In this section
Acute Behavioural Disturbance: Assessment and verbal de-escalation
Acute Behavioural Disturbance: Code Grey
Acute Behavioural Disturbance Management Flowchart for pharmacological management.
Detailed assessment for acute behavioural disturbance can be deferred until the behaviour is controlled. See Acute Behavioural Disturbance: Assessment and verbal de-escalation.
Focus on "What has worked in the past?" and "Why has this episode occurred?"
No investigations are required emergently.
If the situation appears "out of control" then call a Code Grey and involve senior staff early.
Key steps include
Ketamine may be given first-line in the setting of extreme agitation with risk to safety. All medications listed are suitable for all causes of agitation, including recreational drug intoxication.
The following antidotes should be readily available for reversal of potential side effects
Benztropine - 0.02mg/kg (Max 2mg/dose) given IV or IM for reversal of dystonic reactions associated with haloperidol and olanzepine. Repeated doses may be required.
Flumazenil - 10 micrograms/kg (Max 200micrograms/dose) repeated at 1 minute intervals prn for up to 5 doses, for reversal of respiratory depression associated with benzodiazepines only. Do not give unless you are sure the child is not on long term benzodiazepines, and do not give if there is any evidence of co-ingestants which may be associated with seizures. Consider flumazenil infusion if more than 5 doses are required.
The calm, but alert child
The agitated child
Debrief and discuss
The Child / family
Have a low threshold for involving local mental health clinicians in the ongoing care of behaviourally disturbed children, to assist in determining whether acute psychiatric admission would be beneficial, and to ensure appropriate community follow-up.
Some children may require medical admission for stabilisation of a medical cause for their behavioural disturbance, or for observation until resolution of drug toxicity and should be referred to the local paediatric team if this is thought to be likely.
Once the behavioural disturbance is controlled, some children will require transfer to a tertiary psychiatric centre. This can be facilitated following an assessment by local mental health clinicians.
Complications from chemical sedation - respiratory depression, hypotension, extrapyramidal reactions.
Child requiring care beyond the comfort level of the hospital.
For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.
Before discharge, all children with acute behavioural disturbance should have:
If IM or IV medication is required the Code Grey team will provide assistance. Medication will be delivered by medical / nursing staff in the particular clinical area .
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Last updated July, 2017