In this episode, I’ll discuss oral sedation strategies for young patients presenting to the ED with acute severe behavioral disturbance.
When treating children and adolescents who present to the ED with acute behavioral disturbances, the American Association for Emergency Psychiatry states:
There is consensus that PO administration should be tried whenever possible before the IM route.
To determine whether the benzodiazepine diazepam is better at controlling acute severe behavioral distrubances in this population than the atypical antipsychotic olanzapine, a group of authors conducted and published a randomized trial in the journal Annals of Emergency Medicine.
The study was an open-label, multicenter, randomized controlled trial in 9 Australian Emergency Departments. Just under 350 patients were randomized to receive a single weight-based oral dose of olanzapine or diazepam. The study’s primary outcome was successful sedation defined as a Sedation Assessment Tool score less than or equal to 0 without the need for additional sedatives at one hour postrandomization. Secondary outcomes included serious adverse events.
Successful sedation within one hour occurred in 61% of the patients in the olanzapine group vs 57% of patients in the diazepam group. This difference was not statistically significant. There were no differences in serious adverse events between groups either.
While the study finds there is no difference between oral olanzapine and diazepam in this patient population, it also reveals another very important detail about these medications; 40% of the time, they fail to adequately sedate a patient within 1 hour when a single dose is used.
Given that a severely agitated patient can be at risk of harm to themselves, family, and staff it is important for clinicians to have realistic expectations about the effectiveness of medication used to treat the agitation. Given the high probability that a single dose of oral medication will not be adequate to control sedation, clinicians should be vigilant about the need for a repeat dose. The American Association for Emergency Psychiatry advises:
There is consensus that if an initial dose of medication was ineffective, a second dose of the same medication is preferable to adding multiple different medications (unless limited by ADE), as children can be vulnerable to drug-interaction adverse effects. An exception to this was combining haloperidol and lorazepam, which was generally considered preferable to a second dose of a neuroleptic in non-delirious patients. The etiology of agitation should be reassessed continuously, especially after two doses of a particular medication, and youth who have received multiple doses should be monitored continuously.
The exception regarding haloperidol and lorazepam is not generalizable as elsewhere in the same document the authors state:
Do not give with or within 1 hour of any BZD given risk for respiratory suppresion
The article in this episode is a selection from my Hospital Pharmacy Academy’s weekly literature digest. Have you ever felt like your physician colleagues are one step ahead of you with new literature developments? Every week, Academy members are provided a summary curated and explained by me of the top hospital pharmacy-related articles published that week from over 20 major journals and sources to save you time and keep you up to date with the literature. To get immediate access, go to pharmacyjoe.com/academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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