Aim is to adminsiter medications as quickly as possible to prevent injury to staff or self, to prevent morbid or mortal injury due to application of physical restraints, and to allow medical diagnostic and therapeutic plan to proceed.
It should be recognized that control of agitation and agitated delirium in the Emergency Department (ED) may be very different than similar processes on an inpatient ward or in a psychiatric hospital.
|CLASS||DRUG||ROUTE||DOSE||ONSET ACTION (min)||Duration (min)||Relative
0.1 mg/kg (max 5 mg)
May repeat every 10 min
|Disinhibition, respiratory instability||Respiratory depression, disinhibition||
May be ineffective for acute delirium
If inadequate sedation, consider addition of another therapeutic class
|Sedative/Anesthetic||Ketamine||IM||2-4 mg/kg (max 200 mg)||3-4||12-25||Hypertensive urgency, increased ICP, phencyclidine poisoning||Tachycardia, hypertension||Obtain IV access and benzo-diazepines
antipsychotic medications may be titrated at signs of lightening
|IV||1-1.5 mg/kg (max 100 mg)||30 sec||5-10|
0.075 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, extrapryamidal symptoms||Full sedation may take 30 minutes. If patient did not receive any benzo-diazepine, then give concomitant lorazepam IV/IM 0.05 mg/kg (max 2 mg); dose may be repeated every 10 minutes|
|Consider paralysis, rapid sequence intubation, sedation and mechanical ventilation if all the above were ineffective.|
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)