Ep 217 Pediatric Agitation: Assessment and Management

April 28, 2026

AI Summary

5 min read

In a 2019 expose, researchers documented a shockingly high mortality rate from physical restraint in mental health patients, both adults and children. That finding has shaped how pediatric emergency physicians now approach the agitated child—not as a problem to be subdued, but as a patient in crisis whose behavior is a symptom of an underlying condition. Dr. Susan Duffey and Dr. Tom Chun, both from Brown University’s Hasbro Children’s Hospital, walk through a framework that prioritizes anticipation, de-escalation, and etiology-driven medication over reflexive restraint or sedation.

Categorize, then anticipate

The first step is sorting agitation into mild (agitated but cooperative), moderate (disruptive but not dangerous), or severe (imminent risk of harm). This categorization determines where the patient is placed, what level of observation is needed, and how the team responds. But the real leverage point comes earlier: anticipating agitation before it starts. The single most predictive factor is a prior history of aggression. Other red flags include adolescence, male sex, a mental health or behavioral complaint, substance use, neurodevelopmental disorders (autism, developmental delay), and a history of trauma or abuse.

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What you'll learn

1 (01:30) **The Surge in Pediatric Agitation - Why This Episode Matters** - ED visits for pediatric mental health emergencies have risen dramatically, yet many hospitals lack specific protocols for managing agitated children.
2 (05:44) **Categorizing Agitation: Mild, Moderate, and Severe** - The first step is sorting patients into three categories to guide your response, location, and level of observation.
3 (08:42) **Predicting and Preventing Agitation Before It Starts** - Anticipating agitation is the single best strategy, starting at triage with a trauma-informed approach.
4 (12:02) **Simple Moves to De-escalate the Environment** - Concrete, low-effort actions to prevent agitation in high-risk patients.
5 (16:47) **Initial Stabilization: Triage, Location, and Medical Assessment** - A systematic approach from the moment the patient walks in the door.
6 (21:10) **The ABCs of Verbal De-escalation** - A practical, team-based approach to calming the patient without physical force.
7 (25:49) **When and How to Call a Code White** - The critical distinction between appropriate use and overuse of security teams.

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Show Notes

Pediatric agitation in the Emergency Department is one of those presentations that can escalate quickly and leave even experienced clinicians feeling on edge. It is high-risk, resource-intensive, and often unfolds in an already overstimulating environment where small missteps can make things worse. At the same time, agitation is not a diagnosis, it is a clinical presentation that may reflect anything from psychiatric illness to delirium, intoxication, trauma, or simply a child overwhelmed by the ED itself. So how do we approach these patients in a way that is safe, systematic, and effective? In this episode with guest experts, Dr. Susan Duffy and Dr. Thomas Chun, we tackle the questions that come up at the bedside: How do we rapidly distinguish mild, moderate, and severe agitation in a way that actually changes what we do next? Which patients are most likely to escalate, and how can we intervene early to prevent that? When should we be worried about a medical or toxicologic cause rather than assuming this is “behavioural”? What does effective verbal de-escalation actually look like in a busy ED, and why does it so often fail? When is a "code white" for emergency security measures truly indicated, and how do we avoid turning it into an escalation trigger? How should we be thinking about medications: what to choose, when to give them, and how to avoid over-sedation? And once the patient is finally calm, how do we make sure we aren't missing the underlying diagnosis? and many more... Please consider a donation to EM Cases to support ongoing high quality Free Open Access Medical Education https://emergencymedicinecases.com/donation/