ED Pathway for Evaluation/Treatment of Children with Behavioral Health Issues

Medications for Agitated Patients

General Considerations

Tips for Medication Use

Medications for Agitated Patients – No Imminent Threat but Unable to Cooperate with Necessary Medical Care

CLASS DRUG ROUTE DOSE ONSET ACTION (min) Duration (min) Relative
Contra-indications
Side Effects Comments
Benzodiazepine Lorazepam IM
IV
PO

0.05 mg/kg(max 4mg)

May repeat IV/IM every
10 min or PO every 30 min

15-30
2-5
30-60
60-120
60-120
Disinhibition, respiratory instability Respiratory depression, disinhibition

May be ineffective for acute delirium

If inadequate sedation achieved after 2 doses
or
disinhibition occurs, then consider addition of an antipsychotic

Midazolam IN

0.3 mg/kg
(max 5 mg)

May repeat in 5 min

4-8 18-40
Antipsychotic Olanzapine ODT

Wt > 60 kg: 10 mg

Wt 30-60 kg: 5 mg

15-30 30 hrs QT prolongation, anticholinergic intoxication, active seizure disorder QT prolongation, orthostatic hypotension  
Risperidone ODT Wt 15-29 kg: 0.25 mg < 60 15 hrs QT prolongation, anticholinergic intoxication, active seizure disorder QT prolongation, tachycardia, hypertension  
Haloperidol IM
IV

0.025 mg/kg (max 5 mg)

May repeat x 1 in 30 min

10-20 180-360 QT prolongation, anticholinergic intoxication, active seizure disorder, withdrawal syndrome QT prolongation, extrapyramidal symptoms  

Note:

If muscle stiffness or movement problems develop after use of an antipsychotic: Give diphenhydramine 1 mg/kg/dose PO/IM/IV (max 50 mg).

If persistent symptoms:
Consider 2nd dose of benadryl
Consider benztropine 0.05 mg/kg/dose for children > 3 years of age (not recommended for children < 3 due to serious adverse events)

Monitoring the Patient