Pediatric emergency medicine trisk 4203 4203
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After acute stabilization, the prognosis of the child depends largely on the
restoration or creation of a safe and dependable family support system.
Referral for outpatient family therapy should be made unless the child
requires psychiatric hospitalization for further evaluation or treatment. In the
absence of adequate family support, some of these children may eventually
require foster placement, residential treatment, or other placements.
Schizophrenia. The management of an acute schizophrenic episode requires
psychiatric consultation. Patients with suicidal or homicidal ideation require
psychiatric hospitalization. Psychotic patients from disorganized home
environments may also need to be hospitalized for initial treatment. In
general, the approach to the psychotic patient in the ED depends on the
condition of the patient and the anticipated site of the ongoing treatment. For
agitation and dangerous thoughts or behaviors, approaches include
reassurance and a quiet setting, psychotropic medication, and/or physical
restraint. The patient’s vital signs, general condition, and possible side
effects should be monitored frequently. If the patient does not respond to
medication, inpatient psychiatric hospitalization is necessary. If significant
improvement occurs, suicidality and homicidality are absent, and side effects
do not occur, the patient can be considered for discharge to outpatient
psychiatric treatment with careful follow-up, as long as the parents or
caregivers are well organized, appreciate the child’s condition, and feel
capable of managing the child at home.
The original class of antipsychotic medications, referred to as typical
antipsychotics, exert their influence primarily on dopaminergic neurons. The
newer class of antipsychotic medications referred to as atypical
antipsychotics, is now the mainstay of treatment. These medications affect
multiple neurotransmitter systems, most frequently dopamine and serotonin.
In this class are risperidone (Risperdal), clozapine (Clozaril), olanzapine
(Zyprexa), aripiprazole (Abilify), quetiapine (Seroquel), ziprasidone
(Geodon). Recent additions that are not yet commonly used in pediatric
patients include Iloperidone (Fanapt), lurasidone (Latuda), asenapine
(Saphris), and paliperidone (Invega). Clinical advantages offered by this new
class of medications include clinical effects on the “positive symptoms” of
schizophrenia (e.g., an improvement in the ability of the individual to relate
to the environment and to others, not just a positive effect on hallucinations
