Sedation for the agitated adolescent

For paediatric ED doctors who come from a paediatric training background, dealing with agitated adolescents can be stressful. There is so much more to managing the agitated adolescent than just drugs, but sometimes sedation is necessary. As we are not used to sedating children in this way, choosing drugs and doses can be difficult.

In paediatric emergency care, addressing the challenge of adolescent agitation is a complex and evolving task. Dr Elyssia Bourke, based at Ballarat Base Hospital, is actively engaged in this area through her ongoing PhD research. Although this research is still in progress, it promises to shed light on effective strategies for managing these difficult situations. Dr Bourke’s work is not only about deepening academic understanding but also about forging practical approaches to help healthcare professionals navigate the nuanced and often uncertain waters of adolescent care in emergency settings.

Understanding adolescent agitation

In paediatric emergency departments, the management of agitated or disturbed adolescents, while not an everyday event, poses unique challenges. These infrequent yet significant encounters introduce a complexity that intertwines medical and psychological thinking. Tackling these cases goes beyond standard medical intervention; they call for a nuanced understanding of adolescent behavioural and psychological dynamics. In these scenarios, healthcare professionals must combine medical expertise with insight into the psychological underpinnings to offer effective and compassionate care.

The Case of Ashley Smith: A Stark Reminder

The story of Ashley Smith, a young Canadian girl, serves as a stark reminder of the complexities of managing adolescent behavioural disturbances in paediatric emergency settings.

Ashley’s journey began with behavioural changes in her early teens, leading to minor offences. Diagnosed with ADHD, a learning disorder, and personality disorders, her path was fraught with self-harm attempts and over 800 incidents in custody.

Despite being under suicide watch at a federal prison, Ashley’s self-strangulation was tragically not intervened in time by the guards. This led to her death at 19, an outcome ruled as homicide at inquest, indicating others’ contribution to her demise.

Her case, marked by systemic failures in handling mental health issues within the correctional system, resulted in significant public outcry and 104 recommendations for change.

Underlying Causes of Agitation

In addressing behavioural disturbances in young people, understanding the underlying causes is key for effective management. These include:

• Mental Health Disorders: Including a range of conditions from mood disorders to severe psychiatric illnesses.
• Psychosocial Factors: Family dynamics, social pressures, and environmental stressors.
• Neurodevelopmental Disorders: Notably autism and ADHD, which can lead to unique behavioural challenges.
• Substance Use: Particularly relevant in older teenagers, though less common in younger adolescents.
• Organic Illnesses: Often overlooked, these can manifest as behavioural changes.

Recent studies have indicated a significant rise in mental health disorders among young people. Research conducted by Harriet Hiscock and colleagues reveals a notable increase: a 46% escalation in mental health disorders from 2008 to 2015, compared to a 13% increase in physical health disorders

Impact of Adverse Childhood Experiences (ACEs)

Adverse Childhood Experiences (ACEs) play a critical role in the development of behavioural disturbances in adolescents. ACEs, which encompass a range of experiences from physical and emotional abuse to household dysfunction, significantly influence a child’s emotional and behavioural development. By acknowledging the profound effect of these early experiences, healthcare professionals are better equipped to provide compassionate, informed, and effective care, tailored to the unique needs of each adolescent facing behavioural challenges.

The PEACHY Studies

The PEACHY trials, standing for Pharmacological Emergency Management of Agitation in Children and Young People, represent a significant stride in paediatric healthcare research. These studies are focused on identifying the most effective and least harmful medication treatments for agitated adolescents, a group often challenging to manage in clinical settings. The importance of this research lies in its potential to fill a notable gap in evidence-based management practices, offering better and safer treatment options for this particularly vulnerable patient group.

These suggested medications are based on the NSW Health guidelines for managing patients with acute severe behavioural disturbance in the emergency department

Verbal De-escalation of the Agitated Teen

A crucial aspect in managing agitated adolescents is mastering verbal de-escalation. This approach involves using calm, empathetic communication to understand and address the underlying issues triggering the agitation. Key strategies include active listening, maintaining a non-threatening body language, and using a reassuring tone. By validating the adolescent’s feelings and offering choices where possible, we can often diffuse tension effectively.

Five key steps involved in verbal de-escalation are:

1. Remain Calm: Keep your voice calm and controlled, and maintain a non-threatening posture.
2. Active Listening: Show that you are listening attentively and empathetically to understand their perspective.
3. Validate Feelings: Acknowledge the adolescent’s emotions without judgment.
4. Offer Choices: Give them a sense of control by providing options.
5. Seek Resolution: Aim for a peaceful resolution by collaboratively identifying the core issue and discussing potential solutions.

Verbal de-escalation not only helps in avoiding the need for physical intervention but also fosters a therapeutic relationship, crucial for successful treatment outcomes in these sensitive situations.

Oral sedation if the patient will co-operate

Diazepam 0.2mg/kg up to 10mg orally – up to two doses

OR

Olanzapine 5mg (if <40kg) and 10mg (if >40kg) – one dose only – acts within 20 minutes

OR

Risperidone 0.02-0.04mg/kg up to 2mg – one dose only

When using olanzapine, you can use quetiapine as an adjunct – start with 25 mg

Olanzapine and quetiapine can also be used for adolescents with eating disorders who are anxious about eating or NG insertion

Olanzapine can also be used in children with autism and can be helpful if blood tests are necessary

If the patient isn’t settling in 45 minutes or the behaviour is worsening, then consider IV options

Parenteral sedation

Droperidol 0.1-0.2mg/kg IM (max 10mg) – (some people would go with the higher dose to avoid having to repeat the injection)

If the patient does not settle within 15 minutes, then give a second dose of droperidol

If the patient still does not settle, you will need to consider ketamine (4mg/kg IM or 1mg/kg IV) or midazolam (0.1-0.2mg/kg IM/IV – max of 20mg in 24 hours)

You will need to monitor the patient (on a SPOC chart) post each dose of parenteral sedation:

• 5 minutely for 20 minutes
• Then 30 minutely for 2 hours
• Watch for respiratory depression with benzodiazepines – if there is then you can use flumazenil 5-10 mcg/kg titrated to respiratory rate (no consciousness)
• Watch for acute dystonia with anti-psychotic drugs – treat with benztropine 0.02mg/kg IV)

References

Hiscock, H., Mulraney, M., Efron, D., Freed, G., Coghill, D., Sciberras, E., Warren, H. and Sawyer, M., 2020. Use and predictors of health services among Australian children with mental health problems: A national prospective study. Australian Journal of Psychology, 72(1), pp.31-40.