Behavioral Health Issues — Medications — Clinical Pathway: Emergency

Behavioral Health Issues Clinical Pathway — Emergency Department

Medications

General Considerations

  • Review with Psychiatry whenever possible
  • Consider:
    • Underlying etiology of agitation
    • Previous medications that yielded a positive or negative response
    • Current home medications and potential interactions
    • Giving current prescribed medications, consider an extra dose or an early dose
  • Children may require repeat/higher doses than those usually recommended to achieve results
  • If inadequate results with multiple doses of a 1st medication, consider adding another therapeutic class of medication
  • Be mindful of onset of action, allow time for the medication to take effect
  • Assess need for more frequent vital signs based on medication effect

Medications for Agitation

Administer medications as quickly as possible to allow continued medical evaluation/treatment For additional dosing information, see CHOP Formulary.

Medications by Diagnosis

Delirium, Developmental Delay or Autism

Delirium
  • Risperidone, clonidine, olanzapine, haloperidol
  • Avoid benzodiazepines and anticholinergics which may worsen delirium
Developmental Delay
or Autism
  • Consider extra dose of home medication
  • Clonidine, diphenhydramine, antipsychotic (e.g., risperidone, olanzapine)
  • Avoid benzodiazepines due to disinhibition risk
  • Avoid IM route as able

Clear Psychiatric Diagnosis

Catatonia Lorazepam
ADHD
  • Clonidine
  • Diphenhydramine
  • Risperidone
Anxiety, trauma, PTSD
  • Lorazepam
  • Clonidine
Oppositional Defiant Disorder (ODD)
Conduct Disorder (CD)
  • Chlorpromazine
  • Lorazepam
  • Olanzapine
  • Risperidone
Mania/Psychosis
  • Quetiapine
  • Olanzapine
  • Risperidone
  • Chlorpromazine
  • Haloperidol +/- lorazepam +/- diphenhydramine (If EPS concern)

Unknown Etiology

Mild Agitation Behavioral and environmental strategies to deescalate
Moderate Agitation
  • Diphenhydramine
  • Lorazepam
  • Olanzapine
Severe Agitation
  • Chlorpromazine
  • Haloperidol + lorazepam
  • Olanzapine
Unknown Substance Intoxication Lorazepam +/- haloperidol (If severely agitated/hallucinating)

Medications

Drug Route Dose, Max Dose Onset, Duration Comments
Chlorpromazine IM, PO
  • 0.5 mg/kg/dose
  • Max 25-50 mg
  • Onset
    • PO 30-60 min
    • IM 15 min
  • Duration
    • 4-6 hrs
  • Repeat every 6 hrs
  • May cause QT prolongation, reduces seizure threshold
Diphenhydramine IV, IM, PO
  • 0.5-1 mg/kg/dose
  • Max 50 mg
  • Onset
    • PO 1-2 hrs
    • IM 5-15 min
  • Duration
    • 4-6 hrs
  • Consider early use
  • Repeat every 6 hrs
  • Avoid with delirium
  • Contraindications:
    • Prior paradoxical reaction
    • Current anticholinergic, TCA use
  • May cause QT prolongation
Haloperidol PO, IM
  • 0.025 mg/kg
  • Max 5 mg
  • Onset
    • PO 45-60 min
    • IM 20-30 min
  • Duration
    • 3-8 hrs
  • May repeat x 1 in 30 min
  • Full effect may take 30 min
  • Contraindications:
    • QT prolongation, anticholinergic intoxication, active seizure disorder
  • Side Effects:
    • QT prolongation, extrapyramidal symptoms
Lorazepam IV, IM, PO
  • 0.05 mg/kg
  • Max 2 mg
  • Onset
    • PO 20-30 min
    • IM 15 min
    • IV 5-10 min
  • Duration
    • PO, IM 6-8 hrs
    • IV 2 hrs
  • Repeat IV/IM every 20 min
  • Contraindications:
    • Disinhibition, delirium, respiratory instability
  • Side Effects:
    • Respiratory depression, disinhibition
  • If inadequate effect achieved after 2 doses or disinhibition occurs, consider addition of another therapeutic class
Midazolam IN
  • 0.3 mg/kg
  • Max 10 mg
  • Onset
    • 4-8 min
  • Duration
    • 20-30 min
 May repeat in 20 min
Olanzapine PO
  • < 30 kg: discuss with psychiatry
  • 30-60 kg: 5 mg
  • > 60 kg: 10 mg
  • Onset
    • 20-30 min
  • Duration
    • 24 hrs
  • Consent < 4 year old
  • Contraindications:
    • QT prolongation, anticholinergic intoxication, active seizure disorder
  • Side effects:
    • QT prolongation, orthostatic hypotension, dystonic reaction
  • IM olanzapine is restricted to behavioral health – see CHOP formulary. IM olanzapine should not be given any sooner than 3 hrs after lorazepam.
Risperidone PO
  • 15-29 kg: 0.25 mg
  • > 30 kg: 0.5 mg
  • Onset
    • 30-60 min
  • Duration
    • 24 hrs
  • Contraindications:
    • QT prolongation, anticholinergic intoxication, active seizure disorder
  • Side effects:
    • QT prolongation, tachycardia, hypertension

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

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). IV route is preferred.

If persistent symptoms:

  • Consider second dose of diphenhydramine
  • Consider benztropine PO/IM 0.05 mg/kg/dose for children > 3 years of age (not recommended for children < 3 due to serious adverse events such as severe anhidrosis or fatal hyperthermia)

Monitoring the Child

  • Baseline EKG, Continuous CR Monitor and pulse oximetry are optimal
  • Assess MS, HR, RR and effort, oxygen saturation
  • Please refer to standard operating processes