Do young children with known cannabis intoxication benefit from further neurological-based testing or imaging?

BACKGROUND: Recent work has demonstrated that children with unintentional cannabis ingestions often undergo extensive ancillary testing such as head imaging or lumbar puncture. To better understand the yield of these tests, our objective was to describe the frequency of additional significant diagnoses in children with cannabis ingestion. METHODS: We performed a retrospective cross-sectional study of the Pediatric Health Information System (PHIS) database, including ED encounters from January 2016 to April 2023 with a diagnosis indicating cannabis exposure in children <6 years of age. We assessed the frequency of co-diagnoses that would be found on head imaging, lumbar puncture, or toxicology testing. RESULTS: We included 4132 ED encounters for cannabis ingestion from 47 hospitals. Of these, 1243 (30%) received head imaging and 130 (3.1%) underwent lumbar puncture. There were 23 children (0.6%) with diagnosis of skull fracture or intracranial hemorrhage, 4 (<0.1%) with intracranial neoplasm, and 0 (0%) with a diagnosis for meningitis or intracranial abscess. Presence of discharge diagnosis for other drugs was also uncommon. The most frequent drug ingestion co-diagnoses were cocaine in 43 (1.0%) and opioids in 22 (0.5%) encounters. CONCLUSION: In children with cannabis intoxication, high rates of head imaging and lumbar puncture are likely driven by the signs of altered mental status at presentation. These data suggest that if cannabis ingestion is considered early and identified quickly with testing, neuroimaging, particularly that with ionizing radiation, may be low yield.

Cannabis Legalization and Resource Use for Ingestions by Young Children.

OBJECTIVE: In conjunction with widening legalization, there has been a rapid rise in unintentional cannabis ingestions in young children. We sought to determine if the legal status of recreational cannabis was associated with resource use in young children with cannabis poisoning. METHODS: This retrospective cross-sectional study of the Pediatric Health Information System included emergency department encounters between January 2016 and April 2023 for children <6 years of age with a diagnosis indicating cannabis ingestion. The primary exposure was recreational cannabis legalization status in the state in which the encounter occurred. We used logistic regression models to determine the association of recreational cannabis legality with resource utilization outcomes, adjusting for demographic covariates. RESULTS: We included 3649 children from 47 hospitals; 29% of encounters occurred in places in which recreational cannabis was legal. Compared with environments in which recreational cannabis was illegal, cannabis-legal locations had lower uses of advanced neuroimaging (24% vs 35%; adjusted odds ratio [aOR], 0.65; 95% confidence interval [CI]: 0.55-0.77), lumbar puncture (1.6% vs 3.8%; aOR, 0.42; 95% CI: 0.24-0.70), ICU admission (7.9% vs 11%; aOR, 0.71; 95% CI: 0.54-0.93), and mechanical ventilation (0.8% vs 2.9%; aOR, 0.30; 95% CI: 0.14-0.58). Urine testing was more common in places in which recreational cannabis was legal (71% vs 58%; aOR, 1.87; 95% CI: 1.59-2.20). CONCLUSIONS: State-level legalization of recreational cannabis was associated with a significant decrease in the utilization of advanced medical resources in cases of cannabis intoxication in children. These findings suggest the need for a focus on policies and procedures to minimize invasive testing in cases of cannabis intoxication in children.

Pediatric Emergency Medicine Didactics and Simulation (PEMDAS): Pediatric Sedation Complications.

Introduction: Ketamine and propofol are commonly used agents for sedation in the pediatric emergency department (PED). While these medications routinely provide safe sedations, there are side effects providers should be able to recognize and manage. Currently, no pediatric sedation simulations exist in the literature. Methods: We created two sedation simulation cases for learners, including pediatric emergency medicine (PEM) fellows, working in the PED: case 1, a 12-year-old male with a shoulder dislocation requiring reduction under propofol sedation, and case 2, a forearm fracture requiring reduction under ketamine sedation. Learner actions included setting up equipment for sedations, dosing medications correctly, and managing complications. Additionally, in case 2, learners assigned an American Society of Anesthesiologists classification and selected the appropriate candidate for PED sedation from amongst three patients. A debrief followed the cases. Next, a didactic presentation reinforced concepts discussed in the debrief. Participants then completed an evaluation of the simulation. Results: Fifty-eight emergency medicine residents and PEM fellows across four sites at three institutions participated. Participants scored the simulations and the debriefing session on a 5-point Likert scale. Learners rated the scenario as clinically relevant (M = 4.37) and effective at improving their comfort level in caring for critically ill patients (M = 4.36). Learners felt the debrief provided valuable learning (M = 4.40) and was a safe learning environment (M = 4.50). Discussion: These cases can be utilized as resources for learners in any emergency department and can be tailored to any training background of learner providing sedation.

Improving Turnaround Time of Transabdominal Pelvic Ultrasounds with Ovarian Doppler in a Pediatric Emergency Department.

Introduction: Adnexal torsion is an emergent surgical condition. Transabdominal pelvic ultrasound (US) with ovarian Doppler is used to diagnose adnexal torsion and requires a sufficient bladder volume. Reduce the turnaround time for US by 25% in girls 8-18 years of age who present to the emergency department (ED) for 24 months. Methods: Our baseline period was from January 2020 to June 2021, and the intervention period was from July 2021 to June 2023. Patients 8-18 years old who required an US in the ED were included. There are two key drivers: early identification of US readiness and expeditious bladder filling. Interventions were (1) bladder volume screening; (2) utilization of bladder volume nomogram to identify US readiness; (3) epic order panels; and (4) rapid intravenous fluid method. The primary outcome was US turnaround time. Secondary outcomes were percentage of patients requiring invasive interventions to fill the bladder and patients with an US study duration of ≤45 minutes. The percent of patients screened by bladder scan was used as a process measure. Balancing measures used episodes of fluid overload and ED length of stay. Results: Turnaround time for USs improved from 112.4 to 101.6 minutes. The percentage of patients who had successful USs without invasive bladder filling improved from 32.1% to 42.6%. Bladder volume screening using a bladder scan increased from 40.3% to 82.9%. The successful first-pass US completion rate improved from 77% to 90% consistently. Conclusions: Through quality improvement methodology, we have identified pelvic US readiness earlier, eliminated some invasive bladder-filling measures, and implemented a rapid fluid protocol. We have sustained these successful results for 2 years. This study can be generalized to any ED with similar patients.

Selective and brain-penetrant HCN1 inhibitors reveal links between synaptic integration, cortical function, and working memory.

Hyperpolarization-activated and cyclic-nucleotide-gated 1 (HCN1) ion channels are proposed to be critical for cognitive function through regulation of synaptic integration. However, resolving the precise role of HCN1 in neurophysiology and exploiting its therapeutic potential has been hampered by minimally selective antagonists with poor potency and limited in vivo efficiency. Using automated electrophysiology in a small-molecule library screen and chemical optimization, we identified a primary carboxamide series of potent and selective HCN1 inhibitors with a distinct mode of action. In cognition-relevant brain circuits, selective inhibition of native HCN1 produced on-target effects, including enhanced excitatory postsynaptic potential summation, while administration of a selective HCN1 inhibitor to rats recovered decrement working memory. Unlike prior non-selective HCN antagonists, selective HCN1 inhibition did not alter cardiac physiology in human atrial cardiomyocytes or in rats. Collectively, selective HCN1 inhibitors described herein unmask HCN1 as a potential target for the treatment of cognitive dysfunction in brain disorders.