019-2020 ESO Data Collaborative research datasets. We included patients ≤18 years of age who received ketamine or benzodiazepines for EMS primary and secondary impressions indicating behavioral conditions. We excluded patients with first Glasgow Coma Scale (GCS) scores ≤8, those receiving ketamine or benzodiazepines prior to EMS arrival, those receiving both ketamine and benzodiazepines, and interfacility transfers. Effectiveness outcomes included general clinician assessment of improvement, decrease in GCS, and administration of a subsequent sedative. Safety outcomes included mortality; advanced airway placement; ventilatory assistance without advanced airway placement; or marked sedation (GCS ≤8). Chi-square and t-tests were used to compare the ketamine and benzodiazepines groups.

RESULTS

Of 57,970 pediatric patients with behavioral complaints and GCS scores >8, 1,539 received ketamine (13.3%, n = 205) or a benzodiazepine (86.7%, n = 1,334). Most patients were ≥12 years old (89.2%, n = 1,372), predominantly Caucasian (48.3%, n = 744), and were equally distributed by sex (49.7% male, n = 765). First treatment with ketamine was associated with a greater likelihood of improvement (88.8% vs 70.5%, p < 0.001) and a greater average GCS reduction compared to treatment with benzodiazepines (-2.5 [SD:4.0] vs -0.3 [SD:1.7], p < 0.001). Fewer patients who received ketamine received subsequent medication compared to those who received benzodiazepines (12.2% vs 27.0%, p < 0.001). Marked sedation was more frequent with ketamine than benzodiazepines (28.8% vs 2.9%, p < 0.001). Provision of ventilatory support (1.5% vs 0.5%, p = 0.14) and advanced airway placement (1.0% vs 0.2%, p = 0.09) were similar between ketamine and benzodiazepine groups. No prehospital deaths were reported.

CONCLUSION

In this pediatric cohort, prehospital sedation with ketamine was associated with greater patient improvement, less subsequent sedative administration, and greater sedation compared to benzodiazepines. Though we identified low rates of adverse events in both groups, ketamine was associated with more instances of marked sedation, which bears further study.

Epidemiological and Psychopharmacological Study About Off-Label Treatment in Child and Adolescent Psychiatric Emergencies: A Tertiary/Single Center Experience

OBJECTIVE

The study used an epidemiological and pharmacological description of child and adolescent psychiatric emergencies (CAPEs), during which psychotropic medications are frequently administered as off-label therapies.

METHODS

We retrospectively describe CAPE in 190 patients (mean age, 14.7 years) referring in the emergency department of a single tertiary center, from June 2016 to June 2018, focusing on off-label administration rate, most of all in emergency setting.

RESULTS

An intrinsic fragility was observed in this population, where 28.4% of patients present a history of self-harm, 24.7% a concomitant neurodevelopmental disorder, and 17.3% a history of substance abuse. Psychomotor agitation was the most frequent referral reason, and it represents an unspecified clinical presentation of several conditions, while self-harm showed a stronger association with depressive disorders (55.2%).Globally, 811 medications were administered both as baseline therapy (67.8% of off-label rate) and/or in the emergency setting, where the off-label rate raised to 78.3%. Benzodiazepines had the highest rate of off-label use (98.2% as baseline therapy, 92.9% in acute context). Nevertheless, in 83.5% cases of acute administrations, a singular oral benzodiazepine (mostly lorazepam) guaranteed psychomotor agitation resolution, with a lower rate of adverse effects in contrast with atypical antipsychotics.

CONCLUSIONS

Off-label drug use in CAPEs is a recurrent clinical practice. An international agreement about off-label drugs is crucial to obtain standard long-term pharmacoepidemiological, safety, and efficacy data. Pharmacological pediatric trials and international guidelines are also required to regulate pharmacological treatments of CAPEs, most of all in emergency settings.

The agitated pediatric patient located in the emergency department: The APPLIED observational study

Objectives

Focused research on pediatric agitation is lacking despite being a common mental and behavioral health (MBH) emergency. Prevalence of pediatric agitation remains unknown, and prior reports may have underestimated the rate of restraint use for pediatric agitation. This is the largest study to provide a focused evaluation of the prevalence and predictors of pediatric agitation and restraint use as well as the emergency department (ED) length of stay (LOS) and admission rates for agitated patients.

Methods

We reviewed records of patients aged ≤18 years with MBH needs who visited the pediatric ED of a tertiary care hospital during a 3-year-period. We identified and ascertained agitated/aggressive patients using documented signs/symptoms, International Classification of Diseases, Tenth Revision codes, and Behavioral Activity Rating Scale scores. We performed descriptive and multivariable analyses using SAS 9.4 (SAS Institute).

Results

Of 10,172 patients with MBH needs, 1408 (13.8%) were agitated/aggressive. Of these (n = 1408), 63.7% were boys, and the mean age was 11.9 years. Among agitated patients, the prevalence of restraint use was 28.7%, with a predominance of pharmacologic restraint with atypical antipsychotics. Non-Hispanic Blacks were more likely to be agitated (adjusted odd ratio [aOR], 1.8; 95% CI, 1.2-2.7), but not restrained (aOR, 0.8; 95% CI, 0.3-1.8). Predictors of restraint use include history of attention deficit hyperactivity disorder (aOR, 2.2; 95% CI, 1.5-3.3), autism (aOR, 2.9; 95% CI, 1.9-4.5), conduct disorder (aOR, 1.7; 95% CI, 1.2-2.5), psychosis (aOR, 14.3; 95% CI, 2.5-271.8), and substance use/overdose states (aOR, 1.9; CI, 1.2-3.2). Restrained agitated patients had longer ED LOS (8.4 vs 5.0 hours; P < 0.0001) and higher admission rates (aOR, 2.6; 95% CI, 2.0-3.5). Depression (aOR, 0.4; 95% CI, 0.3-0.5) and suicidality (aOR, 0.2; 95% CI, 0.1-0.3) were protective against agitation and restraint use.

Conclusion

Prevalence of acute agitation and restraint use in pediatric EDs may be much higher than previously reported. Predictors of acute agitation and restraint use among MBH patients were consistent with prior reports. Restrained agitated patients had longer ED LOS and higher admission rates.

Factors associated with a change in disposition for mental health patients boarding in an urban Paediatric emergency department

AIM

Paediatric emergency departments (ED) nationwide experience a shared burden of boarding mental health patients. Whilst boarding, some patients have a change in disposition from hospitalization to discharge home. This phenomenon raises concern because EDs often have scarce resources for mental health patients. We sought to understand which patient and clinical factors are associated with a change in disposition outcome.

METHODS

A nested age-sex-race frequency-matched case-control study was conducted including paediatric patients who presented to an urban PED for mental healthcare over a 36-month period. Control patients included patients admitted to an inpatient psychiatric facility, whilst case patients were those discharged home. Descriptive statistics and multivariable logistic regression analyses were performed to compare groups.

RESULTS

Case patients were more likely to receive intramuscular Haloperidol (OR 2.2 [CI 1.1-4.4]) for agitation and a psychiatric consult (OR 2.3 [1.4-3.9]) whilst boarding. Case patients were also more likely to present with behavioural concerns (OR 1.8 [CI 1.1-3.1]) and have additional complexities such as medical comorbidities (OR 1.8 [CI 1.1-2.9]) or suicidal ideation/attempt (OR 2.6 [CI 1.1-6.1]). Amongst the most common themes for disposition change was improved patient status (58.8%).

CONCLUSION

These findings suggest that boarding mental health patients have different disposition outcomes and thus may benefit from patient-specific treatment interventions. Given that patients' statuses may change during the boarding period prompting discharge to home, more focus should be directed to developing brief evidence-based practises that may be implemented in the ED and effectively bridge the gap to outpatient mental health services.

Understanding and management of anti-N-methyl-D-aspartate receptor encephalitis from a child psychiatry perspective: report of five cases

Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a rare autoimmune entity in psychiatry literature that occurs when antibodies attack NMDA-type glutamate receptors in the brain. Principle clinical features include a neurological domain such as seizure, orofacial dyskinesia, dystonia, and choreic-like movements of extremities. Also the psychiatric manifestations of this form of encephalitis may vary from psychotic-like symptoms to mood symptoms like depression or mania. Herein we report on five female child cases diagnosed with anti-NMDAR encephalitis, presented with both neurological and psychiatric clinical picture, and highlight the trajectory of disorder from a psychiatric perspective.

Adherence with an Acute Agitation Algorithm and Subsequent Restraint Use

Timely use of pharmacological interventions to treat acute agitation has the potential to decrease physical restraint use. The aim of this study is to determine if adherence to standardized pharmacological recommendations for the treatment of acutely agitated pediatric patients decreases physical restraint use. Additionally, this study aims to identify predictors of physical restraint use and describe treatment related adverse events. This is a retrospective chart review of patient visits between September 1, 2016 and August 31, 2017. Patient visits were included if the patient presented to the pediatric emergency department, met ICD-10 codes, and received pharmacologic management or physical restraint to treat acute agitation. The differences in rate of physical restraint was assessed between patients treated according to the standardized pharmacological recommendations and patients who were not. 447 patients were included with a mean age of 13 years. No significant difference in physical restraint use was found when standardized pharmacological recommendations were followed compared to when they were not (P = 0.16). Only presentation on day shift when compared to evening shift resulted in increased odds of being restrained (OR 2.03; 95% CI 1.18, 3.50). Nine adverse events possibly related to medications were identified with none considered to be of significant clinical concern. Standardized pharmacological treatment recommendations was not associated with a decrease in physical restraint use for agitated patients presenting to the pediatric emergency department. The pharmacologic strategies utilized were generally safe and well tolerated in this patient population.

Management of Acute Agitation and Aggression in Children and Adolescents with Pro Re Nata Oral Immediate Release Antipsychotics in the Pediatric Emergency Department

Background: Acute agitation in the pediatric emergency department (ED) has the potential to escalate into aggression and result in harm. Rapid and effective management may be warranted. Use of pro re nata (prn) oral immediate-release (IR) quetiapine, haloperidol, loxapine, and chlorpromazine has been observed in the pediatric ED at Surrey Memorial Hospital to manage this condition; however, evidence for oral prn antipsychotic use is limited in the pediatric population. Objectives: The primary objective is to characterize the dose of prn oral IR quetiapine used to manage acute agitation or aggression in a pediatric ED. Secondary objectives include characterizing the dose of prn oral IR haloperidol, loxapine, and chlorpromazine; and describing the 1-hour response rate, admission rate, length of stay (LOS), and adverse drug effects. Method: The medical records of pediatric patients who received at least one prn oral dose of IR quetiapine, haloperidol, loxapine, or chlorpromazine for acute agitation and aggression, without regard to the etiology of symptom presentation, between January 1, 2012 and December 31, 2016, were analyzed retrospectively. Results: Sixty-nine patients met the inclusion criteria. The mean dose of quetiapine was 32 mg/dose (0.54 mg/kg per dose); and the response rate was 53%. The mean haloperidol, loxapine, and chlorpromazine doses were 4 mg (0.07 mg/kg per dose), 13 mg (0.19 mg/kg per dose), and 29 mg/dose (0.53 mg/kg per dose) respectively; and the response rates were 36%, 30%, and 50%, respectively. Between 19% and 60% of patients were admitted, majority to the psychiatry ward. The median LOS in the ED was between 5 and 18 hours for nonadmitted patients. Extrapyramidal side effects (EPS) were reported with first-generation antipsychotics (FGA), but not with quetiapine. Conclusion: Quetiapine appears to be a viable agent for managing acute agitation and aggression in the pediatric ED with low rates of EPS. Further studies are encouraged to compare the effectiveness of quetiapine with FGA. A Clinical Trial Registration number is not applicable for this study.

Ketofol performance to reduce postoperative emergence agitation in children undergoing adenotonsillectomy

Background: Emergence agitation is a reformed state of mindfulness, which starts with a sudden form of anesthesia and progresses through the early repossession age. Thus, the purpose of this study is to evaluate 1:3 ketofol performance on children 3–15 years old undergoing adenotonsillectomy.Methods: A total of 60 children aged 3–15 years undergoing adenotonsillectomy were randomly allocated to receive low-dose ketamine 0.15 mg/kg followed by propofol 0.45 mg/kg i.v. ketofol (1:3) about 10 min before the end of surgery in comparison to 60 children aged 3–15 years who received only normal saline and dextrose. Anesthesia was induced and maintained with sevoflurane. Postoperative pain and EA were assessed with objective pain score (OPS) and the Pediatric Anesthesia Emergence Delirium (PAED) scale, respectively. EA was defined as a PAED 10 points. Recovery profile and postoperative complications were also recorded.Results: The incidence and severity of EA were found significantly lower in the ketofol group in comparison to the control group with a percentage of (13.33% vs 48.33%) (8% vs 15%) respectively (P < 0.05). Also, the time for interaction from anesthetic tainted to extubating in the ketofol set was significantly less than in the control group (P < 0.05). Interestingly, there are no opposing events such as nausea, laryngospasm, bronchospasm, hypotension, bradycardia, bleeding, or postoperative respiratory depression (respiratory rate: <16) were noticed in the ketofol supervision (P > 0.05). Moreover, the heart rate was meaningfully higher in the control group starting at the time of tracheal extubating in comparison to the children undergone ketofol (P < 0.05). Alert score and time from painkilling tainted till liberation from PACU showed substantial significant changes at ketofol set (P < 0.05).Conclusion: Ketofol (1:3) shows significant performance to reduce postoperative agitation in the children undergone adenotonsillectomy.

Pro Re Nata Medication Use in Acute Care Adolescent Psychiatric Unit

Objective: Evidence to support the use of pro re nata (PRN) medication is limited, and the details of PRN use (indication, frequency of administration, patient characteristics) are rarely reported, particularly in youth populations. The goal of this study was to report on the pattern of PRN use over 6 years in an acute care psychiatric unit for adolescents. Methods: A retrospective chart review of patients' records from November 2012 to October 2018 was conducted. Variables extracted from electronic medical records included age, gender, race/ethnicity, clinical rating scores at admission (on a subset of patients), length of stay, psychotropic and nonpsychotropic PRN medication administration, timing of administration, discharge diagnosis, and discharge medication. Results: Records from 2961 individuals with a total 3937 admissions were analyzed. A total of 62% of admissions had at least one PRN medication administration. Severity of symptoms, as indicated by higher scores on clinical rating scales at admission, longer length of stay, and readmission were related to high PRN use. Patients with bipolar spectrum disorders received more psychotropic and nonpsychotropic PRN medications than other patients. Patients who were high psychotropic PRN users were also high nonpsychotropic PRN users. Conclusion: Despite the lack of clear evidence in support of the efficacy of PRN medications, they commonly used to control symptoms in acute care inpatient settings. Youth with severe symptoms utilized not only psychotropic PRN medication but also nonpsychotropic PRN more frequently, suggesting a possible role of systemic disorder among youth with serious mental illness. More research is necessary to examine the efficacy of PRN medications for managing targeted symptoms.

Intranasal Lorazepam for Treatment of Severe Agitation in a Pediatric Behavioral Health Patient in the Emergency Department

The treatment of severe agitation, aggression, and violent behavior in behavioral health patients who present to the emergency department (ED) often requires the intramuscular administration of a sedative. However, administering an intramuscular sedative to an uncooperative patient is associated with the risk of needlestick injuries to both patients and health care providers, and times to onset of sedation range from 15 to 45 minutes. Intranasal absorption is more rapid than intramuscular, with sedatives such as lorazepam reaching peak serum concentrations up to 6 times faster when administered intranasally. We present the first report of using intranasal lorazepam as a needle-free method of providing rapid and effective sedation to treat severe agitation in a pediatric behavioral health patient presenting to the ED.

A Retrospective Review of Antipsychotic Medications Administered to Psychiatric Patients in a Tertiary Care Pediatric Emergency Department

OBJECTIVES

An increasing number of pediatric patients with psychiatric chief complaints present to emergency departments (EDs) nationwide. Many of these patients require treatment with antipsychotic medications to treat agitation. We sought to examine the use of antipsychotic medications in pediatric patients presenting to a tertiary care pediatric ED.

METHODS

We performed a retrospective electronic medical record review of patients presenting to a tertiary care pediatric hospital from January 2009 through February 2016 with a psychiatric chief complaint who received an antipsychotic medication in the ED.

RESULTS

A total of 229 patients were identified, 54.1% of whom were male. Mean age was 14.4 ± 2.6 years. Commonly administered medications included olanzapine (51.1%), aripiprazole (26.6%), haloperidol (24.0%), and risperidone (11.8%). Eighty-seven patients (38.0%) were given at least 1 intravenous or intramuscular dose of antipsychotic medication. A total of 113 patients (49.3%) received only 1 antipsychotic medication, 65 (28.4%) received 2, 30 (13.1%) received 3, and 21 (9.2%) received 4 or more antipsychotics. Median length of stay (minutes) increased significantly with increasing number of medications administered (p < 0.001). Length of stay was significantly shorter in patients given only oral medications (675.6 minutes, IQR 418-1194) compared to those given at least one intramuscular or intravenous dose (951 minutes, IQR 454-1652) (p = 0.014).

CONCLUSIONS

In this retrospective series, the majority of patients were treated with newer oral antipsychotics. Administration of multiple medications was associated with a significantly longer length of stay in the ED, as was parenteral administration of antipsychotics.

What do we really know about PRN use in agitated children with mental health conditions: a clinical review

What is the evidence that 'pro re nata' (PRN) medication is effective for ending agitated outbursts in children and adolescents in psychiatric emergency rooms or inpatient units? Literature search was performed for studies of PRN medication use in children and adolescents that included an outcome measure. One randomised controlled trial, three prospective studies and six retrospective studies that included some outcome measure were identified. Outcome measures were heterogeneous, and frequently did not use standardised metrics assessing agitation level to measure effectiveness. The single small Randomized Controlled Trial (RTC) does not find a difference between placebo and medication, and outcomes of other studies do not control for potential placebo effect of the intervention itself as opposed to the medication. There is insufficient evidence to support the common practice of PRN medications for the management of acute agitation, and no data with which to inform clinical practice, such as which medicines and doses are helpful for specific populations or situations. Psychiatrists have no evidence-based medication interventions for acutely managing agitated outbursts in children and adolescents.

Intravenous Valproic Acid Add-On Therapy in Acute Agitation Adolescents With Suspected Substance Abuse: A Report of Six Cases

The aim of this study was to test efficacy and safety of intravenous (IV) valproate for aggression in children and adolescents with mood or conduct disorder and concomitant substance abuse. Six patients received a 20 mg/kg dose of IV valproic acid as an add-on therapy to their standard therapy with second-generation antipsychotics and benzodiazepines. Agitation and general psychopathology were measured at baseline and after the first injection using the Modified Overt Aggression Scale, the Brief Psychiatric Rating Scale, and the Children's Global Assessment Scale. The findings suggested that in emergency psychiatry clinical settings, IV valproate was effective in reducing agitation and aggressive behaviors with a good tolerability profile and better treatment compliance.

Behavioral Health Care for Children Who Are Medically Hospitalized

Youth admitted to pediatric hospitals face a variety of emotional challenges throughout their stay. In addition to feeling compromised by their acute medical condition, managing the requirements imposed by hospital care can intensify the potential for behavioral dysregulation. Even meeting basic behavioral expectations often requires children to be highly vulnerable, uncomfortable, and in pain, having to trust a parade of people routinely delivering aversive interventions, all in the context of overwhelmed caregivers. Behavioral medicine approaches are thus essential for supporting adaptive coping to optimize emotional and pathophysiological recovery. Clinical implementation requires integration of emotional and behavioral health initiatives into medical services across the broadest of disciplines with hospital-wide vigilance to safety risks. Providers can support behavioral resiliency by nurturing youth who are hospitalized to become increasingly active agents in their care while bolstering the consistency of their behavioral expectations through effective communication and an empathic treatment approach tailored to their socioemotional needs. [Pediatr Ann. 2018;47(8):e323-e327.].

Crisis in the Emergency Department: The Evaluation and Management of Acute Agitation in Children and Adolescents

Acute agitation in children and adolescents in the emergency department carries significant risks to patients and staff and requires skillful management, using both nonpharmacologic and pharmacologic strategies. Effective management of agitation requires understanding and addressing the multifactorial cause of the agitation. Careful observation and multidisciplinary collaboration is important. Medical work-up of agitated patients is also critical. Nonpharmacologic deescalation strategies should be first line for preventing and managing agitation and should continue during and after medication administration. Choice of medication should focus on addressing the cause of the agitation and any underlying psychiatric syndromes.

Special Considerations in the Pediatric Psychiatric Population

Youth with psychiatric and behavioral complaints commonly present to emergency departments (EDs), which often lack dedicated mental health staff. This article addresses techniques EDs can use to better care for children in need of psychiatric assessment and medical clearance, specifically addressing the evaluation of youth with suicidal ideation and coexisting medical and psychiatric needs. The evaluation and management of youth with agitation and aggression are also discussed. The article concludes with a discussion of systems changes needed to truly improve emergency care for psychiatrically ill youth.

A Novel Agent for Management of Agitated Delirium: A Case Series of Ketamine Utilization in the Pediatric Emergency Department

Control of the agitated patient in the emergency department is challenging. Many options exist for chemical sedation, but most have suboptimal pharmacodynamic action, and many have undesirable adverse effects. There are reports of ketamine administration for control of agitation prehospital and in traumatically injured patients. Ketamine is a noncompetitive N-methyl-D-aspartic acid receptor antagonist, making it an effective dissociative agent. We present 5 cases of ketamine administration to manage agitated adolescent patients with underlying psychiatric disease and/or drug intoxication. Ketamine, as a dissociative agent, may be an alternative pharmacological consideration for the control of agitation in patients with undifferentiated agitated delirium.

Intramuscular Ziprasidone Dosing for Acute Agitation in the Pediatric Emergency Department: An Observational Study

BACKGROUND

Intramuscular (IM) ziprasidone is often used to manage acute agitation. Limited data exist on the pediatric dosing of ziprasidone in the emergency department (ED).

OBJECTIVE

To characterize the mg/kg dosing differences between pediatric ED patients who respond to an initial dose of ziprasidone versus patients who do not.

METHODS

This was a retrospective, observational study of 5- to 18-year-old patients who were treated with IM ziprasidone in the pediatric ED from 2007 to 2015. Medical records were reviewed to determine demographic and clinical information. Patients were deemed responders to ziprasidone if they required no additional rescue medication for acute agitation within 30 minutes of the initial dose.

RESULTS

Forty children received 50 doses of IM ziprasidone. Twenty-seven (68%) patients responded to the initial ziprasidone dose, requiring no further medication intervention for their acute agitation. Responders were given a mean initial dose of 0.19 ± 0.1 mg/kg, while nonresponders were given an initial mean dose of 0.13 ± 0.06 mg/kg ( P = .03).

CONCLUSION

A significant dose difference exists between patients who required only one initial dose of ziprasidone compared to those who required additional medication. As a result, an initial dose of 0.2 mg/kg of IM ziprasidone may be considered when managing acutely agitated pediatric patients in the ED.

Safety Profile of Children in an Enclosure Bed

PURPOSE

Pediatric nurses care for many children in the hospital setting whose behavioral challenges can impact safety. One intervention utilized to prevent injury and improve safety when caring for this population of children has been the enclosure bed. Scant information was found in the literature that discusses the use of the enclosure bed in the pediatric setting. The purpose of this article is to examine the use of the enclosure bed in the pediatric setting. A secondary aim is to identify the population of children where an enclosure bed was implemented and the safety factors associated with use of the enclosure bed.

METHODS

An exploratory retrospective chart review was conducted of 208 pediatric enclosure bed encounters in an acute care setting over a 2-year period. Variables included demographics, length of stay and bed use, behavioral medications, restraint and sitter usage, skin breakdown, fall risk, and falls.

RESULTS

Three categories of children based on cognitive function, no cognitive impairment, new cognitive impairment, and congenital cognitive impairment, were extracted from the chart review. Significant differences were found between groups of children and between safety variables observed with enclosure bed use. Children with new-onset cognitive impairment were more likely to incur falls, skin breakdown, and injury during use of the enclosure bed.

CONCLUSION

Use of the enclosure bed is a reasonable intervention in certain children to ensure their safety in the hospital setting. This information will enhance nursing knowledge related to providing safe and optimal care of this challenging population of children.

Agitation Management in Pediatric Males with Anti-N-Methyl-D-Aspartate Receptor Encephalitis

OBJECTIVES

Severe agitation is a common symptom in pediatric cases of anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis-an autoimmune encephalitis with prominent neuropsychiatric symptoms. Agitation is a major barrier to treatment of the underlying disease process and increases patients' risk of harming themselves and others. Furthermore, male patients often have undetectable tumors and are especially at risk for extended hospitalization, but have been infrequently studied. This report presents a case series of four pediatric male patients with anti-NMDAR encephalitis complicated by agitation, the strategies used to address treatment challenges, and a review of the current literature.

METHODS

A chart review of four agitated pediatric male patients with anti-NMDAR encephalitis and a PubMed search of the current literature were conducted.

RESULTS

A number of first-generation and second-generation antipsychotics (SGAs) have been reported for use in child and adult patients; however, treatment with these antipsychotics often has been complicated by movement disorders and autonomic instability caused by the underlying encephalitis that appears similar to and can be exacerbated by adverse effects of antipsychotics, including neuroleptic malignant syndrome (NMS), extrapyramidal symptoms (EPS), and tardive dyskinesia. The literature shows SGAs to be less likely to cause NMS and quetiapine to be one of the least likely SGAs to cause EPS. However, quetiapine has rarely been reported for use in patients with anti-NMDAR encephalitis. In the four pediatric male patients, quetiapine was generally effective, well tolerated, and not associated with NMS or significant EPS.

CONCLUSION

These cases and review of the literature suggest that quetiapine may be particularly beneficial for treating agitation secondary to anti-NMDAR encephalitis in pediatric patients and have fewer adverse effects.

Child Psychiatric Emergencies: Updates on Trends, Clinical Care, and Practice Challenges

Over the past 15 years, the number of pediatric patients presenting to the emergency room in psychiatric crisis has nearly doubled. Suicidality and aggression are among the most common presenting problems, making it important for providers to have up-to-date knowledge about the assessment and management of these frequently encountered clinical issues. Psychometrically sound suicide risk assessment tools are available for use in the emergency room setting, which can be administered efficiently with minimal provider training. Rates of off-label medication use in the pediatric population continue to increase and are often used in the management of acute agitation in the pediatric population. The current literature will be reviewed and summarized for application in emergent treatment settings. Overall, evidence to inform best practice is limited, leading to opportunities for innovation in health care delivery, the development of new research aims, and discussion of challenging clinical dilemmas.