Emergency care considerations for transgender and gender diverse youth: a review to improve health trajectories.

PURPOSE OF REVIEW: Transgender and Gender Diverse (TGD) youth represent a growing subset of pediatric patients who are at increased risk for harmful health outcomes. Consideration of these risks during emergency encounters may decrease these undesired, sometimes fatal, adverse events. RECENT FINDINGS: Gender affirmative care of TGD youth is considered a basic healthcare right as noted by several academic societies including the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the American Psychological Association [1-3] ( Table 1 ). Withholding gender affirmative care can lead to undesired health outcomes including but not limited to an increased incidence of mood disorders, self-injurious behavior, suicidal ideation, sexually transmitted diseases, and delayed presentations of treatable illness. TGD youth often access acute care settings, yet many feel apprehensive due to prior negative experiences or fear of discrimination. Practitioners are also often unaware as to how to effectively provide this type of healthcare. SUMMARY: Acute care settings provide a unique and impactful environment to provide evidence-based, gender-affirming care that can make patients feel validated, mitigate future care avoidance, and minimize negative downstream health effects. In this review, we have consolidated high yield health considerations regarding TGD youth for acute care and emergency providers to deliver optimal care for this population.

Do Unmet Health Needs Drive Pediatric Emergency Department Utilization?: A Population-Based Assessment.

OBJECTIVE: Lack of access to basic health services is thought to increase emergency department (ED) utilization. This study assessed the relationship between unmet health care needs and pediatric ED utilization in the United States. METHODS: The National Survey of Children's Health was used (2016-2017; n = 71,360). Parent/guardians reported number of ED visits and the presence of unmet health needs (medical, dental, mental health, vision, hearing, other) in the last 12 months. Associations were analyzed using multinomial logistic regression modeling and accounted for the weighting and complex survey design of the National Survey of Children's Health. RESULTS: Children with 2 or more unmet health needs had 3.72 times (95% confidence interval, 2.25-6.16) risk of ≥2 ED visits when compared with those with 0 unmet health needs. This risk became nonsignificant when adjusted for race, ethnicity, age, insurance, having asthma, current medication status, health description, number of preventative health visits, and place to go for preventative health (aRR, 1.77; 95% confidence interval, 0.96-3.27). The adjusted association was also nonsignificant for specific types of unmet needs. Race, insurance status, age 0 to 3 years, current medication status, having asthma, ≥2 preventative visits, and poorer health were associated with ≥2 ED visits. CONCLUSIONS: Unmet health needs were not found to be a significant driving force for ED utilization. Other factors were found to be more strongly associated with it. Future studies to understand the perception, motives, and complex interaction of various factors leading to ED use in high-risk populations may optimize care for these children.

Sounding the Alarm on Sleep: A Negative Association Between Inadequate Sleep and Flourishing.

OBJECTIVE: To assess the national prevalence of inadequate sleep among school-age children and its relationship with childhood flourishing. STUDY DESIGN: This cross-sectional study analyzed 49 050 parental responses from the 2016-2017 National Survey of Children's Health for school-age children. Inadequate sleep duration was defined as <9 hours for 6- to 12-year-olds and <8 hours for 13- to 17-year-olds on an average weeknight. Five markers of flourishing were examined individually and as a combined measure. Logistic regression was used with complex survey design and applied weights. RESULTS: Inadequate sleep was found in 36.4% of 6- to 12-year-olds and in 31.9% of 13- to 17-year-olds. Compared with children with adequate sleep, 6- to 12-year-olds with inadequate sleep had increased odds of not showing interest and curiosity in learning (aOR, 1.61; 95% CI, 1.34-1.94), not caring about doing well in school (aOR, 1.45; 95% CI, 1.23-1.71), not doing homework (aOR, 1.44; 95% CI, 1.24-1.68), and not finishing tasks (aOR, 1.18; 95% CI, 1.03-1.35). Children aged 13-17 years with inadequate sleep had increased odds of not doing homework (aOR, 1.36; 95% CI, 1.17-1.58), not staying calm and in control when challenged (aOR, 1.34; 95% CI, 1.16-1.54), not showing interest and curiosity in learning (aOR, 1.34; 95% CI, 1.14-1.58), not finishing tasks (aOR, 1.20; 95% CI, 1.03-1.40), and not demonstrating the combined flourishing measure (aOR, 1.35; 95% CI, 1.17-1.56). CONCLUSIONS: Nationally representative data show that one-third of school-age children have inadequate sleep. Inadequate sleep is associated with decreased flourishing. These data will help inform sleep policies and optimize child development.

New directions in point-of-care ultrasound at the crossroads of paediatric emergency and critical care.

PURPOSE OF REVIEW: The diagnostic capability, efficiency and versatility of point-of-care ultrasound (POCUS) have enabled its use in paediatric emergency medicine (PEM) and paediatric critical care (PICU). This review highlights the current applications of POCUS for the critically ill child across PEM and PICU to identify areas of progress and standardized practice and to elucidate areas for future research. RECENT FINDINGS: POCUS technology continues to evolve and advance bedside clinical care for critically ill children, with ongoing research extending its use for an array of clinical scenarios, including respiratory distress, trauma and dehydration. Rapidly evolving and upcoming applications include diagnosis of pneumonia and acute chest syndrome, identification of intra-abdominal injury via contrast-enhancement, guidance of resuscitation, monitoring of increased intracranial pressure and procedural guidance. SUMMARY: POCUS is an effective and burgeoning method for both rapid diagnostics and guidance for interventions and procedures. It has clinical application for a variety of conditions that span PEM and PICU settings. Formal POCUS training is needed to standardize and expand use of this valuable technology by PICU and PEM providers alike.

Use of a novel pedal-operated compressor is non-inferior to the use of a standard hand-compressed bag-valve mask.

BACKGROUND: The standard bag-valve mask (BVM) used universally requires that a single healthcare practitioner affix the mask to the face with 1 hand while compressing a self-inflating bag with the second hand. Studies have demonstrated that creating a 2-handed seal (with 2 healthcare practitioners) is superior. Our study aims to assess the efficacy of a novel single-practitioner BVM device that uses a foot pedal as the bag compressor, allowing both hands to be available for the seal to facilitate delivery of appropriate tidal volumes during single-practitioner resuscitation. METHODS: This was a prospective, randomized, cross-over study. Participants with various BVM ventilation experience performed 2 minutes of metronome-guided BVM ventilation using a standard BVM and the pedal-operated compressor on a high-fidelity simulation mannequin. Analysis examining differences in mean tidal volume delivered was conducted using a regression model that adjusted for covariates. A secondary analysis using a series of Wilcoxon tests was conducted to compare differences in the additional out-of-range sensed breaths metrics to compare differences by prior BVM ventilation experience. RESULTS: A total of 58 subjects participated. The pedal-operated compressor unadjusted mean tidal volume delivered was 446.5 mL (95% confidence interval [CI], 425.9-467.1) compared with 340.6 mL (95% CI, 312.2-369.0) by standard BVM (mean change, 105.9 mL [95% CI, 71.2-140.6]; P < .001). When modeling a generalized estimation equation regression model, standard BVM ventilation provided a mean difference of 105.9 mL less than pedal-operated compressor ventilation after adjusting for covariates (P = 0.01). For the secondary outcome, the pedal-operated compressor did have a significantly lower median number of out-of-range breaths (median, 3; interquartile range [IQR], 1-11.5) compared with the standard device (median, 13.5; IQR, 6-19; P < 0.001). CONCLUSIONS: Use of a novel pedal-operated compressor may allow a single healthcare practitioner, regardless of prior experience, to deliver consistent, appropriate tidal volumes with more ease compared with the standard BVM during manual respiratory resuscitation.

Titration of Parameters in Shared Ventilation With a Portable Ventilator.

BACKGROUND: Dual-patient, single-ventilator protocols (ie, protocols to ventilate 2 patients with a single conventional ventilator) may be required in times of crisis. This study demonstrates a means to titrate peak inspiratory pressure (PIP), PEEP, and [Formula: see text] for test lungs ventilated via a dual-patient, single-ventilator circuit. METHODS: This prospective observational study was conducted using a ventilator connected to 2 test lungs. Changes in PIP, PEEP, and [Formula: see text] were made to the experimental lung, while no changes were made to the control lung. Measurements were obtained simultaneously from each test lung. PIP was titrated using 3D-printed resistors added to the inspiratory circuit. PEEP was titrated using expiratory circuit tubing with an attached manual PEEP valve. [Formula: see text] was titrated by using a splitter added to the ventilator tubing. RESULTS: PIP, PEEP, and [Formula: see text] were reliably and incrementally titratable in the experimental lung, with some notable but manageable changes in pressure and [Formula: see text] documented in the control lung during these titrations. Similar results were measured in lungs with identical and different compliances. CONCLUSIONS: Pressures and [Formula: see text] can be reliably adjusted when utilizing a dual-patient, single-ventilator circuit with simple, low-cost modifications to the circuit. This innovation could potentially be lifesaving in a resource-limited or crisis setting. Understanding the interactions of these circuits is imperative for making their use safer.

Thyrotoxicosis in a Postpartum Adolescent: A Simulation Case for Emergency Medicine Providers.

Introduction: Thyroid storm is a rare but life-threatening disease process that may be difficult to recognize and mimics other disease processes. It is critical for the emergency medicine clinician to be able to recognize thyroid storm in patients in order to effectively stabilize and treat them. Methods: In this standardized patient case, learners were faced with a 17-year-old postpartum woman presenting to the emergency department with respiratory distress and altered mental status secondary to thyroid storm. The target learners were emergency department providers, including residents, medical students, and advanced practice practitioners. Providers were expected to identify signs and symptoms of thyroid storm and to initiate appropriate diagnostic workup and management of this complex patient. Debriefing followed the simulation using a debriefing guide and PowerPoint presentation. Results: Thirty-four learners participated in this simulation. All learners agreed or strongly agreed that the simulation case was relevant to their work, and 97% agreed or strongly agreed that it was effective in teaching thyroid storm management skills. Eighty-five percent felt that following the simulation, they would be confident in their ability to recognize thyroid storm in a postpartum patient and to recognize and manage respiratory distress and altered mental status in a postpartum patient. Discussion: Learners felt that this case was effective in teaching the skills necessary for caring for postpartum patients with respiratory distress and altered mental status. Future directions include conducting the simulation in situ to include multidisciplinary teams and increasing the learner pool to include OB/GYN residents.

A 17-Year-Old Boy With High-Functioning Autism, Gastrointestinal Illness, and Seizures.

A healthy 17-year-old boy with a high-functioning pervasive developmental disorder presented to the emergency department after having a 4-minute episode of seizure-like activity in the setting of presumed viral gastroenteritis. Within an hour of emergency department arrival, he developed a forehead-sparing facial droop, right-sided ptosis, and expressive aphasia, prompting stroke team assessment and urgent neuroimaging. Laboratory results later revealed a serum sodium of 119 mmol/L. Neurologic deficits self-resolved, and a full physical examination revealed diffuse abdominal tenderness in the lower abdomen with rebound tenderness in the right-lower quadrant. The patient was admitted to the PICU for electrolyte management and monitoring. A computed tomography (CT) scan of the abdomen obtained the following morning revealed the patient's final diagnosis.

Symptoms Attributed to Consumption of Caffeinated Beverages in Adolescents.

Purpose: Pediatric caffeine use has become increasingly prevalent. The American Academy of Pediatrics discourages caffeine use by children and adolescents due to its adverse impact on sleep and blood pressure. The objective of this study was to measure prevalence of physical and emotional symptoms related to caffeine consumption among adolescents receiving primary care. Methods: A convenience sample of patients (N = 179; 73% female) aged 12-17 presenting for routine primary care completed the Composite International Diagnostic Interview Substance Abuse Module questionnaire, which included questions regarding use of caffeine. Descriptive statistics were used to summarize prevalence of caffeine use and caffeine-related symptoms. Associations of number of caffeine-related symptoms with age, gender, and race/ethnicity were also analyzed. Results: Sixty-seven percent of participants (n = 120) reported past 30-day caffeinated beverage consumption. Of those, 68% (n = 82) reported at least one symptom or problem attributed to caffeine use or withdrawal, including caffeine cravings, 24% (n = 29); frequent urination, 21% (n = 25); difficulty falling asleep, 18% (n = 22); and feeling anxious, 3.3% (n = 4). Conclusions: In our sample, caffeinated beverage consumption by adolescents was frequently associated with physical and emotional symptoms, as well as problems attributed to use.