Case

A 9-year-old boy with a history of oppositional defiant disorder, as well as prior admissions to a psychiatric hospital for behavioral concerns, presents to the Emergency Department (ED) of an academic children’s hospital with acute agitation. The patient is brought to the ED via ambulance by emergency medical services and police. The patient is verbally aggressive and attempts to hit, bite, and spit on hospital staff. The patient resists repeated attempts at verbal de-escalation and refuses oral lorazepam. A physician orders olanzapine, which is administered intramuscularly into the patient’s right deltoid by a registered nurse. The patient calms enough to be moved into a hospital stretcher. A history is obtained, and a physical exam is performed. The patient is evaluated by psychiatry and is admitted for further management.

Diagnosis

Acute Agitation

Discussion

ED presentations for mental and behavioral health (MBH) concerns among children are rising nationally. [1] Some of these children exhibit aggressive or agitated behaviors in the ED that pose a risk of physical harm to themselves, their families, and to hospital staff. [2] The use of restraints – which are often categorized as either physical or pharmacologic – to moderate dangerous behaviors and facilitate the evaluation and treatment of these children is common, with one study showing that 28.8% of agitated children presenting to the ED with a MBH chief complaint are subjected to restraint use. [3] Pharmacologic restraint accounts for the majority of restraint use, with a smaller proportion of children undergoing physical restraint, or both pharmacologic and physical restraint. [3]

The Centers for Medicaid and Medicare Services (CMS) defines a restraint as:

“…any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his/her arms, legs, or head freely; or a drug or medication when it is used as a restriction to manage the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition.” [4]

CMS goes on to require:

“Restraint… may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. The type or technique of restraint… used must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm. [4]

CMS does not make recommendations or evaluate the appropriateness of specific medications used as pharmacologic restraints.  Choice of medications tends to be hospital and healthcare provider dependent, though physician groups have weighed in. In 2019, the American Association for Emergency Psychiatry (AAEP) published consensus guidelines of best practices for evaluating and treating agitated children in the ED. [5] The guidelines recommend an “individualized, multidisciplinary, and collaborative” approach at treating agitation and stress that the “etiology of agitation should drive the choice of treatment.” They argue that agitation is a symptom, like pain, of an underlying condition or disease process that must be addressed. Clear, empathetic communication strategies, distraction, offering comfort items or food and drink, and a multitude of other non-pharmacologic measures should first be attempted to calm the aggressive or agitated child. [5]

When reasonable non-pharmacologic de-escalation strategies have been exhausted, the AAEP advises that pharmacologic restraints can be considered to “1) target the underlying cause of distress and 2) calm the patient sufficiently for rapid assessment and treatment.” The guidelines suggest considering an extra dose of a home medication before selecting a new one, as home medications are generally more familiar to children, better tolerated, and pose less risk of drug-drug interaction. Any medication that poses a significant risk of over-sedating a child should be avoided, as children who cannot actively participate in their own ED evaluation cannot be rapidly assessed and treated. [5]

The AAEP stresses that no single medication or combination of medications is appropriate for use in all aggressive or agitated children who present to the ED. Children presenting with acute agitation secondary to substance intoxication, delirium, or in the context of developmental delay, autism spectrum disorder (ASD), or an underlying psychiatric diagnosis should be managed uniquely. It recommends that medications should be administered orally whenever possible. Intravenous (IV) medications can be considered in patients with IV access. Only when these options are refused or not feasible should intramuscular (IM) medications be administered. Diphenhydramine, benzodiazepines such as lorazepam, and alpha-2 agonists such as clonidine tend to induce milder sedating effects and should be considered before alternatives, particularly in cases of mild to moderate agitation. Despite their reputation as being quite safe in the hospital setting, all sedative medications carry a significant side effect risk profile. Diphenhydramine and benzodiazepines can cause paradoxical disinhibition, while clonidine can cause hypotension. [5]

For severe agitation, the AAEP recommends consideration of neuroleptics. Olanzapine is generally favored over either haloperidol or risperidone alone as it can be more sedating, with fewer cardiac adverse events such as QT prolongation or extrapyramidal symptoms. Olanzapine should not be co-administered with benzodiazepines secondary to risk of respiratory depression. If a medication is administered and ineffective, a second dose of that same medication is generally preferred to administering a different medication, given risk for potentially dangerous drug-drug interactions. An important exception to this is combining haloperidol and lorazepam, which is common practice and generally considered safe.  There was consensus that ketamine, barbiturates, and opioids should not be used for the treatment of acute agitation. [5]

Despite these recommendations, it is crucial that the medical staff who order, administer or otherwise partake in the physical or pharmacologic restraint of a child recognize that these interventions are not benign, and that important disparities exist in restraint use among children. Studies have shown that Black children experience more frequent physical [6] and pharmacologic [7] restraint use in the ED. Male children are more likely to be restrained than female children, as are children using public insurance compared to those using private insurance. [6] Another study showed that children with ASD were more than twice as likely to be restrained during their hospitalization than children without ASD, and experience more than four times as many restraint events over the course of their hospitalization. [8] While CMS requires frequent, comprehensive training of hospital staff on proper indications for restraint use, including “training in how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia),” it does not mention or require training on these well-demonstrated inequities. [4] Recognizing that these disparities in restraint use exist is crucial to combatting biases and ensuring equitable treatment of our patients.

A December 2023 commentary in Pediatrics titled Envision Zero: A Path to Eliminating Restraint Use in Children’s Hospitals concludes that “we must come together to collectively define restraint use, measure its scope, and design equitable interventions toward eliminating the use of physical and pharmacologic restraint.” [9] There is hope. A major study of over 500,000 ED visits found that hospitals with a greater volume of pediatric presentations for MBH complaints had lower rates of pharmacologic restraint use, suggesting that staff at these hospitals are more successful in employing non-pharmacologic de-escalation strategies compared to staff at lower volume hospitals. [7] Lessons could be learned from these hospitals regarding their de-escalation techniques, required training, and other strategies to minimize restraint use whenever possible as we Envision Zero.

Take Aways

• The etiology of agitation should drive the choice of treatment and non-pharmacologic measures should first be attempted to calm the aggressive or agitated child.

• Diphenhydramine, lorazepam, and clonidine should be considered before neuroleptics for mild to moderately agitated patients

• Olanzapine can be considered for severely agitated patients

• All sedative medications have a significant side effect risk profile, including death

• Significant racial, economic, and other disparities exist in restraint use among children

Author: Taylor Marquis, MD, is a third-year emergency medicine resident at Brown Emergency Medicine Residency.

Faculty Reviewer: Michelle Myles, MD, is a current attending/clinician educator at Brown Emergency Medicine.

References

1. Bommersbach TJ, McKean AJ, Olfson M, Rhee TG. National Trends in Mental Health-Related Emergency Department Visits Among Youth, 2011-2020. JAMA. 2023 May 2;329(17):1469-1477.

2. Malas N, Spital L, Fischer J, et al. National Survey on Pediatric Acute Agitation and Behavioral Escalation in Academic Inpatient Pediatric Care Settings. Psychosomatics. 2017;58(3):299-306.

3. Manuel MM, Feng S-Y, Yen K, Patel F. The agitated pediatric patient located in the emergency department: The APPLIED observational study. JACEP Open. 2022; 3:e12766.

4. 42 Code of Federal Regulations 482.13.

5. Gerson R, Malas N, Feuer V, Silver GH, Prasad R, Mroczkowski MM. Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the American Association for Emergency Psychiatry. West J Emerg Med. 2019 Mar;20(2):409-418.

6. Nash KA, Tolliver DG, Taylor RA, et al. Racial and ethnic disparities in physical restraint use for pediatric patients in the emergency department. JAMA Pediatrics. 2021;175(12):1283–1285

7. Foster AA, Porter JJ, Monuteaux MC, et al. Disparities in pharmacologic restraint use in pediatric emergency departments. Pediatrics. 2023;151(1):e2022056667

8. Calabrese M, Sideridis G, Weitzman C. Physical and pharmacologic restraint in hospitalized children with autism spectrum disorder. Pediatrics. 2024;153(1):e2023062172

9. Dalton E, Doupnik S. Envisioning Zero: A Path to Eliminating Restraint Use in Children’s Hospitals. Pediatrics. 2024;153(1):e2023064054