Management of Acute Agitation and Aggression in Children and Adolescents with Pro Re Nata Oral Immediate Release Antipsychotics in the Pediatric Emergency Department

Yip, Lisa; Aeng, Elissa S Y; Elbe, Dean

doi:10.1089/cap.2019.0171

Cited by 8 publications

(8 citation statements)

References 21 publications

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“…Although this remains a valid concern, in reality mildly agitated patients may be able to tolerate pro re nata oral medications for agitation control. 33 …”

Section: Discussionmentioning

confidence: 99%

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The agitated pediatric patient located in the emergency department: The APPLIED observational study

et al. 2022

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Objectives Focused research on pediatric agitation is lacking despite being a common mental and behavioral health (MBH) emergency. Prevalence of pediatric agitation remains unknown, and prior reports may have underestimated the rate of restraint use for pediatric agitation. This is the largest study to provide a focused evaluation of the prevalence and predictors of pediatric agitation and restraint use as well as the emergency department (ED) length of stay (LOS) and admission rates for agitated patients. Methods We reviewed records of patients aged ≤18 years with MBH needs who visited the pediatric ED of a tertiary care hospital during a 3‐year‐period. We identified and ascertained agitated/aggressive patients using documented signs/symptoms, International Classification of Diseases, Tenth Revision codes, and Behavioral Activity Rating Scale scores. We performed descriptive and multivariable analyses using SAS 9.4 (SAS Institute). Results Of 10,172 patients with MBH needs, 1408 (13.8%) were agitated/aggressive. Of these (n = 1408), 63.7% were boys, and the mean age was 11.9 years. Among agitated patients, the prevalence of restraint use was 28.7%, with a predominance of pharmacologic restraint with atypical antipsychotics. Non‐Hispanic Blacks were more likely to be agitated (adjusted odd ratio [aOR], 1.8; 95% CI, 1.2–2.7), but not restrained (aOR, 0.8; 95% CI, 0.3–1.8). Predictors of restraint use include history of attention deficit hyperactivity disorder (aOR, 2.2; 95% CI, 1.5–3.3), autism (aOR, 2.9; 95% CI, 1.9–4.5), conduct disorder (aOR, 1.7; 95% CI, 1.2–2.5), psychosis (aOR, 14.3; 95% CI, 2.5–271.8), and substance use/overdose states (aOR, 1.9; CI, 1.2–3.2). Restrained agitated patients had longer ED LOS (8.4 vs 5.0 hours; P < 0.0001) and higher admission rates (aOR, 2.6; 95% CI, 2.0–3.5). Depression (aOR, 0.4; 95% CI, 0.3–0.5) and suicidality (aOR, 0.2; 95% CI, 0.1–0.3) were protective against agitation and restraint use. Conclusion Prevalence of acute agitation and restraint use in pediatric EDs may be much higher than previously reported. Predictors of acute agitation and restraint use among MBH patients were consistent with prior reports. Restrained agitated patients had longer ED LOS and higher admission rates.

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“…Although this remains a valid concern, in reality mildly agitated patients may be able to tolerate pro re nata oral medications for agitation control. 33 …”

Section: Discussionmentioning

confidence: 99%

“…Use of oral psychotropic medication was not considered as pharmacologic restraint due to uncertainties about the indication for such medications. Although this remains a valid concern, in reality mildly agitated patients may be able to tolerate pro re nata oral medications for agitation control 33 …”

Section: Discussionmentioning

confidence: 99%

The agitated pediatric patient located in the emergency department: The APPLIED observational study

et al. 2022

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“…medication use as helpful. 2,3,125,126 De-escalation techniques for managing impairing emotional outbursts are even less well studied, and the data so far are not encouraging, at least in adults. 127 Although a number of initiatives describe strategies to diminish seclusion and restraint during inpatient care, these efforts generally do not assess the impact on outbursts, aggression, or long-term outcomes.…”

Section: Acute Treatment Of Impairing Emotional Outburstsmentioning

confidence: 99%

“…utbursts in children and adolescents are a major public health dilemma and are responsible for a substantial number of referrals to emergency departments, 1,2 inpatient units, [3][4][5] schools, 6 outpatient clinics, [7][8][9] and residential treatment settings. 10 Yet, as outbursts are transdiagnostic and variably defined, they are difficult to track and study across different systems of care.…”

mentioning

confidence: 99%

Narrative Review: Impairing Emotional Outbursts: What They Are and What We Should Do About Them

Carlson

Singh

Amaya-Jackson

et al. 2023

Journal of the American Academy of Child & Adolescent Psych

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“…Oral medications, whenever possible, are the preferred route of delivery for medication to treat acute agitation 6 . However, response rates to oral medications are generally low, varying from 30% (loxapine) to 53% (quetiapine) within 60 min of administration among adolescents with acute agitation in the ED 7 . For children who fail to respond to oral medications or who refuse to take them, intramuscular or intravenous medications may be used to manage acute agitation.…”

Section: Background and Importancementioning

confidence: 99%

A systematic review of the effectiveness and safety of droperidol for pediatric agitation in acute care settings

Ramsden

Pergjika

Janssen

et al. 2022

Academic Emergency Medicine

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Objective: Agitation in children in acute care settings poses significant patient and staff safety concerns. While behavioral approaches are central to reducing agitation and oral medications are preferred, parenteral medications are used when necessary to promote safety. The goal of this systematic review was to evaluate the effectiveness and safety of an ultra-short-acting parenteral medication, droperidol, for the management of acute, severe agitation in children in acute care settings. Methods:A systematic review of randomized controlled trials, observational studies, and case series/reports examined the effectiveness and safety of parenteral droperidol for management of acute agitation in patients ≤21 years old in acute care settings.Effectiveness outcomes included time to sedation and need for a subsequent dose of medication. Safety outcomes were adverse effects such as QTc prolongation, hypotension, respiratory depression, and dystonic reactions. Results: A total of 431 unique articles were identified. Six articles met inclusion criteria: two in the prehospital setting, one in the emergency department, and three in the inpatient hospital setting. The articles included a prospective observational study, three retrospective observational studies, and two case reports. The largest study reported a median time to sedation of 14 min (interquartile range 10-20 min); other studies reported a time to sedation of 15 min or less. Across studies, 8%-22% | 1467 RAMSDEN Et Al. BACKG ROUND AND IMP ORTAN CE Acute agitation in children in the hospital setting poses a serious safety risk to patients and staff. In a national survey of pediatric How to cite this article: Ramsden SC, Pergjika A, Janssen AC, et al. A systematic review of the effectiveness and safety of droperidol for pediatric agitation in acute care settings. Acad

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Management of Acute Agitation and Aggression in Children and Adolescents with Pro Re Nata Oral Immediate Release Antipsychotics in the Pediatric Emergency Department

Cited by 8 publications

References 21 publications

The agitated pediatric patient located in the emergency department: The APPLIED observational study

The agitated pediatric patient located in the emergency department: The APPLIED observational study

Narrative Review: Impairing Emotional Outbursts: What They Are and What We Should Do About Them

A systematic review of the effectiveness and safety of droperidol for pediatric agitation in acute care settings

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