Sedation for the agitated adolescent

Cite this article as:
Tessa Davis. Sedation for the agitated adolescent, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.8023

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)

PAC Conference 2015 – Morris on the difficult adolescent patient

Cite this article as:
Davis, T. PAC Conference 2015 – Morris on the difficult adolescent patient, Don't Forget the Bubbles, 2016. Available at:
https://dontforgetthebubbles.com/pac-conference-2015-morris-on-the-difficult-adolescent-patient/

We have teamed up with APLS to share the videos from their Paediatric Acute Care Conferences. These videos have never been open access before, so if you weren’t able to attend the conferences, then now’s your chance to catch up.

The PAC Conference is run each year by APLS and consists of presentations on a range of topics relevant to paediatric acute and critical care.

Anorexia nervosa

Cite this article as:
Emma MacDonald. Anorexia nervosa, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.2602

A fourteen-year-old girl presents to the emergency department following three months of weight loss.  She has refused all food and water for the past five days.  She complains of feeling dizzy, cold and tired. On examination, she has a temperature of 35.8, HR 42, BP 85/40, RR 20.  Her weight is 39kg and her height is on the 50th centile for her age.  She is cold peripherally with thin lanugo hair. The physical exam is otherwise normal.

Definitions

  • Anorexia nervosa – body weight 15% below expected for age and height, fear of gaining weight with a distorted perception of body size, and amenorrhoea
  • Bulimia nervosa – recurrent episodes of binge eating and inappropriate compensatory behaviour to prevent weight gain
  • Eating disorder not otherwise specified (ED-NOS)– disturbed eating patterns that do not meet the above criteria

Epidemiology

Anorexia affects 0.5-1% of adolescent females while 2-5% have bulimia or ED-NOS.

Risk factors

  • Genetic: female sex, first degree relative with an eating disorder or mental illness (strong predictor for young children)
  • Medical: type 1 diabetes, comorbid psychiatric disorder – particularly OCD in anorexia and alcoholism in bulimia
  • Social: activities which emphasize leanness, e.g. dance, modelling, wrestling; criticism of body weight from peers; unrealistic media portrayal of women
  • Family: high parental expectations, difficulty managing conflict, anxiety/perfectionist traits, weight/appearance important to parents

History

  • Amount of weight loss/poor gain, rate of weight loss
  • Estimated dietary intake, acute food refusal
  • Vomiting, use of laxatives/diuretics, excessive exercise
  • Amenorrhoea, dizziness, palpitations, cold intolerance
  • Thoughts around body image
  • Mental health exam

Examination

  • Vital signs – postural BP drop, bradycardia/tachycardia, hypothermia
  • Height, weight, head circumference, pubertal status, assessment of muscle mass/fat stores –  plot centiles and calculate BMI
  • Skin – pallor, dry scaly skin, lanugo (fine, downy) hair, acne, eczematous scaling due secondary to zinc deficiency
  • Hair – thinning, brittle hair; trichotillomania
  • Stigmata of purging – bruised knuckles, dental enamel erosion, markers of self-harm
  • Peripheral, pretibial and sacral oedema
  • Careful general examination looking for evidence of cardiac, renal or hepatic compromise, and dehydration – if shocked may require intensive care level support
  • Mental state – often significant cognitive impairment, poor reasoning, and poor emotional processing

Investigations

  •  Bloods – Full blood count, urea and electrolytes, glucose, creatinine, eGRF, calcium, phosphate, zinc,  liver function, thyroid function, LH/FSH/oestrodiol, venous blood gas (vomiting induced metabolic alkalosis)
  • ECG –  bradycardia, ventricular tachyarrhythmias, low voltage QRS, P and T waves, presence of U waves, and QTc prolongation (associated with increased risk of arrhythmias and sudden death)
  • DEXA scan

What are the criteria for hospitalisation?

  • Medical instability –  HR <50, BP <80/50, hypothermia, hypokalemia, hypophosphataemia, hypoglycemic, neutropenia, hypoalbuminia (rare and should prompt a search for infection), dehydration, and cardiac/renal/hepatic compromise
  • Rapid weight decline, food refusal, uncontrolled bingeing/purging
  • Co-morbid psychiatric emergency, particularly suicidal ideation
  • Not responding to outpatient treatment

Management: requires a multidisciplinary approach.

  • Weight restoration through graduated re-feeding, often starting with continuous NG feeds, aiming for a gain of 0.5-1 kg/week. Dietitian input crucial with twice-weekly weighing.
  • Behavioural/ward management – bed rest initially with restricted leave;  may require bathroom supervision; meal supervision; restricted activity; discourage parents from bringing food and medications/supplements in the early phases of recovery
  • Medical –  correct electrolyte abnormalities prior to refeeding; commence phosphate, thiamine and multivitamin supplements; daily examination and bloods until medically stable; routine DEXA; bone age in those with primary amenorrhoea
  • Medications – olanzapine reduces hyperactivity and overvalued ideas
  • Psychological –  family therapy is more effective than individual therapy in the paediatric population
  • Physiotherapy – to address exercise motivation, relaxation strategies, graded activity, constipation management. Massage, yoga, and meditation may be beneficial
  • Discharge –  depending on hospital guidelines patients may be transferred from medical to psychiatric services when medically stable.  Patients should reach 90% of their ideal body weight prior to discharge home.

Complications

Profound medical instability is more likely in children <13 years especially if prepubertal.

What about refeeding syndrome?

  • Occurs due to electrolyte and fluids shifts due to stimulation of metabolism following refeeding.  Characteristically results in hypophosphatemia, hypomagnesiumia, and hypokalemia
  • Risk factors: rapid weight loss, very low body weight low phosphate/magnesium/potassium prior to refeeding, acute food refusal
  • Features: weakness, fatigue, dyspnoea, peripheral oedema, hallucinations, seizures, arrhythmias
  • Management: Bed rest, multivitamins including phosphate, thiamine, and zinc, potassium replacement, reduce nutrition, cardiac monitoring

Cardiovascular effects

  • Physiological bradycardia is expected, telemetry should be considered for HR <40
  • Sudden increase in HR to normal range can be a red flag of impending heart failure
  • Decreased cardiac mass results in reduced exercise capacity, fatigue and occasionally mitral valve prolapse

Endocrine effects

  • Hypoglycemia can occur in the early morning and post-prandially due to low glycogen stores and abnormal insulin secretion
  • Sick euthyroid with normal TSH.  Thyroid replacement not beneficial
  • Amenorrhoea may not resolve in 10-30% despite weight gain
  • Osteoporosis occurs in 30% of patients. No evidence for treatment with medications/supplements
  • Young patients may not reach height potential or peak bone mass

Gastrointestinal effects

  • Gastroparesis/bloating can be managed with liquid food supplements, smaller meals, and metoclopramide
  • Constipation should be managed conservatively with fluids and fibre. Laxatives are a last resort

Renal effects

  • Renal impairment can occur due to electrolyte imbalances, acute kidney injury (more likely if bingeing/purging), chronic renal impairment and nephrolithiasis
  • eGFR should be measured.  Creatinine may be within the normal range when renal impairment is present in patients with low muscle mass

Haematological effects

  • Cytopenias can occur; a high index of suspicion for infection is required as fever and tachycardia may be absent

What’s the prognosis?

  • The paediatric population has a better prognosis than adults.
  • Early hospitalization may prevent multiple hospitalisations and a chronic course.
  • 50% good outcome, 25% intermediate, 25% poor.
  • 1/5 mortality rate at two decades from medical complications or suicide.
  • Predictors of poor prognosis include: very low BMI, automated vomiting, long illness duration, failed treatment, concurrent psychiatric diagnoses, strong fears of maturing.

Selected references

Australian and New Zealand clinical practice guidelines for the treatment of anorexia nervosa.  Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for Anorexia Nervosa.

Foreman S. Eating disorders : Epidemiology, pathogenesis, clinical features and course of illness. Uptodate.com

Field A., Javaras K., Aneja P., Kitos N, Camargo C., Taylor C, & Laird N. Family, peer and media predictors of becoming eating disordered. 2008. Arch Pediatri Adolec Med. 162 (6) : 574-579.

Gavin R. Starship Hospital Anorexia guidelines

Hudson L., Nicholls D., Lynn R & Viner R.  Medical instability and growth of children and adolescents with early onset eating disorders.  2012.  Arch Dis Child 2012 ; 97 : 779-784.

Mehler P.  Anorexia nervosa in adults and adolescents: Medical complications and their management.  Uptodate.com

Mehler P. Anorexia nervosa in adults and adolescents: The refeeding syndrome.  Uptodate.com.

Talking to teens

Cite this article as:
Henry Goldstein. Talking to teens, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.3270

The last patient presented in morning handover is Buffy, 14, who was admitted overnight with pyelonephritis. The admitting registrar couldn’t get much more than flank pain and a wee out of her overnight. Your resident rolls her eyes, quietly muttering “Not another teenager!”…