The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

Pediatric Toxidrome Simulation Curriculum: Jimson Weed Toxicity

Introduction

Jimson weed is a poisonous plant containing tropane alkaloids that can cause anticholinergic toxicity. Recognition of anticholinergic toxidrome is important for prevention and management of potentially life-threatening complications of severe toxicity, including dysrhythmia and seizure.

Methods

Designed for pediatric emergency medicine (PEM) fellows, this simulation featured a 15-year-old female presenting to the emergency department (ED) with agitation and hallucinations. The team was required to perform a primary survey of the critically ill patient, recognize anticholinergic toxidrome from jimson weed intoxication, and treat complications of severe anticholinergic toxicity. Learners practiced critical resuscitation skills such as management of generalized tonic-clonic seizure, endotracheal intubation, synchronized cardioversion, and external cooling measures. A debriefing guide and participant evaluation forms were utilized. This simulation was created as both an in-person and a virtual simulation experience to accommodate COVID-19 social distancing guidelines.

Results

Seventeen PEM fellows completed this simulation across three institutions (two in person, one virtual). Using 5-point Likert scales (with 5 being the most relevant or effective), participants rated the simulation as relevant to their work (M = 4.8, SD = 0.5) as well as effective in teaching basic resuscitation skills (M = 4.7, SD = 0.5), management of generalized tonic-clonic seizure (M = 4.8, SD = 0.5), and treatment of ventricular tachycardia with appropriate interventions (M = 4.6, SD = 0.5).

Discussion

This simulation scenario allows pediatric medicine trainees in the ED to practice recognition and management of anticholinergic toxicity and its severe complications secondary to jimson weed ingestion.

Crowding in the Emergency Department: Challenges and Recommendations for the Care of Children

Emergency department (ED) crowding results when available resources cannot meet the demand for emergency services. ED crowding has negative impacts on patients, health care workers, and the community. Primary considerations for reducing ED crowding include improving the quality of care, patient safety, patient experience, and the health of populations, as well as reducing the per capita cost of health care. Evaluating causes, effects, and seeking solutions to ED crowding can be done within a conceptual framework addressing input, throughput, and output factors. ED leaders must coordinate with hospital leadership, health system planners and policy decision makers, and those who provide pediatric care to address ED crowding. Proposed solutions in this policy statement promote the medical home and timely access to emergency care for children.

Crowding in the Emergency Department: Challenges and Best Practices for the Care of Children

Emergency department (ED) crowding has been and continues to be a national concern. ED crowding is defined as a situation in which the identified need for emergency services outstrips available resources in the ED. Crowding is associated with higher morbidity and mortality, delayed pain control, delayed time to administration of antibiotics, increased medical errors, and less-than-optimal health care. ED crowding impedes a hospital's ability to achieve national quality and patient safety goals, diminishes the effectiveness of the health care safety net, and limits the capacity of hospitals to respond to a disaster and/or sudden surge in disease. Both children and adults seeking care in emergency settings are placed at risk. Crowding negatively influences the experience for patients, families, and providers, and can impact employee turnover and well-being. No single factor is implicated in creating the issue of crowding, but elements that influence crowding can be divided into those that affect input (prehospital and outpatient care), throughput (ED), and output (hospital and outpatient care). The degree of ED crowding is difficult to quantify but has been linked to markers such as hours on ambulance diversion, hours of inpatient boarding in the emergency setting, increasing wait times, and patients who leave without being seen. A number of organizations, including the American College of Emergency Physicians, the Emergency Nurses Association, and the National Quality Forum, have convened to better define emergency metrics and definitions that help provide data for benchmarks for patient throughput performance. The Joint Commission has acknowledged that patient safety is tied to patient throughput and has developed guidance for hospitals to ensure that hospital leadership engages in the process of safe egress of the patient out of the ED and, most recently, to address efficient disposition of patients with mental health emergencies. It is important that the American Academy of Pediatrics acknowledges the potential impact on access to optimal emergency care for children in the face of ED crowding and helps guide health policy decision-makers toward effective solutions that promote the medical home and timely access to emergency care.

Unintentional Pediatric Marijuana Exposures at a Tertiary Care Children's Hospital in Washington State: A Retrospective Review

BACKGROUND

Recreational marijuana became commercially available in Washington State in 2014. Children with marijuana intoxication can have lethargy and altered mental status, often resulting in extensive workup.

OBJECTIVES

The aim of this study was to quantify the incidence of pediatric marijuana exposure before and after marijuana legalization/commercial availability in Washington State at a tertiary care children's hospital.

METHODS

Charts of patients 9 years or younger evaluated at a tertiary care pediatric hospital from October 8, 2007, to October 31, 2016, were retrospectively reviewed. Inclusion criteria were positive tetrahydrocannabinol urine toxicology screen and diagnosis consistent with unintentional marijuana exposure. Data included age, sex, exposure date range, symptoms, ancillary tests, consults, disposition, and marijuana source. Data were analyzed in R using descriptive statistics.

RESULTS

Seventeen unintentional marijuana exposures were identified during our study period, 8 cases before and 9 cases after legalization of recreational marijuana, which is 1.19 events per year in the 6.75 years before legalization compared with 3.88 events per year in the 2.32 years after (P < 0.05). Age range was 17 months to 7 years, with a median age of 21 months. Eighty-two percent received laboratory tests, 47% underwent head computed tomography, 6% underwent lumbar puncture, and 100% underwent social work evaluation. Thirty-five percent were discharged from the emergency department, 47% were admitted to general medicine, and 18% were admitted to the critical care unit.

CONCLUSIONS

Unintentional marijuana exposure incidence increased after legalization of recreational marijuana in Washington State at a tertiary care children's hospital. Providers should be aware of this increasing incidence. These data should be considered in the drafting of future marijuana legislation.

Pediatric Toxidrome Simulation Curriculum: Lidocaine-Induced Methemoglobinemia

INTRODUCTION

Lidocaine is a common local anesthetic used during minor procedures performed on pediatric patients. A rare but toxic and life-threatening side effect of lidocaine is methemoglobinemia. It should be considered in children who are hypoxic after exposure to an oxidizing agent.

METHODS

We developed this simulation case for pediatric emergency medicine (PEM) fellows, but it can be adapted for interprofessional simulation. The case involved a 1-month-old male with hypoxia and resulting central cyanosis after exposure to lidocaine. The team performed an initial evaluation and intervention, collected a history, and developed a differential diagnosis for hypoxia and central cyanosis in an infant. Methemoglobinemia was confirmed by CO-oximetry. Preparatory materials, a debriefing guide, and scenario evaluation forms assisted with facilitation.

RESULTS

Fifty-six participants (including 18 PEM fellows) completed this simulation across four institutions. Participants rated the scenario on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree), finding it to be relevant to their work (median = 5) and realistic (median = 5). After participation in the simulation, learners felt confident in their ability to recognize methemoglobinemia (median = 4) and implement a plan to stabilize an infant with hypoxia (median = 4).

DISCUSSION

This simulation represents a resource for learners in the pediatric emergency department. It teaches the recognition and management of an infant with lidocaine toxicity and resultant methemoglobinemia. It uses experiential learning to teach and reinforce a systematic approach to the evaluation and management of a critically ill infant with acquired methemoglobinemia.

Pediatric Emergency Medicine Didactics and Simulation (PEMDAS): Serotonin Syndrome

Introduction

Serotonin syndrome is caused by an accumulation of serotonin in the body from drug interactions or overdose of serotonergic medications, including commonly used antidepressants. Symptoms can be life-threatening and encompass both neurologic and cardiovascular toxicity, including agitation, seizure, tachycardia, rhabdomyolysis, and hyperthermia.

Methods

This simulation case was developed for pediatric emergency medicine fellows and emergency medicine residents in the pediatric emergency department and can be altered to accommodate other learners. The case involved a 16-year-old male, represented by a low- or high-fidelity manikin, who presented with altered mental status/agitation after an overdose of antidepressant medication. The team of learners was required to perform a primary and a secondary assessment; manage airway, breathing, and circulation; and recognize and initiate treatment for serotonin syndrome. The patient had a seizure resulting in airway compromise requiring advanced airway support, as well as developed rhabdomyolysis requiring aggressive fluid hydration. We created a debriefing guide and a participant evaluation form.

Results

Fifty-seven participants across five institutions completed this simulation, which included residents, fellows, faculty, and students. The scenario was rated by participants using a 5-point Likert scale and was generally well received. Participants rated the simulation case as effective in learning how to both recognize (M = 4.9) and manage (M = 4.8) serotonin syndrome.

Discussion

This pediatric emergency simulation scenario can be tailored for a range of learner backgrounds and simulation environments. We used the participant evaluation form to improve future iterations of the simulation.

Epidemiology of cutaneous porphyria in Israel: a nationwide cohort study

BACKGROUND

From a dermatologist's perspective, there are four major types of cutaneous porphyrias (CPs): porphyria cutanea tarda (PCT), erythropoietic protoporphyria (EPP), variegate porphyria (VP) and hereditary coproporphyria (HCP). Scarce data are available regarding the epidemiology of CPs.

OBJECTIVES

To describe the epidemiology of CPs in Israel, including distribution, incidence and prevalence rates of major types.

METHODS

This retrospective study includes all patients who were diagnosed with CPs between the years 1988-2018. It is based on data from Israel's National Service for the Biochemical Diagnoses of Porphyrias, and Israeli patients' nationwide electronic medical charts. Incidence and prevalence rates were calculated.

RESULTS

Of 173 patients with CPs diagnosed during a 30-year period, 65 (38%) had VP, 62 (36%) had PCT, 31 (18%) had HCP and 15 (9%) had EPP; with incidence rates of 0.29, 0.30, 0.17, 0.07, and prevalence rates of 6.3, 4.8, 2.9, 1.6, respectively, per million population. Characteristics of patients with PCT differed from those with other CPs with regard to lack of family history, older mean age at diagnosis [51 vs. 36 (VP), 35 (HCP) and 25 (EPP) years] and male predominance (81% vs. similar distribution). All patients with PCT were diagnosed at adulthood, while 20%, 19% and 15% of patients with VP, HCP and EPP, respectively, were diagnosed during childhood or adolescence.

CONCLUSIONS

Variegate porphyria and PCT were found to be the most prevalent in Israel; however, CPs might be underdiagnosed, thus dermatologists' awareness of these rare disorders is highly important.

Real-life experience in the treatment of solar urticaria: retrospective cohort study

BACKGROUND

Solar urticaria (SU) is a rare photodermatosis causing a significant impact on patients' quality of life (QoL), and treatment is often challenging.

AIM

To analyse clinical experience with a tailored stepwise therapeutic approach.

METHODS

A retrospective cohort design was used. Patients with suspected SU underwent laboratory investigations and photoprovocation. Those with a high minimal urticaria dose (MUD) were treated with a single antihistamine (protocol 1), and those with a lower MUD received three types of antihistamines (protocol 2); both protocols included a leucotriene receptor antagonist (LRA). In cases of failure, treatment was switched to omalizumab at doses of < 300 mg/month with incremental dosage increases as necessary (monthly dose range, 150-600 mg/month). Symptom relief and photoprovocation under treatment were evaluated.

RESULTS

In total, 30 patients (10 men, 20 women) were enrolled. Most (87%) were sensitive to visible light (1-70 J/cm² ) with or without extension to ultraviolet A. Of the 30 patients, 23 opted for our stepwise approach: 22 achieved complete remission on protocols 1 or 2 (n = 17) or after switching to omalizumab (n = 5), and another patient achieved partial remission under omalizumab. There were no treatment-related severe adverse effects.

CONCLUSIONS

Symptoms of SU can be well controlled by treatment with antihistamines and an LRA tailored to the degree of photosensitivity, followed by omalizumab in refractory cases. This has important implications for patient QoL.

Unintentional Pediatric Marijuana Exposures Prior to and After Legalization and Commercial Availability of Recreational Marijuana in Washington State

BACKGROUND

Washington State was one of the first states to legalize recreational marijuana. Increased availability of marijuana may result in more unintentional pediatric exposure, which often presents as altered mental status with unknown cause.

OBJECTIVES

To quantify unintentional pediatric marijuana exposures reported to the Washington Poison Center (WAPC) prior to and after legalization and commercial availability of recreational marijuana.

METHODS

Data were obtained from the WAPC database, toxiCALL®. Patients ≤ 9 years old with a reported marijuana exposure between July 2010 and July 2016 were included in the analysis. Patient and exposure characteristics were summarized and median exposure frequencies were calculated for the periods prior to and after legalization.

RESULTS

There were 161 cases meeting the inclusion criteria that occurred between July 2010 and July 2016. Of these, 130 (81%) occurred in the 2.5-year period after legalization of recreational marijuana in January 2013. The median age of exposed children was 2 years (range 0-9 years). Eighty-one percent of the exposures occurred in the child's own home. The number of exposures per month increased after recreational marijuana was legalized in November 2012, and increased further once recreational marijuana shops were legally allowed to open in July 2014.

CONCLUSION

Reported unintentional pediatric marijuana exposure has increased in the state of Washington since recreational marijuana was legalized. As marijuana becomes more available, clinicians should be aware of the risk of unintentional pediatric marijuana exposure, and this should inform lawmakers regarding regulations around childhood exposure to marijuana.

Pediatric Emergency Medicine Simulation Curriculum: Marijuana Ingestion

Introduction

Altered mental status can be a challenging presenting symptom in children due to the wide differential diagnosis, which ranges from the relatively benign to the life threatening. Marijuana ingestion and unintentional intoxication are becoming an increasingly common cause of altered mental status in children as marijuana use and availability of enticing marijuana edibles increase in the United States. Because children present with altered mental status rather than the typical marijuana toxidrome, appropriately managing these patients in emergency settings can be particularly challenging.

Methods

This simulation-based curriculum involved the evaluation and management of a 6-year-old boy who presented with altered mental status from acute marijuana intoxication unbeknownst to his parents. Participants systematically evaluated a pediatric patient with a broad differential diagnosis of altered mental status and managed the patient with acute marijuana intoxication. This scenario may be modified based on trainee level (medical student vs. resident vs. fellow).

Results

A total of 20 trainees comprising six emergency medicine fellows and 14 pediatric residents and medical students participated in this simulation curriculum over three iterations. Trainees consistently rated it as an overall positive learning experience for pediatric altered mental status and toxidrome education.

Discussion

Low-frequency, high-risk illnesses such as altered mental status due to marijuana intoxication require providers to be familiar with their evaluation and management. This curriculum provides instructors with the materials to successfully implement and improve the simulation over time.

Pediatric Readiness in the Emergency Department

This is a revision of the previous joint Policy Statement titled "Guidelines for Care of Children in the Emergency Department." Children have unique physical and psychosocial needs that are heightened in the setting of serious or life-threatening emergencies. The majority of children who are ill and injured are brought to community hospital emergency departments (EDs) by virtue of proximity. It is therefore imperative that all EDs have the appropriate resources (medications, equipment, policies, and education) and capable staff to provide effective emergency care for children. In this Policy Statement, we outline the resources necessary for EDs to stand ready to care for children of all ages. These recommendations are consistent with the recommendations of the Institute of Medicine (now called the National Academy of Medicine) in its report "The Future of Emergency Care in the US Health System." Although resources within emergency and trauma care systems vary locally, regionally, and nationally, it is essential that ED staff, administrators, and medical directors seek to meet or exceed these recommendations to ensure that high-quality emergency care is available for all children. These updated recommendations are intended to serve as a resource for clinical and administrative leadership in EDs as they strive to improve their readiness for children of all ages.

Pediatric Toxidrome Simulation Curriculum: Liquid Nicotine Overdose

Introduction

Liquid nicotine exposure is becoming more common in the pediatric population. Toxicity may occur with exposure to small quantities given the high concentrations in solutions available commercially. Effects can include altered mental status, seizure, and death.

Methods

This simulation-based case involves the identification and management of a toddler presenting with acute liquid nicotine exposure, with emphasis on the general approach to the acutely ill pediatric patient, consideration in toxic exposures, and the presentation of nicotine exposure. Providers should assess airway, breathing, and circulation while concurrently providing supportive care for an actively seizing simulated patient, necessitating appropriate selection of medications and acute airway management. Additionally, providers must maintain a broad differential diagnosis and obtain a focused history to narrow that differential and identify toxic exposure as a cause of the patient's presentation. Preparatory and didactic material is provided to help the instructor prepare the simulation environment, guide learners through the case, and debrief with learners afterward.

Results

We implemented this curriculum with four pediatric emergency medicine fellows and 15 pediatric residents during two sessions. Feedback was overwhelmingly positive; participants who completed evaluations reported high levels of confidence with knowledge and skills directly related to the educational objectives after participation (mean Likert scores of 4.9 out of 5 in response to effectiveness of the case in teaching evaluation and management of nicotine toxicity).

Discussion

This comprehensive resource will aid in offering continuing education for providers and specifically in educating learners with regard to acute liquid nicotine exposure in a child.

Advocating for Life Support Training of Children, Parents, Caregivers, School Personnel, and the Public

Pediatric cardiac arrest in the out-of-hospital setting is a traumatic event for family, friends, caregivers, classmates, and school personnel. Immediate bystander cardiopulmonary resuscitation and the use of automatic external defibrillators have been shown to improve survival in adults. There is some evidence to show improved survival in children who receive immediate bystander cardiopulmonary resuscitation. Pediatricians, in their role as advocates to improve the health of all children, are uniquely positioned to strongly encourage the training of children, parents, caregivers, school personnel, and the lay public in the provision of basic life support, including pediatric basic life support, as well as the appropriate use of automated external defibrillators.

Pediatric Medication Safety in the Emergency Department

Pediatric patients cared for in emergency departments (EDs) are at high risk of medication errors for a variety of reasons. A multidisciplinary panel was convened by the Emergency Medical Services for Children program and the American Academy of Pediatrics Committee on Pediatric Emergency Medicine to initiate a discussion on medication safety in the ED. Top opportunities identified to improve medication safety include using kilogram-only weight-based dosing, optimizing computerized physician order entry by using clinical decision support, developing a standard formulary for pediatric patients while limiting variability of medication concentrations, using pharmacist support within EDs, enhancing training of medical professionals, systematizing the dispensing and administration of medications within the ED, and addressing challenges for home medication administration before discharge.

Unintentional Marijuana Exposure Presenting as Altered Mental Status in the Pediatric Emergency Department: A Case Series

BACKGROUND

Unintentional tetrahydrocannabinol (THC) exposure in pediatric patients can present as altered mental status. Altered mental status in a pediatric patient often leads to invasive diagnostic testing.

CASE REPORT

The following cases describe 3 pediatric patients in Washington state who presented to a tertiary care children's hospital emergency department (ED) with altered mental status, later found to have urine toxicology screening positive for inactive THC metabolite (positive THC toxicology screen). Case 1 is a 6-year-old boy who presented with vomiting, lethargy, and hallucinations. Case 2 is a 5-year-old girl who presented with nausea, slurred speech, ataxia, and lethargy in the setting of a minor head injury. Case 3 is a 7-month-old boy who presented with vomiting and lethargy in the setting of a minor fall the day prior to ED evaluation. All children had extensive work-ups before the diagnosis was made; 2 were discharged home and 1 was admitted to the pediatric intensive care unit. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: As access to marijuana increases with growing legalization, it is important to be familiar with state marijuana legislation, to consider and ask families about access to marijuana products as a potential contributor to altered mental status, and to be aware of potential caretaker reluctance regarding disclosure of marijuana use secondary to perceived stigma. Maintaining awareness of the clinical effects of THC exposure in children may limit invasive testing in a hemodynamically stable child with altered mental status.

Lack of Benefit of Physical Therapy on Function Following Supracondylar Humeral Fracture: A Randomized Controlled Trial

BACKGROUND

The goal of the study was to evaluate the efficacy of physical therapy in restoring function and mobility after a pediatric supracondylar humeral fracture.

METHODS

The study included sixty-one patients from five to twelve years of age with a supracondylar humeral fracture that was treated with casting or with closed reduction and pinning followed by casting. Patients were randomized to receive either no further treatment (no-PT group) or six sessions of a standardized hospital-based physical therapy program (PT group). The ASK-p (Activities Scale for Kids-performance version) and self-assessments of activity were used to assess function at one, nine, fifteen, and twenty-seven weeks after injury. Motion was measured at nine and fifteen weeks after injury by a blinded therapist. Anxiety was measured at one and nine weeks after injury with a self-assessment. Differences in ASK-p scores and anxiety level were analyzed with use of multivariate generalized estimating equations.

RESULTS

ASK-p scores were significantly better in the no-PT group at nine and fifteen weeks after injury (p = 0.02 and 0.01, respectively) but the difference at twenty-seven weeks was not significant. There were no differences between groups with respect to performance of activities of daily living or time to return to sports. Anxiety at nine weeks was associated with worse ASK-p scores at nine and fifteen weeks in the PT group and with better ASK-p scores in the no-PT group at these time points (p = 0.01 and 0.02, respectively). There were no differences between the groups with respect to elbow motion in the injured arm at any time. Severity of injury had no impact on function or elbow motion in either the PT or the no-PT group.

CONCLUSIONS

Children undergoing closed treatment of a supracondylar humeral fracture that was limited to approximately three weeks of cast immobilization received no benefit involving either return of function or elbow motion from a short course of physical therapy.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Laundry detergent capsules and pediatric poisoning

QUESTION

A 4-year-old girl was brought into the emergency department vomiting after having had ingested a laundry detergent capsule (LDC) from under the sink at her house. What is the risk of LDC poisoning? What can be done to treat these children?

ANSWER

Laundry detergent capsules are relatively new to supermarket shelves in North America, and there has been an emergence of case reports in the literature describing LDC poisoning, which is worse than poisoning from other laundry detergents. Very little is known about the mechanisms causing these severe reactions, which include airway compromise and esophageal perforation, but the attractive appearance of these capsules and easy access at home has governments and health officials concerned about an increase in poisoning. No residual problems have been associated with these cases to date; however, further research is needed to assess long-term effects.

Factitious lithium toxicity secondary to lithium heparin-containing blood tubes

INTRODUCTION

Lithium concentrations analyzed from blood collected in inappropriate tubes may lead to misdiagnosis and lead to unnecessary hospitalization and intervention. We sought to assess the magnitude of falsely elevated lithium levels in green top lithium heparin-containing blood tubes.

METHODS

Serum lithium concentrations from two types of commonly used standard green top tubes were evaluated against a control tube. Blood samples obtained from 5 healthy volunteers who have never ingested pharmaceuticals containing lithium were aliquoted into a control serum separator tube (SST), a light green heparin-containing tube, and a dark green heparin tube at the following volumes: full draw, 2cc, and 1cc. Serum lithium levels in lithium heparin blood tubes were compared to standard blood tubes.

RESULTS

All levels are reported as mmol/L. Mean serum lithium level for the control was 0.16 [range: 0.1-0.2]. Levels for the light-green tubes at full-draw, 2cc, and 1cc were 1.05 [1.0-1.1], 1.99 [1.68-2.3], and 3.31 [2.8-4.2] respectively. Levels for the darkgreen tubes at full-draw, 2cc, and 1cc were 1.07 [1.0-1.14], 2.35 [2.1-2.55], and 4.04 [3.8-4.4] respectively.

CONCLUSIONS

Falsely elevated lithium levels may occur when using green-top lithium containing blood tubes and may contribute as much as 4 mmol/L to the level in tubes not completely filled.

Tetracycline-induced esophagitis in adolescent patients

Ulcerative esophagitis may be caused by corrosive agents and by commonly prescribed medications. We report severe esophagitis in five adolescents after ingestion of tetracycline preparations with minimal water immediately before going to bed.