Intramuscular drug regimens for acute severe behavioural disturbance in children
Managing a patient with acute behavioural disturbance is a detailed flowchart for managing a patient with acute behavioural disturbance.
The indications for intramuscular sedation for acute severe behavioural disturbance in children are detailed here.
Most emergency departments and hospitals have protocols for the safe use of parenteral sedation—follow local protocols or consensus state guidelines if available.
When considering the use of intramuscular sedation in children, always seek expert advice. If intramuscular sedation is used, monitor the patient closely for adverse drug effects. For information about minimum monitoring and equipment requirements, see Principles of monitoring a patient with acute behavioural disturbance.
The aim of pharmacological management is to calm the patient with a sufficient initial dose of a sedative drug. Repeated subtherapeutic doses that are inadequate to reduce the patient’s distress and calm their behaviour can prolong the risk of harm to the patient or others. This can also result in larger cumulative doses, or multiple drug administration, both of which increase the risk of adverse drug effects, especially in children.
The most common drugs used in children to manage acute behavioural disturbance are benzodiazepines and antipsychotics, which are used for their sedative effects. The sedative effects of antipsychotics occur much sooner than the antipsychotic effects.
The choice of antipsychotic depends on the situation and individual patient factors. Droperidol is more sedating than olanzapine and is preferred for its rapid effect in highly agitated or drug-affected young people; olanzapine is shorter acting than droperidol and is preferred for a younger child who needs to be settled, but requires a full assessment within an hour.
When selecting a suitable drug dose and regimen, consider patient factors, such as their level of agitation and distress (eg measure with a Sedation Assessment Tool [SAT] score), age, body size, sex, comorbidities, drug history, previous response to sedative drugs and response to treatment.
If intramuscular sedation is indicatedfor a child with acute severe behavioural disturbance, in combination with nonpharmacological techniques, suitable first-line drugs include:
1 droperidol 0.1 to 0.2 mg/kg up to 10 mg intramuscularly. If required, repeat after at least 15 minutes; if more than 0.4 mg/kg up to 20 mg in total is required, seek expert advice1 acute severe behavioural disturbance, child droperidol
OR
2 olanzapine 5 mg intramuscularly (for children less than 40 kg) and 10 mg intramuscularly (for children 40 kg and over). If required, repeat after 30 minutes; if more than 10 mg (total for children less than 40 kg) or 20 mg (total for children 40 kg and over) is required, seek expert advice. acute severe behavioural disturbance, child (intramuscular) olanzapine
Midazolam can be used second line (to an antipsychotic) for a child. A suitable regimen for intramuscular use is:
midazolam 0.1 to 0.2 mg/kg up to 10 mg intramuscularly. If required, repeat after at least 15 minutes; if more than 20 mg in total is required, seek expert advice. acute severe behavioural disturbance, child midazolam
Always monitor the patient closely for potential adverse effects after administering an intramuscular sedative drug.