PEM Currents – Agitation in Children – Episode 2: Non-Pharmacologic Management

Original podcast posted on PEM Currents – Hosted by Brad Sobolewski (@PEMTweets) and co-authored by Dennis Ren (@DennisRenMD)

This podcast series by PEM Currents is a co-production with the Emergency Medical Services for Children Innovation and Improvement Center (EMSC IIC), whose mission is to minimize morbidity and mortality of acutely ill and injured children across the emergency continuum. 

The emDOCs.net team is very happy to collaborate with PEM Currents and EMSC IIC to further disseminate this 5-part podcast series focusing on agitation in children and adolescents.

Podcast: Play in new window | Download (Duration: 17:49 — 24.5MB)

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Non-Pharmacologic Management

In episode 1 of this series, we discussed differentiating organic vs psychiatric causes of agitation in children. But what about the patient who is agitated, and is a potential danger to themselves or to the ED staff? Do we Redirect? Restrain? Sedate?

Patient that are agitated should always be treated with dignity and respect. This entails utilizing the least invasive non-pharmacologic means of assisting them, before moving to physical or chemical restraints.

After listening to this episode you will be able to:

• Discuss specific age-appropriate non pharmacologic management strategies for agitated children
• Discuss how we can safely use holds and restraints, and how these are temporary measures

Environment

Remove any dangerous objects/equipment. This should ideally be proactive, and mean that if you have a large volume of mental health patients in your environment, then setting up safe spaces is key.

• No sharp objects in the room
• Walls with rounded corners
• Heavy or immovable furniture to prevent barricading or throwing
• Doors that swing outward
• Tamper-resistant fixtures and breakaway shower rods
• High ceilings 
• Room placement away from entries and exits
• No glass mirrors and televisions placed behind Plexiglass
• Open floor plans for visibility
• Our environment has secure “garage door” style rolling doors that lock in place in front of the monitors and wall mounted equipment. Additionally supply sleeves have a pass through and can be accessed outside of the room
• Removing any triggers which can include family or caregivers
• Dimming lights and minimizing noise (especially in neurodivergent children or children with sensory processing disorders)
• Presence of security staff or law enforcement may make things worse if the child feels threatened. Conversely they may need to be present for patient and staff safety

What if a patient arrives in handcuffs in police custody?

Patients may be brought to hospital by police under restraint (e.g. handcuffs)

• Police officers and handcuffs should remain in place during initial assessment
• Handcuffs can be removed once the patient has been assessed and it is deemed safe to do so
  • Before removal of handcuffs medication may need to be given for the patient’s own protection or that of the staff

Initial steps

• Recognition of warning signs of potential violence before escalation occurs
• Prioritize assessment of escalating patients (delays can worsen the situation)
• Always ensure safety of self, staff and others present (e.g. other patients, family members), and the patient
• Ensure patient cannot obstruct exit route
• Avoid excessive stimulation
• Avoid aggressive postures and prolonged eye contact
• Request aid (e.g. security staff) early if the situation is deteriorating or is expected to deteriorate
• If the patient has an existing behavioral safety plan, employ it as early as possible – this is especially important in neurodivergent children, and patients with diagnoses such as intermittent explosive disorder

Verbal de-escalation

De-escalation is the act of responding to a child’s agitation and in a way that controls, diffuses, and/or calms the situation. The EMSC innovation and Improvement Center has some excellent resources and tip sheets (see resources below for details).

It involves tracing the situation back to the point where things got out of control and addressing the root of the behavior rather than simply trying to quiet the child. Begin by stating your role and use both your own name and the patient’s name (personalize the interaction).

Avoid Trying to Reason With Them

When agitated, a child’s prefrontal cortex is suppressed by the cortisol and epinephrine induced fight-or-flight reaction. This physiological state is due to a perceived threat – deescalate by reassuring them that they are safe, remaining calm, and making sure their physical needs are met.

Validate Their Feelings, Not Their Actions

When a child is overwhelmed by emotions it is best to acknowledge their feelings – “I bet you are angry, I can see how upset that made you.” This establishes a common ground to begin. Be patient and listen, and then listen more — not to reply, but to validate and to understand, responding only with, “I think I understand. That was difficult for you. Tell me more”. The patient may not want advice or examples or anything, but listening and validation. Give the patient time to state their concerns, and avoid giving opinions on issues and grievances beyond your control.

If you are in a position to communicate, this it is important that children understand the error of their behavior and give them alternative ways of managing their emotions.

Be the Child’s Advocate

An agitated child may feel scared, threatened or embarrassed.  If they are having an outburst in triage for instance, let the child know that you are there to help them in a public way. Be their advocate. Escort them safely to a private room or area for discussion. All in all, it is important to be calm, empathetic and non-judgemental in your approach, but also by setting appropriate boundaries.

• You can also provide food, drinks or other assistance as required (e.g. seating, access to a telephone to call a parent or guardian, address physical needs, etc.)
• Offer oral medication to alleviate patient’s stress

This allows assessment of the patient’s responsiveness to verbal de-escalation and allows you to more immediately assess risk of self-harm or harm to others.

If necessary, you may have to show force:

• Involves security staff in view providing back up to the clinician while trying to negotiate with the patient
• In these situations adopting an overly casual posture may not be advised
• Used when verbal de-escalation is ineffective or inappropriate
• May persuade the patient to cooperate with an appropriate clinical intervention. Otherwise physical restraint and/or chemical restraint will be required to ensure safety of the patient, staff and others present

Be patient as these situations are not easy!

Restraints

The use of restraints should be taken seriously. Utmost care in keeping both staff and patient safe. All available alternative options should be considered before administering  physical restraint, as it infringes on a person’s autonomy and dignity. We must also acknowledge that there are racial and other disparities in the use of physical and chemical restraints. We need to be cognizant of this when making the decision to employ them.

Manual restraint 

Only staff trained and certified in the use of manual restraint should use these methods. These are typically temporary as other methods of physical restraint are being prepared. It is beyond the scope of a podcast episode to describe these in detail, but these include therapeutic hold.

Physical restraints

Physical restraint is any manual method, device, or equipment that immobilizes or reduces the ability of a patient to move their body freely.

I should also mention seclusion (aka involuntary confinement), which is the act of placing  of a patient alone in a room or area from which the patient is physically prevented from leaving. This is commonly done while having a “sitter” – a health care provider that is constantly obesrving the patient. This need for 1-on-1 observation is a major challenge for EDs and health care systems from a staffing standpoint.

Physical restraints are indicated when there is actual or high risk of harm to self, others or property, where verbal de-escalation and other treatments are inappropriate or ineffective.

You should not use physical restraints if the patient is medically unstable, if there is a risk of harm to the staff when applying restraints, and again, if other strategies are more appropriate

There are soft limb restraints or elbow splints and mittens, but often when we think of restraints we think of leather restraints on all 4 limbs.

The technique

Again ensure that everyone is safe. This includes adequate numbers of trained personnel, with personal protective equipment. DO NOT attempt physical restraint if inadequate staff available. If it is truly unsafe and the patient attempts to escape or does so, call the Police if appropriate. Ideally you should have policies and care pathways in place with a trained team. 

1. This should be a 6 member team: one for each extremity, one for the head, and one to apply the restraints. The provider at the head of the bed should have airway skills if possible. Allocate roles and state plan of action in an initial huddle. Decide on a trigger word to be used to initiate action plan
2. Remove all objects which are potentially dangerous (pens, stethoscopes, lanyards etc.) and don PPE (ie gloves, gowns and face-masks, Kevlar sleeves)
3. Calmly explain to the patient that restraints are being applied to ensure the safety of the patient and others. It is important to emphasize the restraints are not being used as punishment, but rather have therapeutic value. Give the patient a final chance to comply with requests with restraint team in attendance (‘show of force’)
4. Initiate physical restraint by keeping the patient supine, arms beside and body & legs extended. Alternative is to have one arm up (reduces movement). Medical grade restraints should be applied securely to each extremity and tied to the solid frame of the bed (not side rails).
   • Avoid neck or torso restraint (unsafe for patient), and avoid hobble restraints (i.e. tying hands and legs behind back).
   • Spit hoods have been applied by prehospital providers recently, but these cover the face and encircle the neck representing a possible airway concern.
   • It is key to explain to patient what is happening at all times!
5. Lower extremities should be tied to the opposite side of the bed to prevent flailing or generation of lateral force if possible.
6. After restraints have been applied, the patient should be closely monitored. Restraints should not be applied indefinitely, and multiple reevaluations should be done to determine when it is safe to remove restraints. Document appropriate reassessments per institutional and regional policy (ie every 30 minutes, or every hour)
   • Documentation: Reason for restraint, alternative therapies attempted, assessment of potential injuries and any complications of restraint, monitoring plan, thresholds for further interventions, ongoing sedation options and sedation chart
     
   • Elevate head of bed to 30 degrees if possible (decrease aspiration risk)
   • No pillows (decrease suffocation risk)
   • Perform cyclical limb release if possible
   • Ensure appropriate fluid maintenance, toileting and pressure cares
7. Removal of restraints as soon as possible once patient is calm and/or sedated. Remove restraints from one limb at a time – start with a leg then contra-lateral arm

Physical restraints can be a bridge to safely administering chemical restraints – more on that in episode 3 of this series.

Summary

All right, so that’s it for this episode – hopefully you learned a bit more about how to safely deescalate an agitated child, and how we can keep them and ourselves as providers safe in a stressful environment. The third episode in this series will focus on medical management of acute agitation

Resources

• emDOCs.net Articles
  • emDOCs Cases: ED Approach to Agitation
  • Pediatric EM Morsels: Agitation
  • The Art of the ED Takedown
  • Ketamine for the Agitated/Violent Patient
  • ToxCard: Dexmedetomidine & Ketamine in Toxicologic Causes of Agitation
  • Droperidol Use in the Emergency Department – What’s Old is New Again
• PEM Blog via Brad Sobolewski (@PEMTweets)
• EMSC IIC (Emergency Medical Services for Children Innovation and Improvement Center)
  • EMSC IIC: Pediatric Education and Advocacy Kit (PEAK): Agitation
    • EIIC/TREKK: Care of the Agitated Patient Algorithm
    • EIIC/TREKK: Agitation Medication Dosing Recommendation Table
    • EIIC: De-escalation Tips for Pediatric Agitation Infographic
    • EIIC: Emergency Department Management of the Agitated Pediatric Patient Interactive Learning Module
    • EIIC: Agitation in Neurodivergent Patients with Drs. Alice Kuo and Ilene Claudius Podcast
    • EIIC: Safe Control of the Agitated Patient Webinar Series with Dr. Marianne Gausche-Hill
    • New England EMSC: New England Regional Behavioral Health Toolkit
  • For more info, please email km@emscimprovement.center or follow on Twitter @EMSCImprovement

Other Episodes in the Agitation Series

Episode 1: Differentiating organic versus psychiatric causes of agitation and altered mental status

Episode 2: Non-pharmacologic management of agitated children (Current)

Episode 3: Pharmacologic management of agitated children (Coming May 31, 2023)

Episode 4: Safe pre-hospital transport of the agitated child (Coming June 7, 2023)

Episode 5: Management of the child with mental health problems who is boarded in the Emergency Department (Coming June 14, 2023)

References

Berzlanovich AM, Schöpfer J, Keil W. Deaths due to physical restraint. Dtsch Arztebl Int. 2012 Jan;109(3):27-32. PMC3272587.

Coburn VA, Mycyk MB. Physical and chemical restraints. Emerg Med Clin North Am. 2009 Nov;27(4):655-67, ix. doi: 10.1016/j.emc.2009.07.003. PMID: 19932399.

Downes MA, Healy P, Page CB, Bryant JL, Isbister GK. Structured team approach to the agitated patient in the emergency department. Emerg Med Australas. 2009 Jun;21(3):196-202. PMID: 19527279.

Knox DK, Holloman GH Jr. Use and avoidance of seclusion and restraint: consensus statement of the american association for emergency psychiatry project Beta seclusion and restraint workgroup. West J Emerg Med. 2012 Feb;13(1):35-40. PMC3298214.

Melamed E, Oron Y, Ben-Avraham R, Blumenfeld A, Lin G. The combative multitrauma patient: a protocol for prehospital management. Eur J Emerg Med. 2007 Oct;14(5):265-8. PMID: 17823561.