Unfortunately the Emergency Department is a place where you will see many agitated patients who are displaying or are at risk for violent behavior. You should always try non-physical and non-pharmacological de-escalation techniques first. remember, the patient, especially a young child is likely very scared. Being surrounded by unfamiliar faces and by people who are bigger than you can trigger aggression. Talk to the child. be calm. Show them that you care and offer them something to drink and a snack. This often goes a long way. When working with developmentally delayed patients consider medications early. Once agitated, it may be hard to reason with them and de-escalate verbally. Always ask caregivers what has worked for their child in the past and involve them heavily in the decision making.
For younger patients (<10 years of age)
Verbal aggression alone and if they will take a PO medication, options in order of preference include:
- Zyprexa zydis 5mg PO
- Risperdal 0.5mg PO
- Lorazepam 0.5mg PO
For physically aggressive patients, and those who won’t take an oral med you will need to go IM. Options, again in order of preference include:
- Geodon 10mg IM
- Zyprexa 5mg IM
- Lorazepam 1mg IM
- Diphenhydramine 1mg/kg (max 50mg) IM
For older patients (>10 years of age)
Verbal aggression alone and if they will take a PO medication, options in order of preference include:
- Zyprexa zydis 10mg PO
- Risperdal 2mg PO
- Lorazepam 1mg PO
- Haldol 2mg PO + Benztropine 1mg PO
For physically aggressive patients, and those who won’t take an oral med you will need to go IM. Options, again in order of preference include:
- Geodon 20mg IM
- Zyprexa 10mg IM
- Lorazepam 2mg IM
- Haloperidol lactate 5mg IM + Benztropine 1mg PO/IM
- Diphenhydramine 1mg/kg (max 50mg) IM
Other pearls
- Avoid Geodon in cardiac patients and those with known prolonged QTc
- Follow Geodon with lorazepam or diphenhydramine if you need more
- Always call psychiatry if you experience an unexpected reaction
