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Acute Sedation (Adult & Children)

This document is a summarised version of DG-GC6-Pharmacological Management of Acute Behavioural Disturbance in the Emergency Department and DP-EP4-Prevention and Management of Patients with Behaviours of Concern in the Emergency Department. The summary has been created to be Emergency Department specific, and has been endorsed by the ED Leadership Team . Staff should review the full documents if they require further information.

Overview

This QRG assists in initial pharmacological management of the patient with acute behavioural disturbance in the Emergency Department.  It is not designed to replace clinical judgement, and should be used with appropriate medical involvement, appropriate investigation and continuous reassessment are required.

Applicability

This QRG applies to all nursing and medical staff involved with the assessment and treatment of agitated patients in the Emergency Departments at Western Health.

Responsibility

It is the responsibility of the Nurse Unit Managers and Directors of the Emergency Departments at WH to ensure staff are familiar with this QRG and its content, that it is implemented as outlined within, and that there is compliance by all staff.

Guideline Details

  • Pharmacological management, or sedation, should be used as a last resort to protect the safety of patients, other patients and visitors, and staff.
  • Choice of sedative should be guided by
    • Behaviours of Concern (BOC) score
    • acute clinical considerations, and
    • medical comorbidities.
  • Please see attached tables for guidance on options for
    • Children, <16yo (Table 1)
    • Adults, 16-65yo, (Table 2) and
    • Older adults, >65yo (Table 3)

Process Details

  • Use of other agents should be in consultation with Senior Medical Officers only.
  • Sedation should be carefully considered in consultation with Senior Medical Officers when administered in The Hub and BAU (including BAR rooms) in SHED. These rooms do not contain monitoring equipment.
Table 1: Children <16years or < 50kg

­­RISK ASSESSMENT

What is the situation?

Patient Behaviour

Mild Agitation

 

 

Anxious and agitated

But able to be redirected and reassured

Escalating Behaviour

 

 

Becoming more agitated with possible risk of loss of self control and aggression

Behavioural Crisis

 

 

Severe agitation and distress posing risk to patient and staff safety

Behavioural Emergency

 

Persisting aggressive behaviour despite sedation

Aim of Intervention

Maintain safe environment Prevent a crisis situation Restore a safe environment Maintain staff and patient safety at all times

Immediate Considerations

Introduce non pharmacological strategies, involve family member if appropriate Maximise non pharmacological strategies

Consider BAR/BOCR

Low stimulus environment

Code grey – Security present

Least restrictive practice

Consider BAR/BOCR if appropriate

Continued security presence

Move to monitored area

ED consultant involvement

Medication

In a child with known behavioural disorder consider giving additional dose of usual medication

Olanzapine wafer PO

<40kg 2.5-5 mg PO (max 10 mg daily)

>40kg 5-10  mg PO (max 20 mg daily)

or

Diazepam PO (available in liquid form)

0.2-0.4 mg/kg PO

Max 10 mg

Droperidol IM

0.1-0.2mg/kg

(max 10mg)

Or

Olanzapine IM

<40kg  5 mg

>40kg 10mg

Repeat in 15 min – if not settling escalate to Behavioural Emergency

Ketamine IM/IV

4 mg/kg IM

(max 400mg)

OR

1mg/kg IV (max100mg)

Or

Midazolam IM/IV

0.1-0.2 mg/kg

IM or IV

(max 20 mg/24hours)

 

 

Table 2: Adults < 65years

­­RISK ASSESSMENT

What is the situation?

Patient Behaviour

Mild Agitation

  • BOC-score 0
  • Anxious, agitated
  • But able to be redirected and reassured
Escalating Behaviour

  • BOC-score 1-2
  • Becoming more agitated with possible risk of loss of self control and aggression
Behavioural Crisis

  • BOC-score >2
  • Aggressive behaviour is overt, imminent safety threat
Behavioural Emergency

  • BOC-score >2
  • Persisting aggressive behaviour despite sedation

Aim of Intervention

Maintain safe environment Prevent a crisis situation Restore a safe environment Maintain staff and patient safety at all times

Immediate considerations

  • Consider BAR/BOCR
  • Low stimulus environment
  • Consider BAR/BOCR
  • Low stimulus environment
  • Code Grey
  • Consider BAR/BOCR
  • or move to monitored area
  • Continued security presence
  • Move to monitored area
  • ED consultant/senior registrar involvement

Medication

Diazepam PO 10-20 mg PO

 

 

 

 

 

 

 

Repeat in 2 hours if necessary

Olanzapine PO

5-10mg PO

 

And/OR

 

Diazepam PO

10-20mg PO if not given already

 

Repeat in 2 hours if necessary

Droperidol IM

10 mg IM

If remains unsettled in 15 minutes

Repeat Droperidol IM

10 mg IM

 

If remains unsettled in a further 15 minutes

 

Escalate to Behavioural Emergency

consider

Midazolam IM/IV

5-10 mg IM

OR

2.5-5 mg IV

 

OR

 

Ketamine IM/IV

4-5 mg/kg IM

OR

1-2 mg/kg IV

 

 

 

Table 3: Adults > 65years

RISK ASSESSMENT

What is the situation?

Patient Behaviour

Mild Agitation

  • BOC-score 0
  • Anxious and agitated. But able to be redirected and reassured
Escalating Behaviour

  • BOC-score 1-2
  • Becoming more distressed and agitated with possible risk of unintended aggression
Behavioural Crisis

  • BOC-score >2
  • Severe agitation and distress posing risk to patient and staff safety
Behavioural Emergency

  • BOC-score >2
  • Persisting aggressive behaviour despite sedation

Aim of Intervention

Maintain safe environment Prevent a crisis situation Restore a safe environment Maintain staff and patient safety at all times

Immediate Considerations

Prefer non pharmacological strategies Maximise non pharmacological strategies

Consider BAR/BOCR

Low stimulus environment

Code grey – Security present

Least restrictive practice

Consider BAR/BOCR if appropriate

Continued security presence

Move to monitored area

ED consultant/senior registrar involvement

Medications

Choose one of:

Haloperidol (if no history of Parkinsonism) PO

0.25-0.5mg  PO

repeat after 2 hours (max of 3mg/24hours)

OR

Quetiapine (preferred in Parkinsonism) PO

12.5-25 mg PO

Repeat after 2 hours (max 100 mg/24 hours)

OR

Olanzapine PO

2.5mg PO – repeat after 2 hours (max 5 mg /24 hours)

OR

Risperidone (if already on it from RCF) PO

0.5 mg PO – repeat after 2 hours (max 2 mg/24 hours)

Choose one of:

Haloperidol (if no history of Parkinsons) IM/IV

0.5-1mg IM – repeat after 1 hour (max of 3mg/24 hours)

OR

0.5-1mg IV – repeat after 30 minutes

(max 3 mg/24 hours)

OR

Midazolam – IM/IV – Single dose only

1-2mg IM  (max 2 mg/24 hours)

0.5-1mg IV – repeat after 15-30 minutes

(max 2mg/24hours)

OR

Olanzapine – IM – Single dose only

2.5-5mg IM (max 5 mg/24 hours)

 

Supporting Documents

 

Document Governance 

 

Title:  Acute Sedation (Adult & Children)
Version: 2.0
Date Published: June, 2022
Date of scheduled review: 01/06/2023
Author: Approver:
ED Leadership Team ED Leadership Team

 

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