32.2 Relative Efficacy of Psychotropic Medications for the Management of Acute Agitation in Children and Adolescents in the Psychiatric Emergency Room

Abstract

Children and adolescents frequently present to the emergency room (ER) with acute agitation and often require physical restraint (PR). Due to a dearth of evidence-based guidelines, clinicians may find it daunting to choose the most appropriate pharmacologic intervention in a given patient encounter. Our retrospective cohort study aims to compare the efficacy of psychotropic medications used to treat acutely agitated youth in our ER, as measured by the subsequent need for PR. A retrospective chart review of patients aged 5 to 17 years who visited our ER from January 1, 2019 to December 31, 2020 was conducted. Data on pharmacologic management of “agitation” or “aggression” were gathered to assess the subsequent need for PR use (primary outcome measure). Data analysis was completed to evaluate the relative differences between neuroleptic, anxiolytic, and combination medication use, and of PR use. We identified 1346 total admissions (630 males, 716 females), of which 59 (47 males, 12 females; average age 14.1 years) required PRN medications for agitation. Thirty-two patients (54.2%) who required medication received a combination of anxiolytics and neuroleptics, whereas 20 (33.9%) received anxiolytics alone, and 3 (0.05%) received neuroleptics alone. Thirty-two patients (54.2%) required PR despite pharmacologic attempts at de-escalation. Specifically, 23 (71.9%) who received combination medications, 7 (35%) who received anxiolytics alone, and 2 (66.7%) who received neuroleptics alone subsequently required PR use. The most common diagnoses among patients requiring PRN medications were ADHD (35.6%), ODD (33.9%), autism spectrum disorder (27.1%), and bipolar disorder (20.3%). Further analysis is being conducted for specific medications, formulations, and dosages. Our results correlate with current consensus guidelines for the potential benefit of anxiolytic medication use alone as compared to combination medication or neuroleptics alone in providing first-line pharmacological management of agitation in this patient population. Through continued research, we aim to give providers confidence to use anxiolytics to effectively de-escalate agitated patients. Further consideration should be given to tailoring pharmacologic approaches to the etiology of agitation and to reproducibly demonstrating these findings through prospective studies.