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

Medications for Violent Patients – Imminent Danger to Staff, Self, and/or Property

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
Contra-indications
Side Effects Comments
Benzodiazepine Lorazepam IM
IV

0.1 mg/kg (max 5 mg)

May repeat every 10 min

15-30
2-5
60-120
60-120
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
and/or
antipsychotic medications may be titrated at signs of lightening
IV 1-1.5 mg/kg (max 100 mg) 30 sec 5-10
Antipsychotic Haloperidol IM
IV

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.

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