Acute Management of the Agitated Child

James Waxmonsky and Nina Muriel

1. Consider medical/organic/toxic causes

(consult or transfer to Pediatrics as needed)

Possibilities: med overdose (accidental/deliberate), recreational drug intoxication, withdrawal from prescribed/recreational drugs, metabolic abnormalities (including glucose level), elevated lead level (especially in <5 yrs), seizure disorder, …

2. Control environmental variables

a. Decrease stimulation: ask family/caregivers to leave if increasing agitation, or to join child if they are soothing.

b. Offer meal or snack: an irritable child may be a hungry child.

c. Consider other distractions: TV, video, toys, stories

3. Medicate

listed in order of preference; if in doubt, don’t hesitate to call Child Psych for assistance

a. Existing prn medication, or an additional dose of a standing sedating/calming medication (ask parents what has been helpful)

b. Benadryl elixir PO (IM if necessary) 25-50mg x 1 depending on size/age (general guideline 1.25mg/kg/dose, but check w/pediatrics for younger children if in doubt) – avoid if child has a history of paradoxical reaction

c. Clonidine 0.05mg-0.1mg PO x 1 depending on size/age

d. Risperdal 0.5mg- 1mg PO x 1 depending on size/age

e. If IM medication and rapid sedation required, consider Thorazine 12.5mg-25mg x 1

f. If acutely agitated adolescent 16 yrs or older, treat like smaller adult with PO/IM: Haldol 2mg-5mg, Ativan 1mg, Benadryl 50mg.

4. Use physical restraints

a. Usually need emergency meds as well

b. Four point locked leathers only as needed

c. Ask family to leave during process of restraining.

d. See DMH forms for guidelines for various ages.