Behavioural problems

Disclaimer These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.  Read the full PCH Emergency Department disclaimer.

Aim

• To guide PCH Emergency Department (ED) staff with the assessment and management of behavioural problems in the Emergency Department.
• The focus is safety – to prevent the patient from causing harm to themselves, their family, Emergency Department (ED) staff or the ED environment.
• Prevent disruption to the rest of ED workflow.
• Use minimal intervention or force.

Actions

• PCH has a zero tolerance for aggression or inappropriate behaviour.
• If there is an immediate risk of physical harm to staff or patients then a code black should be called immediately (phone 55 and state ‘Code Black’ and your location). This summons immediate attendance of security staff.
• The PCH Security Department can be contacted directly on ext 63003 to request their support with aggressive patients.
• Personal safety, the safety of other staff members, patients and visitors is a priority.

 

ED staff should

• Recognise signs of increasing agitation.
• Respond to these patients as a priority in order to prevent potential deterioration
  • Verbal escalation, posturing and threats usually precede actual physical violence.
• Promptly involve the Senior ED Doctors and Nursing staff when escalation is probable.
• Engage in a discussion with the patient and/or family regarding their concerns and expectations, encouraging their involvement.
• Prepare staff in an area to deal with the expected problem.
• Involve the Psychiatric Team (Mental Health Nurse, Psychiatric Registrar or Consultant).
• Request Security Staff assistance when required (ext 63003).

De-escalation

• Isolate the child to prevent patient self-harm, harm to other staff, equipment and to minimise ED disruption.
  • The ED Behavioural Assessment Room can be used for this purpose.
  • This room provides a safe environment to help facilitate an optimal outcome in a timely manner.
• Speak in a calm, non-threatening but confident and assertive voice.
• Actively listen to the patient.
• Offer support – a drink, food, use of a telephone.
• Negotiation and attempting to find a solution in a non-threatening manner can refocus the aggressor
• Avoid any language which may further increase the patient’s aggression.
• Avoid sudden movements, prolonged eye contact and intimidating body language.
• Maintain a safe distance between yourself and the patient, and always be mindful of the exit location.
• Reorient the aggressor to the current situation and insist on being mindful of other patients and their environment: i.e other unwell children and babies.
• Ensure adequate staff is present and confirm that Security are en route.
• If verbal de-escalation is unsuccessful, then proceed to physical restraint or chemical sedation. Refer to CAHS Policy: Restraint of Patient/Clients (internal WA Health only).

Police escorts

• If police have brought in a handcuffed patient, the handcuffs should be removed as soon as an initial assessment has been completed (and it is deemed safe to do so).
• The police must remain with the patient until an initial management plan has been decided. Refer to PCH Policy: Custodial Persons and Young Persons in Custody (internal WA Health only)

Assessment

Undertake an assessment of possible causes or contributors to the current behavioural issue, for example:

• Delirium from an underlying medical condition
• Substance intoxication (e.g. alcohol, prescription or illicit drugs)
• Behavioural issues
• Psychiatric disorders
• Family or social conflicts

Obtain as much collateral information as possible from any family members present, police and ambulance officers.

Management

• Doctors can apply the principle of ‘duty of care’ or the relevant mental health care act when giving treatment without consent, however it should be ethical and professional at all times.
• Careful documentation is essential in these situations – for example, providing the rationale for treatment, and whether the patient lacked the ability to make appropriate decisions.

Initial management

• Always attempt to de-escalate the situation by talking to the aggressor first.
• If de-escalation is unsuccessful, consider physical restraint or chemical sedation.
• Oral medications are the first line option for chemical sedation – ask the patient if they will take some oral medication to help calm them.
• If oral medications are unsuccessful, parenteral sedation options should be considered.
  • Intramuscular administration is usually safer for both the staff and patient, and should be utilised as a first line route of administration.
• Once the risk to staff has been reduced, an IV cannula can be inserted for ongoing IV sedation if this is required.
• IV sedation is very effective as it provides a rapid onset of effect, allows titration of the dosage, and has a shorter duration of action.
• Move a violent or aggressive patient to the ED Behavioural Assessment Room immediately to ensure safety for the patient and staff.
• Agitated or aggressive patients require 1:1 nursing observation whilst in the Behavioural Assessment Room.

Physical restraint

• The decision to physically restrain a patient is made after consideration of the appropriateness of this action (e.g. mental health care act), or under duty of care.
• The Senior ED Doctor should always be involved in this decision process.
• The patient should be restrained in the supine position (not prone).
• Physical restraint must be coordinated with 6 staff members in order to perform the task safely and with minimum force:
  • 1 person per limb
  • 1 person for the head
  • 1 person (usually ED Doctor) to administer sedatives and insert an IV cannula
• Other combinations may be decided on a case by case basis with the Senior ED Doctor being involved in the decision process. Refer to CAHS policy: Restraint of Patient/Clients (internal WA Health only).

Monitoring after sedation

• All patients who have been sedated require 1:1 nursing care in Acute Pod area.
• The patient should receive cardiac and oxygen saturation monitoring.
• Document the level of sedation along with the observations.
• The patient should have hourly medical reviews by the ED Doctor.

Documentation

The event must be well documented and should include:

• Use of physical restraint.
• Medications given, administration times, and the rationale for their use.
• Whether the patient lacked the ability to make appropriate decisions (document prior to sedation).
• A treatment plan should be established in consultation with the Psychiatric Team.

Use of the ED Behavioural Assessment Room

• Can be used for agitated or aggressive patients with behavioural or psychiatric issues.
• An aggressive patient should be immediately moved to the room for ongoing assessment.
• It is a safe, contained environment where you can attempt to de-escalate an agitated patient by talking to them.
• Whilst in the room, the patient must have 1:1 nursing and be under continuous visual observation.
• The room is only to be used for non-sedated patients – once sedation is given successfully, the patient must be moved to Acute Pod area so that monitoring can be performed.
• Patients should not be kept in this room for a long period of time (maximum 30 minutes).

Medications

Oral sedation

Lorazepam:

• Dosage: 0.05 mg/kg (max 2 mg per dose and 4mg/24 hours)^1,2,3,4
• Children up to the age of 16 years 

AND / OR

Olanzapine:

• Wafers recommended over tablets 
• Dosage: 
  • < 40kg: 2.5 to 5 mg (max 10mg/24 hours)^4,5,6  
  • > 40kg: 5 to 10 mg (max 20 mg/24 hours)¹⁰
•  Patient Group: Children >6 years of age¹⁰

OR

Quetiapine:

• Dosage: 12.5 to 25mg (up to 50mg per dose)^4,5,6
  • Maximum 400mg/24 hours for children 6 to 12 years old^4,5,6
  •  Maximum 750mg/24 hours for children over 12 years old^4,5,6
•  Patient Group: Children > 6 years of age
• Allow oral medications 30 to 60 minutes to take effect before attempting further sedation. 
• If there is a poor initial response to oral medications, it is recommended to switch to intramuscular or intravenous medications rather than to persist with the oral route.

Intramuscular sedation

• To be used when oral sedation is refused or greater sedation is required.

Olanzapine:

• Dosage: 2.5 to 5mg per dose^7,9,10
• Dosage:
  • < 40kg: 2.5 to 5 mg (max 10mg/24 hours)^4,5,6,11  
  • > 40kg: 5 mg (max 20 mg/24 hours)^10,11
  • Patient Group: Children >6 years of age^10,11
    •  Olanzapine dose may be increased at intervals of 2.5mg¹⁰
  • Special Instructions: If IM olanzapine and IM benzodiazepines are used within ONE hour of one another monitor for over-sedation, respiratory and cardiovascular depression using close physical observations and Emergency Department Observation Escalation Score (EDOES) criteria.

OR

Droperidol:

• Dosage: 0.1 to 0.3mg/kg ¹⁰ (max 5 mg)
• Maximum of 10mg/24 hours¹⁰
• Doses can be repeated every 30 minutes to a maximum of 4 doses in 24 hours¹⁰
• Patient Group: Children over 6 years of age

Consider combining in same syringe with:

Midazolam:

• Dosage: 2.5 to 10mg (50 to 150microgram/kg)^1,3,8 
• Maximum of 10mg/24 hours for a 6-16 years of age^1,3,8
  •  Maximum of 20mg/24 hours for children >16 years of age1,3,8
  • Calculate dose using ideal weight in obese children¹⁰
• Special Instructions: If IM olanzapine and IM benzodiazepines are used within ONE hour of one another monitor for over-sedation, respiratory and cardiovascular depression using close physical observations and Emergency Department Observation Escalation Score (EDOES) criteria.  
• Review intramuscular sedation after 30 minutes to assess efficacy before attempting further sedation. Continue physical restraint until sedative effect is achieved.

Intravenous sedation

Midazolam:

• Dosing as per IM administration (see above). 
• This medication works rapidly and can be titrated to achieve the desired clinical response. 
• Dosages can be repeated after 5 minutes.

Droperidol: 

• Dosing as per IM administration (see above)

Medication side effects

• Likely side effects to the majority of the above medications include; respiratory depression, airway compromise and hypotension. It is important to vigilantly watch for these side effects.
• Benzodiazepines can cause over-sedation
  • Over-sedation can be reversed using flumazenil (see dosing guideline below)
• Paradoxical reactions can occur, particularly with benzodiazepines: these include increased agitation and anxiety. 
• Antipsychotics such as olanzapine can lead to extrapyramidal reactions (dystonia, dyskinesia, oculogyric crisis).
  • Extrapyramidal side effects can be alleviated using benzatropine (see dosing guideline below).

 

Treatment for:		Dose and frequency
Benzodiazepine (Lorazepam or Midazolam) overdose	Flumazenil	IV dose: 5 microgram/kg (max 200microg) repeated every 60 seconds to a maximum 5 doses total2.
Extrapyramidal side effects (EPSE)	Benztropine	3-12 years of age: Oral dose: 20 to 50 microgram/kg (maximum 2mg) 12 to 24 hourly2,10 IV, IM dose: 20 microgram/kg/dose (maximum 1mg) stat. May repeat after 15 minutes (maximum 4mg daily)2,10 > 12 years of age:  Oral dose: 1-2mg 12 to 24 hourly10 IV, IM dose: 1-2mg. May repeat after 15 minutes (maximum 8mg daily)10,11

Discharge criteria

• A plan for discharge from the ED to an appropriate facility or location in the hospital for ongoing treatment must be expedited
• Options can include admission to the Mental Health Ward at PCH (Ward 5A), admission to a medical ward or the Paediatric Critical Care (PCC) Unit if very sedated. 

Nursing

•  If the patient has been sedated or is in the Behavioural Assessment room they require 1:1 nursing care.
  • Whilst in the Behavioural Assessment room, the patient must be under continuous visual observation. Document visual observations 5 to 10 minutely. 
  • Sedated patients must have cardiac monitoring attached and oxygen saturation probe.
  • Document the level of sedation with the observations.
  • The patient must be reviewed hourly by the ED Doctor.

Bibliography

1. WA Health, Child and Adolescent Health Service Pharmacy Manual. Arousal and Agitation Drug Management July 2014
2. Child and Adolescent Child Psychiatry, 3rd Edition Robert Goodman, Stephen Scott Sep 2012 Wiley- Blackwell
3. Rutter's Child and Adolescent Psychiatry M. Rutter et al [Wiley-Blackwell; 5th edition]
4. Practitioner's Guide to Psychoactive Drugs for Children and Adolescents JS Werry and MG Aman [Springer, 2nd Edition] 

References

1. Royal Children's Hospital - Melbourne. Paediatric Pharmacopeia [online]: Lorazepam Monograph. Available from: http://ww2.rch.org.au.pklibresources.health.wa.gov.au/pharmacopoeia/pages/loraze pam.html . Accessed online 12 March 2014.
2. Allardice J, editor. Psychotropic Guidelines. Version 7, 2013. West Melbourne: Therapeutic Guidelines Ltd.
3. Taketomo CK, Hodding JH, Kraus DM, editors. Pediatric dosage handbook with international tradename index. 20th edition. Ohio: Lexi-Comp Inc; 2013-2014. p. 1162, 1276
4. F Group, the Royal Pharmaceutical Society. BNF for Children [online] London: Pharmaceutical Press accessed online 2/2/17. Lorazepam, Quetiapine, Olanzapine.
5. Buck ML. Pediatric Pharmacotherapy, newsletter, volume 7 number 8 2001. [online], Accessed online 12 March 2014 http://www.medicine.virginia.edu/clinical/departments/pediatrics/education/pharmnews/2001-2005/200108.pdf
6. Antipsychotic medications for children and adolescents. Pediatr Ann 2001; 30:138 – 45 [online]. Accessed online 12 March 2014 http://www.medscape.com/viewarticle/415081_6
7. Prescribing information Zyprexa intramuscular; pages 1-6 [online] http://pi.lilly.com/us/zyprexa-pi.pdf Literature revised July 26, 2013 by Eli Lilly and Company, Indianapolis, IN 46285, USA, Accessed online 12 March 2014.
8. Data on file for Zyprexa intramuscular postmarketing reports of fatalities. Indianapolis: Lilly Research Laboratories; 2005.
9. Chan EW et al. Intravenous droperidol or olanzapine as an adjunct to midazolam for Arousal and Agitation Drug Management Page 6 of 6 Medication Management Manual the acutely agitated patient: a multicenter, randomized, double-blind, placebocontrolled clinical trial. Ann Emerg Med. 2013 Jan; 61(1):72-81. Available online at http://www-ncbi-nlm-nihgov.pklibresources.health.wa.gov.au/pubmed/22981685?dopt=Citation , accessed 12 March 2014.
10. Australian Medicines Handbook Children's Dosing Companion. 2020. AMH CDC Olanzapine, AMH CDC Benztropine.
11. Gold Standard, Inc. Olanzapine. Clinical Pharmacology [database online]. Available at: http://www.clinicalpharmacology.com. Accessed: May, 25, 2020.

Reviewer/Team:	Meredith Borland (ED Director), Dennis Chow (ED Consultant), Deirdre Speldewinde (ED Consultant), Gabrielle Anstey (ED CNS), Craig Hasler (ED CNM), Vince Martino (Pharmacist)	Last reviewed:	Jun 2020
		Review date:	Jun 2023
Endorsed by:	Drugs and Therapeutics Committee	Date:	Jun 2020

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