Acute Agitation

Acute agitation is a heightened state of anxiety, emotional arousal, and increased motor activity that occurs not uncommonly in the pediatric setting, for example, in states of acute intoxication, sedative withdrawal, and delirium, as well as in the context of emergency department evaluations or in patients with primary mood and psychotic disorders (Jibson 2007). Patients with organic brain syndromes or with cognitive impairments may also be at higher risk of such behaviors. In these situations, rapid control of agitation is needed to prevent harm or injury to both the patient and staff.

Unfortunately, there are no published studies that compare psychopharmacological treatments of the acutely agitated child seen in emergency department settings (Hilt and Woodward 2008). Dorfman and Kastner (2004) reported on the frequency of current medication choices in the emergency department and found that benzodiazepines, haloperidol, and histamines were the most commonly used agents in order of frequency of use. Extrapolating data from adult studies, it is clear that the two most common categories of psychiatric medications include antip-sychotics and benzodiazepines, either alone or in combination. Some data suggest that the combination of medications, most commonly haloperidol with lorazepam, is more effective than one alone (Battaglia et al. 1997). Medication choice may also be influenced by whether the patient is willing and able to take oral medications.


Although the benzodiazepines differ in potency, speed of onset of action, and route of administration, there are no data to support the use of one specific benzodiazepine over another in terms of therapeutic efficacy. Lorazepam, which is available in oral, intramuscular, and intravenous formulations, is the most frequently used benzodiazepine for treatment of acute agitation, and at least one study in adults has shown that it had comparable efficacy with intramuscular haloperidol (Salzman et al. 1991). Intramuscular midazolam also has been used to treat acute agitation with superior results compared with both haloperidol and lorazepam, although midazolam's short duration of action may limit its utility (Nobay et al. 2004; Rund et al. 2006). Limitations on the use of benzodiazepines in pediatric patients may occur as a result of both excessive sedation and behavioral or emotional disinhibition.

Antipsychotic Agents

Antipsychotic agents are widely used in the treatment of acute agitation, delirium, mania, and psychosis. Traditionally, haloperidol has been one of the most commonly used antipsychotic agents, and

Table 30-5. Target symptom approach in pediatric consultation

Target symptom

Medication considerations

Acute agitation

Antipsychotic agent


Diphenhydramine (younger children)








Antipsychotic agent


Selective serotonin reuptake inhibitor

Norepinephrine selective reuptake inhibitor









Hypnotics (e.g., zolpidem or zaleplon)




Tricyclic antidepressant

Norepinephrine selective reuptake inhibitor (e.g., duloxetine)




Antipsychotic agent






there is a growing literature base that supports its safety and efficacy in intravenous use (Arrants 2001; Citrome 2002) and even one report of intranasal use (Miller et al. 2008). However, intramuscular and oral formulations of aripiprazole, olanza-pine, and ziprasidone, and rapidly disintegrating formulations of aripiprazole, olanzapine, and ris-peridone have all been shown to be more effective than placebo and comparable in efficacy with halo-peridol with or without lorazepam for acute agitation in adults with schizophrenia or mania (Andre-

zina et al. 2006; Daniel et al. 2001; Fulton et al. 2006; Wright et al. 2001).

Generally, current adult emergency department practices tend to favor risperidone or olanzapine for patients who are willing to take oral medications, due to the more favorable side-effect profile (Hilt and Woodward 2008). For patients requiring intramuscular administration, both ziprasidone and olanzapine have become widely acceptable alternatives to the use of haloperidol. In one study, intramuscular ziprasidone was found to be significantly more effective than haloperidol in reducing symptoms of acute agitation (Brook et al. 2000). There has also been a single case report describing the use of intravenous ziprasidone to treat acute delirium (Young and Lujan 2004). Tollefson et al. (1997) also reported on the safe and effective use of intramuscular olanzapine. Droperidol, once a popular medication choice in the emergency department setting, is now rarely used after concerns arose about cardiac toxicity, although the evidence supporting this relationship has more recently been questioned (Rund et al. 2006).

Do Not Panic

Do Not Panic

This guide Don't Panic has tips and additional information on what you should do when you are experiencing an anxiety or panic attack. With so much going on in the world today with taking care of your family, working full time, dealing with office politics and other things, you could experience a serious meltdown. All of these things could at one point cause you to stress out and snap.

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