Agitation in children-what's your preferred IM?

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Madden007

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Affective or psychotic agitation in younger children 3-16 y/o, what's your go to IM? 5/2/2 [haldol/Ativan/benadryl]? Thorazine? zyprexa? ativan?

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I feel many times it goes with the culture of the institution, but I like thorazine. It's anticholingeric properties negate the use of additional medications (don't give with Benadryl), plus you can redose it quicker..
 
My program does not have a preference. I usually will use Haldol/Benadryl or Zyprexa. Or if they are just really anxious more than anything, a benzo and see what happens. This usually works for most of what I have seen. Most of the kids I see are behavior and not psychosis.
 
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At the lower end of the age spectrum, say 4-9, I mostly have just used IM Benadryl 50mg. That's worked fairly well. Above age 10 I'll try Benadryl 50 IM, and if that doesn't work well, the next time I'll just use Zyprexa 5. For really tall/heavy patients ill use Haldol 5/Ativan 2/Benadryl 50, just like for adults.
 
For some reason our institution is absolutely 100% opposed to using Benadryl for agitation in children, so inevitably we end up using Zyprexa 5. Frankly if it were my child I would vastly prefer them to get diphenydramine, but I think we may have been involved in a lawsuit that was connected to diphenydramine for sedation at some point and so it is strictly verboten.
 
I think we may have been involved in a lawsuit that was connected to diphenydramine for sedation at some point and so it is strictly verboten.
That’s funny but yet so representative of how we conceptualize medicine. I’m trying to think how this scenario wouldn’t have been worse with Zyprexa or another antipsychotic. It’d be like having a lawsuit with benzos so to avoid that in the future you just give barbs.
 
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I hope this goes without saying here. The assumption is you treat the underlying cause of agitation and not just sedating the child, e.g. hyperactivity and impulsivity treat with a stimulant and maybe standing risperidone. And of course, verbal redirection and behavioral plans, and all other non psychotropic interventions. But, when those things do not work and the child is so out of control that they might actually hurt themselves or staff, what medication do you prefer to use? Obviously, this is not ideal and only to address the immediate safety or psychosis until the appropriate behavioral plan is in place or meds are figured out.
 
What would you give?
I know this question isn’t posed to me but this becomes an institutional problem. Nursing staff initially notice a problem and request an intervention. They’re conditioned to having request met with the patient being slammed with some Zyprexa/Haldol/Thorazine/whathaveyou and notice significant reduction in their occupational anxieties. If you come in and go against the rest of conventional wisdom, get ready for being the ignorant physician and prepare yourself for nocebo by proxy. The question isn’t really what would you give instead, the question is how you will deal with the inevitable fallout of not ‘adequately’ addressing the issue, and that’s a much larger problem than the acute issue before you. It’s a lose-lose-win situation where the patient, temporarily, benefits.
 
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I hope this goes without saying here. The assumption is you treat the underlying cause of agitation and not just sedating the child, e.g. hyperactivity and impulsivity treat with a stimulant and maybe standing risperidone. And of course, verbal redirection and behavioral plans, and all other non psychotropic interventions. But, when those things do not work and the child is so out of control that they might actually hurt themselves or staff, what medication do you prefer to use? Obviously, this is not ideal and only to address the immediate safety or psychosis until the appropriate behavioral plan is in place or meds are figured out.
The point at which behaviors become dangerous to self/others is again a threshold highly dependent on the quality of your nursing staff, and, more importantly, your administration’s support for appropriate nursing staff. I know this is vague, but the real answer is to not practice in the environments that are toxic to staff and patients because ultimately it doesn’t matter what you do.
 
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I know this question isn’t posed to me but this becomes an institutional problem. Nursing staff initially notice a problem and request an intervention. They’re conditioned to having request met with the patient being slammed with some Zyprexa/Haldol/Thorazine/whathaveyou and notice significant reduction in their occupational anxieties. If you come in and go against the rest of conventional wisdom, get ready for being the ignorant physician and prepare yourself for nocebo by proxy. The question isn’t really what would you give instead, the question is how you will deal with the inevitable fallout of not ‘adequately’ addressing the issue, and that’s a much larger problem than the acute issue before you. It’s a lose-lose-win situation where the patient, temporarily, benefits.
Exactly this. Restraint situations are stressful for everyone involved--security, all of nursing, other patients on the unit. What you do is as much to treat the milieu as to treat the individual patient.
 
The point at which behaviors become dangerous to self/others is again a threshold highly dependent on the quality of your nursing staff, and, more importantly, your administration’s support for appropriate nursing staff. I know this is vague, but the real answer is to not practice in the environments that are toxic to staff and patients because ultimately it doesn’t matter what you do.
You are right. But let's assume that this is that rare situation where the child would benefit from medication. What would you choose? and how do you think through your medication options?
 
You are right. But let's assume that this is that rare situation where the child would benefit from medication. What would you choose? and how do you think through your medication options?

Take our professional hats off, and I'm sure most of us would cringe at the thought that our 3, 5 or even 10 year-old would be given Thorazine or something similar no matter what they were doing. Especially in/within a controlled and "safe" environment.

I recall when I worked in an MR/IDD facility, an order for PRN Vistaril for an adult was met with days of "QI meetings" afterwards. That seemed a bit excessive, but I really do get their point.
 
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DOUBLE POST
 
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I don't do peds anymore so been awhile, but I seem to remember plenty of times when IMs seemed reasonable for kids, most of these I remember from night coverage so I don't remember the whole cases.

*Kid literally trying to scratch his eyes out, had already managed to get a scratch in on face and was bleeding. Was for psychotic reasons if I remember.
*Kid repeatedly trying to smash his face on the ground during some sort of rage episode, may have been psychotic as well.
* 180lb+ kid assaulting staff in ER
* Kids intoxicated on meth or crack in the ER and getting aggressive.
 
PRNs for kids are used a lot more than you guys seem to think. Absolutely depends on your nursing staff and their ability to handle these types of situations/staffing/training. You'll find that a lot of general pediatrics floor staff are very uncomfortable with these situations (or act like they're comfortable but will then go do things like telling an aggressive teenager very constructive statements like "stop acting like a little kid" and "I'm not scared of you"). Also may be very understaffed for these situations unless they have a sitter.

Unless they have a previously diagnosed psychiatric disorder or are floridly psychotic, kids tend to just be "mad" (like I want to go home or stop telling me what to do mad for neurotypical kids or you're messing up my routine/not giving me something I'm used to/messing up my environment for kids with autism/DD/ID). In general I think benzo and giving some time to relax works when all your behavioral or de-escalation interventions are exhausted. We're trying to move towards atypical antipsychotics if you end up needing to reach for an antipsychotic just due to the lower side effect profile.

Agree that older/bigger/intoxicated teenagers for all relevant purposes need to be treated like adults, mainly because they tend to have good enough reasoning capacity to be spoken to as an adult and for safety reasons.
 
One of the local, extremely poor quality hospitals in this area is now being sued for giving kids "booty juice" - yes, they actually called it this, and yes, referred to "emergency" IMs as this to the kids - inappropriately and in the absence of a true emergency indication. They're regimen included the usual haloperidol/lorazepam/diphenhydramine at various doses.

I'll admit I know next to nothing about child psych, but when I did a month on the inpatient unit the preferred emergency medication was ziprasidone. I can't remember hearing any kids ever receiving emergency medications when I was there, however. The unit staff much preferred behavioral interventions, and even with the occasional psychotic patient those interventions were effective enough to at least prevent the use of IM meds.
 
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One of the local, extremely poor quality hospitals in this area is now being sued for giving kids "booty juice" - yes, they actually called it this, and yes, referred to "emergency" IMs as this to the kids - inappropriately and in the absence of a true emergency indication. They're regimen included the usual haloperidol/lorazepam/diphenhydramine at various doses.

I'll admit I know next to nothing about child psych, but when I did a month on the inpatient unit the preferred emergency medication was ziprasidone. I can't remember hearing any kids ever receiving emergency medications when I was there, however. The unit staff much preferred behavioral interventions, and even with the occasional psychotic patient those interventions were effective enough to at least prevent the use of IM meds.

Hey maybe they got some cans of booty sweat to go with their "booty juice"


I've seen this...basically just wanting to knock kids out that they don't want to deal with. Pretty sad when you see real psych units that don't even have to use meds most of the time.
 
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