Behavioral Health Issues — Medications for Violent Children — Clinical Pathway: Emergency

Behavioral Health Issues Clinical Pathway — Emergency Department

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

Aim is to administer medications as quickly as possible 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.

Medications

Drug Route Dose, Max Dose Onset, Duration Comments
Lorazepam IM, IV
  • 0.1 mg/kg/dose
  • Max 2 mg
  • Onset
    • IM 15 min
    • IV 5-10 min
  • Duration
    • IM 6-8 hrs
    • IV 2 hrs
  • May repeat IV/IM every 20 min
  • Contraindications:
    • Disinhibition, delirium, respiratory instability
  • Side Effects:
    • Respiratory depression, disinhibition
  • May be ineffective for acute delirium
  • If inadequate effect, consider addition of another therapeutic class
Haloperidol IM, IV
  • 0.075 mg/kg
  • Max 5 mg
  • Onset
    • 10-20 min
  • Duration
    • 3-8 hrs
  • Full effect may take 30 min
  • If IV ordered, EKG necessary before initiation
  • Contraindications
    • QT prolongation, anticholinergic intoxication, active seizure disorder
  • Side Effects
    • QT prolongation, extrapyramidal symptoms
Ketamine IM, IV
  • IM 2-4 mg/kg
  • Max 200 mg
  • IV 1-1.5 mg/kg
  • Max 100 mg
  • Onset
    • IM 3-5 min
    • IV 30 sec
  • Duration
    • IM 12-15 min
    • IV 5-10 min
  • Contraindications:
    • Hypertensive urgency, increased ICP, phencyclidine poisoning
  • Obtain IV access and benzodiazepines and/or antipsychotic medications may be titrated at signs of lightening
  • Side effects:
    • Tachycardia, hypertension

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