Pharmacotherapy for Agitation Management in a Pediatric Emergency Department

In the treatment of agitation in a pediatric emergency department (PED), it is common to use once or as needed (PRN) medications when nonpharmacological management options have failed. Currently, there is limited available evidence on the treatment of pediatric agitation. The objective of this analysis was to characterize the prescribing practices of once or PRN medications for the treatment of agitation in a PED at an academic medical center.

This was a retrospective chart review of all encounters in which a patient was administered once or PRN medications for agitation treatment in the PED from July 1, 2021, to June 30, 2022. Once or PRN medications were defined as any medication in the antipsychotic, benzodiazepine, and barbiturate classes along with diphenhydramine, clonidine, ketamine, and guanfacine. The primary outcome was to describe the prescribing patterns of the most utilized agents for the treatment of agitation in the PED. Secondary outcomes were to assess effectiveness and safety of the agents utilized.

We reviewed 109 patient encounters in which a once or PRN medication was used for agitation treatment. The most common initial regimens were benzodiazepine monotherapy (n = 47; 43%), antipsychotic monotherapy (n = 23; 21%), and concurrent use of an antipsychotic, benzodiazepine, and diphenhydramine (n = 16; 15%). Patients required another administration of a once or PRN medication within 5 to 120 minutes of initial administration 11% (n = 12) of the time. No patients required rapid sequence intubation and one patient (0.9%) needed treatment for extrapyramidal symptoms.

Results indicate that there is not a standard regimen choice in the treatment of agitation in the PED; however, benzodiazepine monotherapy was used most frequently. Few adverse events occurred. Further research is needed to identify the optimal regimen choice for patients presenting with agitation in a PED.