Acute behavioural disturbance: Acute management


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    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • See also:

    Acute Behavioural Disturbance: Assessment and verbal de-escalation 

    Acute Behavioural Disturbance: Code Grey

    Acute Behavioural Disturbance Management Flowchart for pharmacological management.

    Key Points

    1. Management should emphasise the child's safety and non-pharmacological strategies in the first instance, and parental involvement where appropriate.
    2. If pharmacological treatment is required, a step-wise approach should be taken, depending upon the level of agitation.
    3. If the child has an existing behavioural management plan, this should be followed.
    4. Any physical restraint is a last resort, and should only be used to facilitate rapidly effective pharmacological treatment.

    Background

    • The most important initial action is to control the behaviour to reduce distress, and to reduce the risk of harm.
    • Once the behaviour is controlled, further assessment and specific management of the underlying cause should occur.
    • Acute behavioural disturbance should be managed in the context of a Code Grey response, with appropriate leadership and allocation of roles.

    Assessment

    Detailed assessment for acute behavioural disturbance can be deferred until the behaviour is controlled. See Acute Behavioural Disturbance: Assessment and verbal de-escalation.

    History

    Focus on "What has worked in the past?" and "Why has this episode occurred?"

    Examination

    • Assess the level of agitation
    • Brief assessment (while ensuring staff and child safety at all times) for
      • Obvious focal neurology
      • Evidence of toxidrome / intoxication
      • Acutely painful condition
    • A comprehensive examination should occur once the behaviour is controlled
    • Consider assessment for weapons and/or other sources of self-harm.

    Investigations

    No investigations are required emergently.

    • A blood glucose level should be considered once the child's behaviour is controlled.
    • Breathalyser blood alcohol assessment if appropriate
    • Further investigations can then be used to exclude any possible organic causes.

    Management

    If the situation appears "out of control" then call a Code Grey and involve senior staff early.

    Key steps include

    • Verbal de-escalation if possible
    • Step-wise approach to pharmacological treatment (see flowchart)
    • Post-sedation monitoring
    • Treat the underlying cause
    • Debrief the child/family and staff
    • Documentation

    Acute Behavioural Disturbance Management Flowchart

    acute management

    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. 

    Medication Adverse effects

    1. Respiratory depression - More commonly seen with benzodiazepines but can also occur with olanzepine and haloperidol. Usually requires supportive care only, although flumazenil can be used in very specific circumstances (see below)
    2. Extrapyramidal reactions - more commonly seen with droperidol or haloperidol but may be seen with olanzapine after only 1 dose.  Reactions include; dystonia, dyskinesia, oculogyric crisis and akathisia (restlessness). Reversible with benztropine.
    3. Neuroleptic Malignant Syndrome - A rare complication of typical and atypical antipsychotics characterised by hyperthermia, muscle rigidity, autonomic dysfunction and altered mental status. Call hospital emergency team (ie: MET call) if suspected and check serum CK as it is invariably elevated. Immediately inform consultant and Psychiatry team.
    4. Paradoxical reactions - Administration of a benzodiazepine results in increasing agitation and anxiety as opposed to its normal sedating effect. This is more commonly seen in children with developmental delay and / or a history of aggressive behaviour. 

    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.

    Post-sedation monitoring

    Vigilant monitoring, particularly for signs of airway obstruction, respiratory depression, hypotension and extrapyramidal reactions is mandatory.
    Monitoring should be performed in a safe environment within the clinical setting.
    Some flexibility in observations is acceptable, so as not to unnecessarily wake or irritate the child further and to permit sufficient rest.

    The child with decreased level of consciousness
    • Requires one to one nursing
    • Continuous oxygen saturation monitoring 
    • Blood glucose should be checked
    • ECG should be performed if IM sedation used
      • ECG monitoring may be required based upon the suspected cause of the behavioural disturbance (overdose, intoxication), or an abnormal 12-lead ECG.
    • Vital signs (temp, HR + rhythm, BP, resp rate) and neurological observations should be performed every 10 mins until stability is clinically evident

    The calm, but alert child

    • Half-hourly observations for 2 hours after last sedation medication

    The agitated child

    • Need continuous clinical observation

    Assessment and treatment of the underlying cause

    Consider

    • Severe / extreme anxiety in unfamiliar surroundings (common in ASD)
    • Pain
    • Medical condition
    • Intoxication (alcohol, illicit drugs, medications)

    Debrief and discuss
    The Child / family

      • Acknowledge and understand the child's experience. Avoid justifying treatment as it is likely to be counterproductive.
      • Answer questions from the child and/or their carer/family regarding the incident of acute behavioural disturbance and its treatment.
      • Ensure the child / family understands how to avoid acute behavioural disturbance in the future (where possible).

    Staff

      • What was done well? What could be improved?

    Documentation

    Include

    • Reasons for sedation (in medical notes)
    • Medications used – dose and route
    • What worked? What was unsuccessful?
    • As applicable, additional documentation may be required to address:
      • Code Grey
      • Physical restraint
      • Mental Health Act
      • Staff safety / OHS
      • Patient safety / Riskman

    Consider consultation with local paediatric team when:

    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.

    Consider transfer when:

    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.

    Consider discharge when:

    Before discharge, all children with acute behavioural disturbance should have:

    • Resolution of behavioural disturbance
    • Exclusion of significant medical or psychiatric illness
    • Treatment of any identified underlying cause
    • Carers capable of and willing to take the child home
    • A clear plan for medical and/or psychiatric follow-up.

    Information Specific to RCH

    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 .

    RCH intranet links

    Last updated July, 2017