For paediatric ED doctors who come from a paediatric training background, dealing with the agitated adolescent can be very 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.
This post is a brief overview of suggested management and is based on the NSW Health guidelines for managing patients with acute severe behavioural disturbance in ED, along with some tips from Joanne’s Morris’ PAC Conference talk.
1. Aim for verbal de-escalation. Talk to your patient in a non-threatening way.
2. Aim for 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 mins or the behaviour is worsening, then will need to consider IV options
3. 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 as above
- 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)
It can be rather challenging getting a sats probe on an angry teen and I get a bit exasperated when people suggest that sats need to be recorded immediately after drug administration. Pink, warm, breathing/ swearing ? is more realistic. Once they are calm/ sleeping, you have a better chance but please remember the hard plastic sats probes are very uncomfortable left on and should be frequently moved.
Remember the risk of precipitating seizures/status with flumazenil in patients that chronically use benzos. Something to consider in this population.
Honestly I would go with Geodon / ziprisadone as first line IM – unless it is not available in your healthcare system
I’ve never heard of it being used in Australia, but I will ask around – thanks Brad.