Pediatric emergency medicine trisk 4169 4169
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current dose or an increased dose of one of their medications may be
appropriate.
The choice of medication(s) should be based on the level of the patient’s
agitation or dangerousness. For mild agitation, antihistamines, alphaadrenergic agents such as clonidine, or benzodiazepines are the first line of
treatment. For moderate to severe agitation, possible medications include
benzodiazepines, alpha-adrenergic agents, typical antipsychotics, and
atypical antipsychotics. The ED physician should choose between these
different agents on the basis of the degree of agitation, the patient’s
willingness to take oral medications, and the medication side-effect profile.
The newer, atypical antipsychotics may have fewer adverse effects than
traditional antipsychotics (e.g., extrapyramidal symptoms [EPS], dystonic
reactions, neuroleptic malignant syndrome [NMS]). However, their use in
the ED may be limited in that ziprasidone, aripiprazole, and olanzapine are
the only atypical antipsychotics that have an immediate release parenteral
form, and there is limited experience using these medications in pediatric
populations. The rapidly dissolving oral forms of olanzapine, aripiprazole,
and risperidone may be an acceptable alternative to physicians and patients.
For patients with severe agitation, rapid tranquilization is the strategy
favored by many experts. In this approach, a dose of a benzodiazepine and
an antipsychotic are given simultaneously. These medications can be given
orally but often will need to be given parenterally. If needed, subsequent
doses can be given 60 and 120 minutes after the initial dose. This approach
may be more effective than a single agent alone and may result in the use of
less total medication. A variation of this approach is to alternate
medications, that is, give a dose of one medication and reassess the patient
30 minutes later. If the patient’s agitation has not sufficiently resolved, a
dose of the other medication is given. The patient is reassessed every 30
minutes and redosed with the appropriate medication as needed.
Both haloperidol and the atypical antipsychotics, ziprasidone to the largest
degree, may cause QTc prolongation. As such, patients receiving these
medications should be closely monitored. There is no consensus regarding
the prophylactic use of benztropine (1 mg oral [PO]/intramuscular [IM]) or
other anticholinergic agents in patients receiving antipsychotics. Some
experts favor giving such medications to all patients receiving
