Acute Severe Behavioral Disturbance Requiring Parenteral Sedation in Pediatric Mental Health Presentations to Emergency Medical Services: A Retrospective Chart Review

Study Objectives: To describe the epidemiological factors of mental health presentations in young people to emergency medical services (EMS) and define those experiencing acute severe behavioral disturbance by reviewing parenteral sedation use. Methods: We performed a retrospective review of records of EMS attendance for young people (aged <18 years) with mental health presentations between July 2018 and June 2019 to a statewide EMS system in Australia of a population of 6.5 million persons. In addition, epidemiological data and information about parenteral sedation for acute severe behavioral disturbance and any adverse events were extracted from the records and analyzed. Results: A total of 7,816 patients had mental health presentations with a median age of 15 years (IQR 14-17). The majority (60%) were female. These presentations accounted for 14% of all pediatric presentations to EMS. Out of them, 612 (8%) received parenteral sedation for acute severe behavioral disturbance. A number of factors were associated with increased odds of parenteral sedative medication being used, including autism spectrum disorder (odds ratio [OR] 3.3; confidence interval [CI], 2.7 to 3.9), posttraumatic stress disorder (OR 2.8; CI, 2.2 to 3.5) and intellectual disability (OR 3.6; CI, 2.6 to 4.8). The majority (460, 75%) of young people received midazolam as their first-line medication, with the remaining patients being provided ketamine (152, 25%). No serious adverse events were noted. Conclusion: Mental health conditions were a common presentation to EMS. A history of autism spectrum disorder, posttraumatic stress disorder, or an intellectual disability increased the odds of receiving parenteral sedation for acute severe behavioral disturbance. Sedation appears generally safe in the out-of-hospital setting.