Pediatric emergency medicine trisk 4168 4168
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physical restraint, as well as psychological harm (e.g., feelings of shame
and/or of being personally violated, frank symptoms of posttraumatic stress
disorder [PTSD]) have all been reported. Both the Centers for Medicare and
Medicaid Services (CMS) and The Joint Commission mandate that
healthcare institutions monitor their use of these methods, and develop and
maintain protocols in which patients are treated in the least restrictive
manner possible. ED physicians and staff thus need to be familiar with their
institution’s restraint policies, practices, and guidelines.
Emergency Agitation Medications. Medications can be a useful tool in
helping to manage unsafe behaviors in the pediatric emergency setting and
can be used to treat agitation related to the patient’s underlying condition.
This is distinct from the concept of chemical restraint, which CMS defines
as “a medication used to control behavior or to restrict a patient’s freedom of
movement and not standard treatment for the patient’s medical or psychiatric
condition.” Although medications are extensively used to treat agitation and
there are numerous published studies of their use in the adult ED and
psychiatric settings, there is scant literature on their use in pediatric
populations. In addition, as is the case with many medications and pediatric
populations, few of the medications have FDA-approved indications for
treating agitation associated with pediatric mental health conditions, and
none are approved for the purpose of emergent treatment of agitation in
children and adolescents. Any medication used for emergency agitation is
thus an “off-label” use of the medication. Although there are multiple
published studies using the oral forms of the newer, atypical antipsychotics
in children and adolescents, there is scant published evidence regarding the
parenteral forms of these medications. These limitations aside, it is widely
held by experienced psychiatric and pediatric emergency physicians that
these medications are both safe and efficacious. Adverse reactions to these
medications in the acute setting are rare and usually easily managed when
they arise.
Medications that are commonly used for agitation and the appropriate
initial dose of these medications are listed in Table 126.8 . It is acceptable to
round the dose to the nearest half or whole milligram or the nearest whole
pill dose. Alternatively, for patients already on psychiatric medications, their
