Aggressive patients are rare in the pediatric ED compared to the adult world, but they present a unique set of challenges. It is important to look for the etiology of the patient's aggression/discontent. If it can be easily removed from the patient's environment, it should be. Aggressive patients need to be well supervised where they do not have the means to harm themselves or others. If verbal reassurance is ineffective in diffusing the aggression, positioning law enforcement within view of the patient can add gravity to verbal direction given by medical personnel. Escalation in care proceeds to seclusion and therapeutic holding with at least two people physically restraining the patient.22 In brief, the recommendations of the American Academy of Pediatrics are to: (1) explain the necessity of restraint to the patient, (2) have specific physician orders including indication for and duration of restraint, (3) explain everything to the family, and (4) perform and document ongoing assessment of correct application of restraints, skin and neurovascular integrity, as well as efficacy of the restraints in meeting the indication for application.22 Documentation for all restraints (physical/chemical) should mention what was done to protect the patient's well-being, best interest, rights, privacy, and self-respect.
Physical restraint is a good initial step in stabilization. If care requires escalation, chemical restraint may be warranted. The goals of chemical restraint are to: (1) decrease the patient's anxiety and discomfort, (2) minimize disruptive behavior, (3) prevent escalation of behavior, and (4) reverse the underlying cause.23 Many agents have been employed, about half of which have FDA approval for indications in children. All chemical restraint use requires careful monitoring of the patient on cardiac, apnea, and pulse oximetry monitoring. Benzodiazepines work to sedate patients by activating GABA receptors and can, therefore, be helpful in aggressive behavior modification. Midazolam has the shortest duration of action of the benzodiazepines. Diazepam is available in a per rectum (PR) formulation as well. The major side effect is respiratory depression. Neuroleptic drugs, such as haloperidol, have been utilized extensively in treating the aggressive patient in the acute care setting, owing to their sedating effects rather than their antipsychotic effect, which usually takes 7 to 10 days to take effect. The rare incidence (1%) of extrapyramidal symptoms (EPSs) can occur after one dose of neuroleptic drugs. Most commonly seen is dystonic reaction involving eyes, neck, and/or back. Rarely does EPS affect the airway. The treatment for EPS is diphenhydramine (IV or IM) and/or benztropine (IV or IM).23 Neuroleptic malignant syndrome is a potentially fatal reaction characterized by fever, sweating, hypertension, severe muscle rigidity, and delirium sometimes progressing to coma. Patients should be treated with dantrolene and supportive care. Droperidol is another neuroleptic drug used in the treatment of the aggressive patient. It alters the action of dopamine at subcortical levels to produce sedation and a dissociative state with a faster onset of action than haloperidol. In 2001, the FDA issued a black box warning of fatal arrthymias associated with droperidol use; however, subsequent studies have not corroborated this particular risk, but have confirmed the most common side effect of dystonia.23 Atypical antipsychotics, such as ziprasidone and olanzapine, are gaining favor in the acute management of aggressive patients. With a lower incidence of EPS, multiple routes of administration, and better tolerance, they are commonly used in the pediatric ED. Ziprasidone and olanzapine are recommended for the agitated schizophrenic patients. Olanzapine is also indicated for aggression/agitation associated with bipolar disorder. Hydroxyzine is an antihistamine that has been used as an anxiolytic, can be administered IM, and has an onset of action comparable to that of lorazapam.