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Best Practices in Managing Child and Adolescent Behavioral Health Emergencies -

Best Practices in Managing Child and Adolescent Behavioral Health Emergencies
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Publication Date: January 2018 (Volume 15, Number 1)


Vera Feuer, MD
Director, Pediatric Emergency Psychiatry, Cohen Children’s Medical Center; Assistant Professor, Psychiatry and Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, New Hyde Park, NY
Babar M. Saggu, MD
Research Track Fellow, Child & Adolescent Psychiatry, Zucker Hillside Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, New Hyde Park, NY.
Jason M. Andrus, MD
Assistant Professor in the Department of Psychiatry, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, New Hyde Park, NY
Joshua Rocker, MD
Associate Chief and Medical Director, Division of Pediatric Emergency Medicine, Assistant Professor of Pediatrics and Emergency Medicine, Cohen Children's Medical Center of New York, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY

Peer Reviewers

Steven Rogers, MD, MS
Associate Professor, University of Connecticut School of Medicine, Director of Emergency Mental Health Services and Pediatric Emergency Medicine Physician, Connecticut Children’s Medical Center, Hartford, CT
Genevieve Santillanes, MD
Associate Professor of Emergency Medicine, LAC+USC Medical Center, Keck School of Medicine of USC, Los Angeles, CA

Behavioral health emergencies most commonly present as depression, suicidal behavior, aggression, and severe disorganization. Emergency clinicians should avoid relying solely on past medical history or previous psychiatric diagnoses that might prematurely rule out medical pathologies. Treatments for behavioral health emergencies consist of de-escalation interventions aimed at preventing agitation, aggression, and harm. This issue reviews medical pathologies and underlying causes that can result in psychiatric presentations and summarizes evidence-based practices to evaluate, manage, and refer patients with behavioral health emergencies.

Excerpt From This Issue

A 16-year-old adolescent girl presents to the ED after ingesting an entire bottle of ibuprofen 4 hours prior. The patient vomited a few times before arrival to the ED. Her initial vital signs are: temperature, 37°C (98.7°F); heart rate, 90 beats/min; blood pressure, 100/70 mm Hg; respiratory rate, 15 breaths/min; and oxygen saturation, 100% on room air. The girl is alert and oriented. Her physical examination is significant for mild epigastric tenderness and numerous well-healed bilateral cut marks on her wrists and thighs. A quick neurological examination reveals no abnormalities. The patient is a high school student who had excelled academically, but has had poor examination results recently. Her long-term boyfriend ended their relationship 1 week prior. The girl denies any substance use. She states that when she took the pills, she had wanted to kill herself because, “everything is horrible and overwhelming.” While you evaluate her privately, she does not make eye contact and remains silent when you ask about her current intent for suicide. You begin to think about the precautions you should take to keep this patient safe and what the next steps in the management should be...

A 15-year-old adolescent boy is brought to the ED by police because he threatened his mother with a knife. The police report states that he “trashed the house.” The patient’s mother arrives in the ED and states that their argument started because she would not allow her son to go out with a group of older friends whom she believes are a bad influence. She reports that her son has been abusing “oxy” that was initially prescribed following a football-related back injury. Since the injury, depression and truancy have been significant problems. The patient’s family history is concerning for both depression and substance abuse. When you evaluate the patient, he is diaphoretic and his pupils are dilated. Initially, he is cooperative and admits that he wants to “stop using the pills.” He adds that he has had transient thoughts of suicide but has never made a plan or attempted suicide. As you continue questioning the patient, his behavior begins to escalate and, despite redirection, he starts yelling. What should you do to ensure the safety of this patient and the ED staff? How should you respond if the patient’s aggressive behavior escalates further?


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