Caring for Patients with Anxiety

Anxiety is a normal emotional and physiological response to uncomfortable, novel or frightening situations. During an emergency department (ED) visit, anxiety can be experienced by any child or adolescent as well as by their caregivers. It may be the primary reason for the visit or develop during assessments, procedures, or investigations.

How individuals experience anxiety during an ED visit can vary. Approaches to recognize, assess and manage anxiety need to be patient- and family-centred.¹

For an Acutely Agitated Patient Refer to TREKK’s Care of the Agitated Patient Algorithm.

Anxious patients can exhibit a range of emotional and physical complaints.

Use an empathic and uncritical approach to establish rapport, de-escalate stress and worries, and facilitate communication.

DO:

• Ensure the patient and their caregiver know the limits of confidentiality in the health care setting and ask the adolescent what they are okay with you sharing with their caregiver.
• Manage the environment: dim lights, minimize noise and interruptions within room.
• Address needs (e.g., food/drink, personal space from caregivers, headphones).
• Ask patient/caregivers what is most helpful in approach.
• Sit down, speak slowly, calmly, and clearly, and allow time for questions.
• Build trust and reassurance through statements such as, “You are being very brave. You are doing a great job staying still and squeezing the nurse’s hand.”
• When possible, allow for choice in the care provided.
• Validate the patient/caregiver experience and the challenges they face.
• Recognize and acknowledge culture can impact experiences and care.

AVOID:

• Statements like “Calm down”, “You don’t need to worry about that”, or “You’ll be fine.”
• Attributing all physical complaints to underlying anxiety.
• Focusing on the presenting complaint and ignoring the patient/caregiver’s emotional well-being.
• Minimizing the distress anxiety causes.

Prepare and support

• Approach every patient as though they have had a past traumatic experience to ensure they feel safe and in control.
• Consider speaking with an adolescent patient and caregiver separately to provide privacy while also obtaining collateral history from caregivers.
• Give patient and caregiver information about what to expect during the ED visit (e.g., wait times, nursing checks, evaluation by emergency physician (and learners) to determine best plan, how information will be communicated).

Offer comfort measures

• Consider who should be with the patient for reassurance.
• Ask the patient what would be helpful and offer suggestions such as music, food, or a warm blanket.
• Check in with caregiver to ensure their comfort. Do they need breaks and how staff can support them?

Explain

• Experiences that are uncomfortable, novel, or frightening can result in physical and emotional anxiety- based responses (e.g., mind-body connection).
• Validate the distress arising from physical symptoms of anxiety and explain that these symptoms are not dangerous.²
• Anxiety occurs on a spectrum from adaptive (e.g., distress in a new/difficult situation that can be overcome) to maladaptive (e.g., extreme emotional responses are experienced and new/uncomfortable situations are avoided).
• There may be identifiable precipitants, symptoms may be present for brief periods of time, or symptoms may be chronic in nature.

Co-create a patient- and family-centered approach to manage anxiety in the ED

• Active distraction: Playing with an electronic device (smartphone, tablet), square or 5-finger breathing.
• Passive distraction: Watching TV, listening to music.
• Support from allied health professional (e.g., RN, Social Worker, Child Life Specialist), if available.

Pharmacotherapy

• Pharmacotherapy should be reserved for patients with severe anxiety resulting in serious behavioral escalation and acute safety concerns during the ED visit. Refer to TREKK’s Care of the Agitated Patient Algorithm.
• Lorazepam is the preferred first-line medication for use in the ED for severe anxiety³:
  – 0.05 mg/kg/dose, range 0.02 – 0.05 mg/kg/dose, MAX 2 mg/dose PO/SL q 4-8h PRN

Provide resources to help manage anxiety after the ED visit

• Online evidence-based information: anxietycanada.com; keltymentalhealth.ca; kidshelpphone.ca

Thank you to the following content experts who led the development of the Caring for Patients with Anxiety Bottom Line Recommendations:

Amanda Newton, PhD, RN
Professor, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta

Mohamed Eltorki, MBChB, MSc, FRCPC
Associate Professor of Pediatrics and Pediatric Emergency Medicine, University of Calgary

Matthew Morrissette, MD, FRCPC
Assistant Clinical Professor, Department of Psychiatry, University of Alberta

Alexa Bagnell, MD, FRCPC
Professor, Department of Psychiatry, Dalhousie University, IWK Health

Thank you to the TREKK Editorial Committee, editor Dr. Sarah Reid (CHEO), and the CHRIM Parent and Youth Advisory Committee who provided editorial support and expertise in the development of this resource.

1. Klein B, Rajendram R, Hrycko S, et al. Anxiety in children and youth: Part 1-diagnosis. Paediatr Child Health. 2023;28(1):37-51.
2. Campo JV and Fritz G. A management model for pediatric somatization. Psychosomatics. 2001;42(6):467-476.
3. Gerson R, Malas N, Feuer V, et al. Best practices for evaluation and treatment of agitated children and adolescents (beta) in the emergency department: Consensus Statement of the American Association for Emergency Psychiatry. West J Emerg Med. 2019 Mar;20(2):409-418.

To see our resource development process please visit our website.

For a complete list of the evidence that informed the creation of the Caring for Patients with Anxiety Bottom Line Recommendations see the Evidence Repository.

The purpose of this document is to provide healthcare professionals with key facts and recommendations for caring for children and youth with anxiety in the emergency department. The TREKK Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. THIS DOCUMENT IS SUBJECT TO FULL DISCLAIMER HERE: trekk.ca/terms-of-use