Prehospital Restraint Use in Pediatric Patients With Mental and Behavioral Health Emergencies.

OBJECTIVES: The aims of the study are to characterize children with mental and behavioral health conditions (MBH) transported by emergency medical services (EMS) and examine differences in patient, emergency department (ED), and EMS transport characteristics based on restraint interventions during EMS transport. METHODS: This is a retrospective cohort study of EMS patients with MBH crises, aged 5-18, transported to 2 pediatric EDs over 9 years. Demographic and ED data were collected electronically; EMS data were extracted manually from prehospital care records. Field interventions studied included pharmacologic and mechanical restraints by EMS clinicians. Univariate analysis compared variables between patients who received EMS restraints and those who did not and multivariable logistic regression identified patient factors independently associated with EMS restraint use. RESULTS: Among 10,264 patients transported by EMS for MBH crises, 1400 encounters were randomly selected, with 768 records available. EMS restraint interventions were used in 73 (9.5%) patients: 5 (0.7%) received only pharmacologic restraints, 58 (7.6%) received only physical restraints, and 10 (1.3%) received both. Those who received EMS restraints were more likely to be younger (35.6% vs 19.6%, P = 0.001), male (71.2% vs 44.6%, P < 0.0001), and had longer scene times (13 vs 9 min). Restraint use was more common when patients were picked up from schools (30.1% vs 14.8%, P = 0.007). EMS-restrained patients were also more likely to receive physical (12.3% vs 2.3%, P < 0.0001), mechanical (15.1% vs 1.0%, P < 0.0001), or pharmacologic (24.7% vs 3.9%, P < 0.0001) restraints in the ED. Predictors of EMS restraint use were male sex (odds ratio, 3.00; 95% confidence interval, 1.74-5.17) and being picked up from schools (odds ratio, 2.08; 95% confidence interval, 1.13-3.81), whereas age group, race, and insurance type were not independent predictors. CONCLUSIONS: Nearly 1 in 10 pediatric patients experiencing mental health crises and transported by EMS required restraint interventions in the field. Male patients, younger aged children, and those picked up from school represent a distinct and vulnerable population that could benefit from specialized prehospital care to manage agitation.

Emergency Medical Services and Police Utilization for Pediatric Mental and Behavioral Health Concerns Within a Large Hospital System.

OBJECTIVE: This study aimed to compare emergency medical services (EMS) and police utilization trends, epidemiology, and emergency department (ED) outcomes between pediatric patients with mental or behavioral health (MBH) emergencies and those with non-MBH concerns transported to a large children's hospital system. METHODS: This was a retrospective cohort study of patients aged 5 to 18 years transported via EMS and police to two EDs affiliated with a children's hospital from January 2012 through December 2020. Data were abstracted from electronic hospital records. Encounters for MBH emergencies were identified using diagnostic codes and chief complaints. Trends of EMS and police transports of patients with MBH emergencies were examined. Patient demographics and ED outcomes were compared between children presenting with MBH emergencies and those with non-MBH concerns. RESULTS: During the 9-year study period, out of 40,663 transports to the EDs, 36,137 (89%) arrived via EMS, and 4,526 (11%) arrived via police. A total of 10,250 (28.4%) EMS transports were for MBH emergencies. The volume of patients transported by EMS for MBH emergencies increased by 1.4% per year (P < 0.01) with no significant change in total EMS patient volumes. Patients with MBH emergencies transported by EMS were more likely to be older, female, of White race, and publicly insured; require restraint in the ED; and be admitted (P < 0.001). Of police transports, 4153 (91.8%) were for MBH emergencies, with no statistical change in the proportion of police transports that were for MBH emergencies. Police-transported MBH patients compared to non-MBH police-transported patients were more likely to be younger, female, and of White race (P < 0.001); 8.7% required mechanical/physical restraints in ED, 6.7% required pharmacologic restraint medications in ED, and 53% were admitted. CONCLUSIONS: The proportion of pediatric transports for MBH emergencies by EMS is rising and comprises the majority of police transports. Distinct from non-MBH pediatric patients transported, MBH patients necessitate significant ED resources, including ED-administered restraints and admission, highlighting their unique burden on the prehospital and ED systems.

Findings from a Randomized Controlled Trial of SMART: An EHealth Intervention for Mild Traumatic Brain Injury.

OBJECTIVE: The aim of this study was to examine the efficacy of the SMART (Self-Management After Recent Traumatic brain injury) program and potential moderators. METHODS: Parallel randomized controlled trial (ClinicalTrials.gov Identifier: NCT03498495) was conducted. Eligibility criteria included treatment for mild traumatic brain injury in the emergency department and age 11-18 years. Participants were assigned equally to SMART (n = 35) or usual care (UC; n = 36). SMART included symptom monitoring and online modules supporting the return to activities and symptom management. Coping and quality of life (QoL) (primary outcomes) and post-concussive symptoms (secondary outcome) were assessed at baseline and weekly for 4 weeks. RESULTS: Groups did not differ in coping, QoL, or return to pre-injury symptom levels at any time point. Problem-focused engagement (PFE) moderated group differences over time (p = .02). At high PFE, UC participants reported lower QoL at time 1 (effect size [ES] = 0.60); SMART participants did not report a decline at any point. At low PFE, SMART participants reported declining QoL from pre-injury to time 1 (ES = 0.68), whereas UC participants reported an increase from time 1 to 3 (ES = 0.56). PFE also moderated group differences on the Health and Behavior Inventory (HBI) cognitive (p = .02) and somatic symptom scales (p = .05). At high PFE, SMART participants reported a more rapid return to pre-injury levels than UC participants (p = .05). Resilience also moderated group differences in QoL and HBI cognitive recovery. CONCLUSION: Effectiveness of the SMART app varied based on preinjury coping styles and resilience, underscoring the potential need to tailor treatments to individual characteristics.

Usage Patterns of an mHealth Symptom Monitoring App Among Adolescents With Acute Mild Traumatic Brain Injuries.

OBJECTIVE: To understand usage patterns of SMART (Self-Monitoring Activity Regulation and Relaxation Treatment) mHealth app among adolescents with acute mild traumatic brain injuries (mTBIs) and to identify individual characteristics that influenced app usage. SETTING: Emergency departments of tertiary care children's medical center. PARTICIPANTS: Children aged 11 to 18 years with mTBI in the past 2 weeks, English-speaking, no evidence of severe TBI, and no preexisting neurological impairment. DESIGN: Nested cohort of the intervention arm of a randomized clinical trial (n = 34). MHEALTH APP INTERVENTION: SMART was a month-long educational program on mTBI designed to promote self-monitoring and management of recovery. SMART included digital symptom and activity self-monitoring surveys, feedback on symptom changes, and 8 modules providing psychoeducation, strategies for symptom management, and training in active problem solving. MAIN MEASURES: App usage time, navigation, and interaction data were automatically collected. Usage involved inputting symptom ratings/activities and reviewing modules. Patterns of symptom/activity reporting and completion of learning modules data were analyzed. Predictors of app utilization, including individual characteristics, resilience (Connor-Davidson Resilience Scale), and coping (Coping Strategies Inventory-Short Form), were analyzed using Spearman correlations. RESULTS: Participants completed symptom monitoring an average of 9 days over the month. Participants completed an average of 1.87 learning modules out of 7. Parent income and education, comorbid attention-deficit/hyperactivity disorder (ADHD), and emotional engagement coping style predicted symptom monitoring. Parental income, comorbid ADHD, and greater reliance on emotional engagement coping predicted module completion. SIGNIFICANT ADVERSE EVENTS: None. CONCLUSION: Adolescents of higher socioeconomic status and those who manage their emotions using active engagement spent more time on both components of the SMART program.

Efficacy of levetiracetam, fosphenytoin, and valproate for established status epilepticus by age group (ESETT): a double-blind, responsive-adaptive, randomised controlled trial.

BACKGROUND: Benzodiazepine-refractory, or established, status epilepticus is thought to be of similar pathophysiology in children and adults, but differences in underlying aetiology and pharmacodynamics might differentially affect response to therapy. In the Established Status Epilepticus Treatment Trial (ESETT) we compared the efficacy and safety of levetiracetam, fosphenytoin, and valproate in established status epilepticus, and here we describe our results after extending enrolment in children to compare outcomes in three age groups. METHODS: In this multicentre, double-blind, response-adaptive, randomised controlled trial, we recruited patients from 58 hospital emergency departments across the USA. Patients were eligible for inclusion if they were aged 2 years or older, had been treated for a generalised convulsive seizure of longer than 5 min duration with adequate doses of benzodiazepines, and continued to have persistent or recurrent convulsions in the emergency department for at least 5 min and no more than 30 min after the last dose of benzodiazepine. Patients were randomly assigned in a response-adaptive manner, using Bayesian methods and stratified by age group (<18 years, 18-65 years, and >65 years), to levetiracetam, fosphenytoin, or valproate. All patients, investigators, study staff, and pharmacists were masked to treatment allocation. The primary outcome was absence of clinically apparent seizures with improved consciousness and without additional antiseizure medication at 1 h from start of drug infusion. The primary safety outcome was life-threatening hypotension or cardiac arrhythmia. The efficacy and safety outcomes were analysed by intention to treat. This study is registered in ClinicalTrials.gov, NCT01960075. FINDINGS: Between Nov 3, 2015, and Dec 29, 2018, we enrolled 478 patients and 462 unique patients were included: 225 children (aged <18 years), 186 adults (18-65 years), and 51 older adults (>65 years). 175 (38%) patients were randomly assigned to levetiracetam, 142 (31%) to fosphenyltoin, and 145 (31%) were to valproate. Baseline characteristics were balanced across treatments within age groups. The primary efficacy outcome was met in those treated with levetiracetam for 52% (95% credible interval 41-62) of children, 44% (33-55) of adults, and 37% (19-59) of older adults; with fosphenytoin in 49% (38-61) of children, 46% (34-59) of adults, and 35% (17-59) of older adults; and with valproate in 52% (41-63) of children, 46% (34-58) of adults, and 47% (25-70) of older adults. No differences were detected in efficacy or primary safety outcome by drug within each age group. With the exception of endotracheal intubation in children, secondary safety outcomes did not significantly differ by drug within each age group. INTERPRETATION: Children, adults, and older adults with established status epilepticus respond similarly to levetiracetam, fosphenytoin, and valproate, with treatment success in approximately half of patients. Any of the three drugs can be considered as a potential first-choice, second-line drug for benzodiazepine-refractory status epilepticus. FUNDING: National Institute of Neurological Disorders and Stroke, National Institutes of Health.

Comparison of children receiving emergent sepsis care by mode of arrival.

OBJECTIVE: To determine if differences in patient characteristics, treatments, and outcomes exist between children with sepsis who arrive by emergency medical services (EMS) versus their own mode of transport (self-transport). METHODS: Retrospective cohort study of patients who presented to the Emergency Department (ED) of two large children's hospitals and treated for sepsis from November 2013 to June 2017. Presentation, ED treatment, and outcomes, primarily time to first bolus and first parental antibiotic, were compared between those transported via EMS versus patients who were self-transported. RESULTS: Of the 1813 children treated in the ED for sepsis, 1452 were self-transported and 361 were transported via EMS. The EMS group were more frequently male, of black race, and publicly insured than the self-transport group. The EMS group was more likely to have a critical triage category, receive initial care in the resuscitation suite (51.9 vs. 22%), have hypotension at ED presentation (14.4 vs. 5.4%), lactate >2.0 mmol/L (60.6 vs. 40.8%), vasoactive agents initiated in the ED (8.9 vs. 4.9%), and to be intubated in the ED (14.4 vs. 2.8%). The median time to first IV fluid bolus was faster in the EMS group (36 vs. 57 min). Using Cox LASSO to adjust for potential covariates, time to fluids remained faster for the EMS group (HR 1.26, 95% CI 1.12, 1.42). Time to antibiotics, ICU LOS, 3- or 30-day mortality rates did not differ, yet median hospital LOS was significantly longer in those transported by EMS versus self-transported (6.5 vs. 5.3 days). CONCLUSIONS: Children with sepsis transported by EMS are a sicker population of children than those self-transported on arrival and had longer hospital stays. EMS transport was associated with earlier in-hospital fluid resuscitation but no difference in time to first antibiotic. Improved prehospital recognition and care is needed to promote adherence to both prehospital and hospital-based sepsis resuscitation benchmarks.

Intravenous Magnesium in Asthma Pharmacotherapy: Variability in Use in the PECARN Registry.

OBJECTIVE: To examine the use, efficacy, and safety of intravenous magnesium sulfate (IVMg) in children with asthma whose emergency department (ED) management is recorded in the Pediatric Emergency Care Applied Research Network (PECARN) Registry. STUDY DESIGN: This multicenter retrospective cohort study analyzed clinical data from 7 EDs from 2012 to 2017. We described use of IVMg in children aged 2-17 years treated for acute asthma and its effect on blood pressure. We also used multivariable analysis to examine factors associated with use of IVMg and its association with return visits within 72 hours. RESULTS: Across 61 854 asthma visits for children, clinicians administered IVMg in 6497 (10.5%). Median time from triage to IVMg administration was 154 minutes (IQR 84, 244). During 22 495 ED visits resulting in hospitalization after ED treatment, IVMg was administered in 5774 (25.7%) (range by site 15.9%, 50.6%). Patients were discharged home from the ED after 11.1% of IVMg administrations, and hypotension occurred after 6.8%. Variation in IVMg use was not explained by patient characteristics. Revisits did not differ between patients discharged after IVMg and those not receiving IVMg. CONCLUSIONS: In PECARN Registry EDs, administration of IVMg occurs late in ED treatment, for a minority of the children likely to benefit, with variation between sites, which suggests the current clinical role for IVMg in preventing hospitalization is limited. Discharge after IVMg administration is likely safe. Further research should prospectively assess the efficacy and safety of early IVMg administration.

Characterization of Children with Septic Shock Cared for by Emergency Medical Services.

Objective: To inform the future development of a pediatric prehospital sepsis tool, we sought to 1) describe the characteristics, emergent care, and outcomes for children with septic shock who are transported by emergency medicine services (EMS) and compare them to those self-transported; and 2) determine the EMS capture rate of common sepsis screening parameters and the concordance between the parameters documented in the EMS record and in the emergency department (ED) record. Methods: This is a retrospective cohort study of children ages 0 through 21 years who presented to a pediatric ED with septic shock between 11/2013 and 06/2016. Data, collected by electronic and manual chart review of EMS and ED records, included demographics, initial vital signs in both EMS and ED records, ED triage level, site of initial ED care, ED disposition, ED therapeutic interventions, outcomes, and times associated with processes. Potential screening parameters were dichotomized as normal vs. abnormal based on age-dependent normative data. Results: Of the children with septic shock treated in our ED, 19.3% arrived via EMS. These children as compared to those self-transported were more likely (i.e., p < 0.05) to be male, have public insurance, receive initial care in the ED resuscitation suite, be hypotensive on arrival, receive their first ED fluid bolus sooner (33 vs. 58 minutes), receive vasoactive agents, be mechanically ventilated in the first 24 hours, and have slightly longer length of hospital stays. Both groups had similar times to antibiotics. While poor outcomes were rare, the 3- and 30-day mortalities were similar for both groups. EMS capture rates were highest for heart rate and respiratory rate and lowest for temperature, glucose, and blood pressure. Interrater reliability was highest for heart rate. Conclusions: Children presenting to the ED with septic shock transported by EMS represent a critically ill subset of modest proportions. Realization of a sepsis screening tool for this vulnerable population will require both creation of a tool containing a limited subset of objective parameters along with processes to ensure capture.

Emergency Department Care of Young Children at Risk for Traumatic Brain Injury: What Are We Doing and Do Parents Understand?

OBJECTIVES: The aims of the study were to describe emergency department (ED) management of young children with head injury and to assess parental comfort level and perceptions of ED care. METHODS: This was a prospective observational study of children younger than 5 years who presented to a pediatric ED after head injury. Children were eligible if clinical observation was an appropriate ED management option per the Pediatric Emergency Care Academic Research Network's neuroimaging clinical decision rule. Demographics, injury variables, and ED clinician surveys explaining the care provided were collected at time of study enrollment. Parents were subsequently contacted to assess understanding of ED management and comfort with care. RESULTS: One hundred four children were enrolled with a mean (standard deviation) age of 1.19 (1.34) years. Thirty (29%) had emergent neuroimaging and 59 (57%) were placed into a period of observation per clinician report. A total of 37 children received a head computed tomography, of which 21 (57%) were normal. Eighty-four parents (81%) completed the phone follow-up. Of these children, there was a significant difference between whether parents and clinicians reported that the child had been clinically observed in the ED (P < 0.0001). Parents of children who did not receive a head CT were more likely to be uncomfortable with the decision to obtain neuroimaging compared with those who did receive a head CT (P = 0.003). CONCLUSIONS: Parents are not always comfortable with the medical care practices provided and are often unaware of clinical observation when it does occur. Better parent-clinician communication could improve parental understanding and reduce overall discomfort.

Describing pediatric acute kidney injury in children admitted from the emergency department.

OBJECTIVE: To define those children who develop acute kidney injury (AKI) within 48 h of admission from the emergency department (ED) and ascertain patient-related factors in the ED associated with AKI. METHODS: Retrospective, cohort study of children, birth to 19 years, admitted to a tertiary pediatric hospital from the ED between January 2010 and December 2013 who had serum creatinine (SCr) drawn as part of clinical care. AKI was defined as a 50% increase in SCr above baseline, as measured within 48 h of hospital presentation. Multivariable logistic regression was performed to determine factors associated with AKI by comparing those with and without kidney injury on hospital presentation. RESULTS: Of all ED admissions, 13,827 subjects (27%) were included; 10% developed AKI. Of kids with AKI, 75% had a measured SCr consistent with AKI while in the ED, 36% were admitted to the intensive care unit, and 2% died (all significantly more than children without AKI). Young age, history of AKI or solid organ transplant, receipt of intravenous fluids or central venous access in the ED, and admission to intensive care were factors independently associated with AKI (AUC = 0.793, 95% CI 0.78-0.81). CONCLUSIONS: One in 10 children who had SCr measured and were admitted to a tertiary pediatric hospital had AKI on or within 48 h of presentation. Inherent characteristics, identifiable in the ED, are associated with an increased risk of AKI. Future research should focus on improving AKI recognition in the ED by the development of a risk stratification tool.

Factors influencing ED care of young children at-risk for clinically important traumatic brain injury.

OBJECTIVES: Care decisions for young children presenting to the emergency department (ED) with head injury are often challenging (e.g. whether to obtain neuroimaging). We sought to identify factors associated with acute management of children at-risk for clinically important traumatic brain injury (ciTBI) and describe symptom management. METHODS: Observational evaluation of children, ages 0-4years, presenting to a pediatric ED following minor head injury. Children with ≥1 risk element per the Pediatric Emergency Care Academic Research Network's decision rule were deemed "at-risk" for ciTBI. Clinician surveys regarding their initial clinical management were used to identify three care groups. Nonparametric tests analyzed group differences and logistic regression investigated associations of putative high-risk factors with neuroimaging. RESULTS: Of 104 children enrolled: (i) 30 underwent neuroimaging, (ii) 59 were observed, and (iii) 15 were discharged following the clinician's initial patient exam. Children with a non-frontal scalp hematoma were more likely to receive immediate neuroimaging and children not acting like themselves per caregiver report were more likely to be initially observed, relative to the other care groups (p≤0.01). Among high-risk factors, altered mental status (OR 5.12, 95% CI 1.8-21.1), presence of ≥3 risk elements of the decision rule (OR 3.5, 95% CI 1.2-10.6), unclear skull fracture on exam (OR 31.3, 95% CI 5.4-593.8), and age<3months (OR 5.3, 95% CI 1.5-21.9) were associated with neuroimaging. No child had ciTBI. TBI symptoms (e.g. vomiting) were infrequently treated. CONCLUSIONS: ED management varied for young children with similar risk stratification. Investigation of how age in concert with specific risk factors influences medical decision making would advance evidenced-based care.

Cervical Spine Injuries in Children Associated With Sports and Recreational Activities.

OBJECTIVE: The aim of this study was to ascertain potential factors associated with cervical spine injuries in children injured during sports and recreational activities. METHODS: This is a secondary analysis of a multicenter retrospective case-control study involving children younger than 16 years who presented to emergency departments after blunt trauma and underwent cervical spine radiography. Cases had cervical spine injury from sports or recreational activities (n = 179). Comparison groups sustained (1) cervical spine injury from other mechanisms (n = 361) or (2) other injuries from sports and recreational activities but were free of cervical spine injury (n = 180). RESULTS: For children with sport and recreational activity-related cervical spine injuries, common injury patterns were subaxial (49%) and fractures (56%). These children were at increased odds of spinal cord injury without radiographic abnormalities compared with children with cervical spine injuries from other mechanisms (25% vs 6%). Children with sport and recreational activity-related trauma had increased odds of cervical spine injury if they had focal neurologic findings (odds ratio [OR], 5.7; 95% confidence interval [CI], 3.5-9.4), had complaints of neck pain (OR, 3.1; 95% CI, 1.9-5.0), were injured diving (OR, 43.5; 95% CI, 5.9-321.3), or sustained axial loading impacts (OR, 2.2; 95% CI, 1.3-3.5). Football (22%), diving (20%), and bicycle crashes (11%) were the leading activities associated with cervical spine injury. CONCLUSIONS: In children injured during sports and recreational activities, focal neurologic findings, neck pain, axial loading impacts, and the possibility of spinal cord injury without radiographic abnormality should guide the diagnostic evaluation for potential cervical spine injuries. Certain activities have a considerable frequency of cervical spine injury, which may benefit from activity-specific preventive measures.

Adolescents with Mild Traumatic Brain Injury Get SMART: An Analysis of a Novel Web-Based Intervention.

BACKGROUND: There have been few trials of interventions to facilitate recovery following mild traumatic brain injury (mTBI) in adolescence. To address this gap, we developed and piloted a novel Web-based intervention, entitled Self-Management Activity Restriction and Relaxation Training (SMART), and examined its impact on symptom burden, functional disability, and executive functioning during the month following mTBI in adolescents. MATERIALS AND METHODS: Open-label, single arm study. Adolescents with recent mTBI and a parent were recruited from the emergency department and provided access upon discharge to SMART-a Web-based program designed to facilitate recovery via self-management and education about symptoms and sequelae associated with mTBI. Symptom burden, functional disability, and executive functioning were rated by both the adolescent and the parent initially and at assessments at 1-, 2- and 4-weeks postinjury. Mixed models analyses were used to examine trajectories on these outcomes. RESULTS: Of the 21 adolescent/parent dyads enrolled, 13 engaged in the program and reported significant improvement in symptoms over the 4-week program (adolescent, p = 0.0005; parent, p = 0.004). Adolescents spent a median of 35.5 min (range 1.1-107.6) using the program. Parent ratings of the adolescent's functional disability and executive functioning significantly improved over the 4-week period from baseline (p = 0.009 and p = 0.03, respectively), whereas adolescents themselves did not report significant changes in either outcome. All participants improved and there were no adverse outcomes. CONCLUSION: The SMART program, a novel Web-based intervention, may serve as a self-management tool for adolescents and their parents to assist with the recovery following a recent mTBI.

Feasibility and Potential Benefits of a Web-Based Intervention Delivered Acutely After Mild Traumatic Brain Injury in Adolescents: A Pilot Study.

BACKGROUND: There is a paucity of evidence-based interventions for mild traumatic brain injury (mTBI). OBJECTIVE: To evaluate the feasibility and potential benefits of an interactive, Web-based intervention for mTBI. SETTING: Emergency department and outpatient settings. PARTICIPANTS: Of the 21 adolescents aged 11 to 18 years with mTBI recruited from November 2013 to June 2014 within 96 hours of injury, 13 completed the program. DESIGN: Prospective, open pilot. INTERVENTION: The Web-based Self-Management Activity-restriction and Relaxation Training (SMART) program incorporates anticipatory guidance and psychoeducation, self-management and pacing of cognitive and physical activities, and cognitive-behavioral principles for early management of mTBI in adolescents. MAIN MEASURES: Primary: Daily Post-Concussion Symptom Scale (PCSS). Secondary: Daily self-reported ratings of activities and satisfaction survey. RESULTS: Average time from injury to baseline testing was 14.0 (standard deviation = 16.7) hours. Baseline PCSS was 23.6 (range: 0-46), and daily activity was 1.8 (range: 0-5.75) hours. Repeated-measures, generalized linear mixed-effects model analysis demonstrated a significant decrease of PCSS at a rate of 2.0 points per day that stabilized after about 2 weeks. Daily activities, screen time, and physical activity increased by 0.06 (standard error [SE] = 0.04, P = .09), 0.04 (SE = 0.02, P = .15), and 0.03 (SE = 0.02, P = .05) hours per day, respectively, over the 4-week follow-up. Satisfaction was rated highly by parents and youth. CONCLUSIONS: Self-Management Activity-restriction and Relaxation Training is feasible and reported to be helpful and enjoyable by participants. Future research will need to determine the comparative benefits of SMART and ideal target population.

Are UCH-L1 and GFAP promising biomarkers for children with mild traumatic brain injury?

OBJECTIVES: To compare serum biomarker levels between children with mild traumatic brain injury (mTBI) and orthopaedic injury (OI), acutely following injury. Secondarily, to explore the association between biomarker levels and symptom burden over 1 month post-injury. METHODS: This was a prospective cohort study of children aged 11-16 years who presented to the emergency department within 6 hours of sustaining mTBI or isolated extremity OI. Serum was drawn at the time of study enrollment and levels of ubiquitin carboxyl-terminal hydrolase L1 (UCH-L1) and glial fibrillary acid protein (GFAP) were analysed. Symptom burden was assessed by the Post-Concussion Symptom Scale (PCSS) acutely following injury and at three subsequent time points over 1 month. RESULTS: Twenty-five children with mTBI and 20 children with OI were enrolled. The average age for the overall cohort was 13 (± 1.6) years and the majority were male and injured playing sports. GFAP levels and PCSS scores were significantly higher acutely following mTBI vs OI (p < 0.01). There was not a significant group difference in UCH-L1 levels. Neither GFAP nor UCH-L1 were predictive of PCSS scores over the 1month post-injury. CONCLUSIONS: GFAP may be a promising diagnostic tool for children with mTBI. Additional approaches are needed to predict symptom severity and persistence.

Investigating the Feasibility and Utility of Bedside Balance Technology Acutely After Pediatric Concussion: A Pilot Study.

OBJECTIVE: To examine postural instability in children acutely after concussion, using the Wii Balance Board (WBB). We hypothesized that children with traumatic brain injury would have significantly worse balance relative to children without brain injury. DESIGN: Prospective case-control pilot study. SETTING: Emergency department of a tertiary urban pediatric hospital. PARTICIPANTS: Cases were a convenience sample 11-16 years old who presented within 6 hours of sustaining concussion. Two controls, matched on gender, height, and age, were enrolled for each case that completed study procedures. Controls were children who presented for a minor complaint that was unlikely to affect balance. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The participant's postural sway expressed as the displacement in centimeters of the center of pressure during a timed balance task. Balance testing was performed using 4 stances (single or double limb, eyes open or closed). RESULTS: Three of the 17 (17.6%) cases were too dizzy to complete testing. One stance, double limbs eyes open, was significantly higher in cases versus controls (85.6 vs 64.3 cm, P = 0.04). CONCLUSIONS: A simple test on the WBB consisting of a 2-legged standing balance task with eyes open discriminated children with concussion from non-head-injured controls. The low cost and feasibility of this device make it a potentially viable tool for assessing postural stability in children with concussion for both longitudinal research studies and clinical care. CLINICAL RELEVANCE: These pilot data suggest that the WBB is an inexpensive tool that can be used on the sideline or in the outpatient setting to objectively identify and quantify postural instability.

Structural connectivity abnormality in children with acute mild traumatic brain injury using graph theoretical analysis.

The traumatic biomechanical forces associated with mild traumatic brain injury (mTBI) typically impart diffuse, as opposed to focal, brain injury potentially disrupting the structural connectivity between neural networks. Graph theoretical analysis using diffusion tensor imaging was used to assess injury-related differences in structural connectivity between 23 children (age 11-16 years) with mTBI and 20 age-matched children with isolated orthopedic injuries (OI) scanned within 96 h postinjury. The distribution of hub regions and the associations between alterations in regional network measures and symptom burden, as assessed by the postconcussion symptom scale score (PCSS), were also examined. In comparison to the OI group, the mTBI group was found to have significantly higher small-worldness (P < 0.0001), higher normalized clustering coefficients (P < 0.0001), higher normalized characteristic path length (P = 0.007), higher modularity (P = 0.0005), and lower global efficiency (P < 0.0001). A series of hub regions in the mTBI group were found to have significant alterations in regional network measures including nodal degree, nodal clustering coefficient, and nodal between-ness centrality. Correlation analysis showed that PCSS total score acquired at the time of imaging was significantly associated with the nodal degree of two hubs, the superior frontal gyrus at orbital section and the middle frontal gyrus. These findings provide new evidence of acute white matter alteration at both global and regional network level following mTBI in children furthering our understanding of underlying mechanisms of acute neurological insult associated with mTBI.

Can Computerized Neuropsychological Testing in the Emergency Department Predict Recovery for Young Athletes With Concussions?

OBJECTIVE: The objective of this study was to determine if computerized neurocognitive testing (Immediate Post-Concussion Assessment and Cognitive Testing [ImPACT]) in the emergency department (ED) can be used as a prognostic tool to detect young athletes at risk of having protracted concussive symptoms. METHODS: This was a prospective cohort study of athletes aged 11 to 18 years who presented to an ED less than 24 hours after sustaining a sports-related concussion. ImPACT was administered in the ED, and performance was categorized as "poor" if the athlete had 3 (of 4) or greater low domain scores. Participants completed the Post-Concussion Symptom Scale (PCSS) in the ED and by phone at 1 and 2 weeks after injury. Athletes were symptomatic if their PCSS score was more than 6 in males and more than 8 in females. RESULTS: One hundred nine patients were enrolled; 60% and 36% remained symptomatic at 1 and 2 weeks after injury, respectively. "Poor" ImPACT performance was not particularly useful in predicting athletes with protracted symptoms (at 1 week: positive predictive value, 70.8%; negative predictive value, 43.5%; at 2 weeks: positive predictive value, 47.8%; negative predictive value, 68.9%). In bivariate analysis, a higher ED PCSS score was associated with protracted symptoms (at 1 week: odds ratio, 1.1 [confidence interval, 1.0-1.1]; at 2 weeks: odds ratio, 1.0 [confidence interval, 1.0-1.1]). CONCLUSIONS: Computerized neurocognitive testing in the ED has limited usefulness in predicting protracted symptoms. Total acute symptom burden may be a useful prognostic tool in the ED evaluation of concussed young athletes, yet further research is necessary.

Characteristics of the pediatric patients treated by the Pediatric Emergency Care Applied Research Network's affiliated EMS agencies.

OBJECTIVE: To describe pediatric patients transported by the Pediatric Emergency Care Applied Research Network's (PECARN's) affiliated emergency medical service (EMS) agencies and the process of submitting and aggregating data from diverse agencies. METHODS: We conducted a retrospective analysis of electronic patient care data from PECARN's partner EMS agencies. Data were collected on all EMS runs for patients less than 19 years old treated between 2004 and 2006. We conducted analyses only for variables with usable data submitted by a majority of participating agencies. The investigators aggregated data between study sites by recoding it into categories and then summarized it using descriptive statistics. RESULTS: Sixteen EMS agencies agreed to participate. Fourteen agencies (88%) across 11 states were able to submit patient data. Two of these agencies were helicopter agencies (HEMS). Mean time to data submission was 378 days (SD 175). For the 12 ground EMS agencies that submitted data, there were 514,880 transports, with a mean patient age of 9.6 years (SD 6.4); 53% were male, and 48% were treated by advanced life support (ALS) providers. Twenty-two variables were aggregated and analyzed, but not all agencies were able to submit all analyzed variables and for most variables there were missing data. Based on the available data, median response time was 6 minutes (IQR: 4-9), scene time 15 minutes (IQR: 11-21), and transport time 9 minutes (IQR: 6-13). The most common chief complaints were traumatic injury (28%), general illness (10%), and respiratory distress (9%). Vascular access was obtained for 14% of patients, 3% received asthma medication, <1% pain medication, <1% assisted ventilation, <1% seizure medication, <1% an advanced airway, and <1% CPR. Respiratory rate, pulse, systolic blood pressure, and GCS were categorized by age and the majority of children were in the normal range except for systolic blood pressure in those under one year old. CONCLUSIONS: Despite advances in data definitions and increased use of electronic databases nationally, data aggregation across EMS agencies was challenging, in part due to variable data collection methods and missing data. In our sample, only a small proportion of pediatric EMS patients required prehospital medications or interventions.

Emergency Department Pediatric Mental and Behavioral Health Patients Transported by Emergency Medical Services and Police: Trends and Interventions.

OBJECTIVE: We aimed to understand transport utilization trends, demographics, emergency department (ED) interventions, and outcomes of pediatric mental and behavioral health (MBH) patients transported by emergency medical services (EMS), police, or self-transported. METHODS: This retrospective cohort study utilized electronic health record data from patients aged 5 to 18 years presenting with acute MBH conditions at 2 affiliated pediatric EDs from January 2012 to December 2020. Data included demographics, ED interventions for aggression/agitation, Brief Rating of Aggression by Children and Adolescents (BRACHA) scores, and ED dispositions. Descriptive statistics and comparative analyses were conducted using chi-square, Wilcoxon rank sum tests, and multivariable logistic regression. Linear regression analyzed trends. RESULTS: Of 440,302 ED encounters, 70,557 (16%) were for acute MBH concerns, with 14.6% transported by EMS and 5.9% by police. The proportion of MBH visits increased from 9.9% in 2012 to 19.8% in 2020 (95% (confidence interval) CI [0.7, 1.7], P = 0.0009), with a concurrent 0.4% annual increase in those transported by EMS (95% CI [0.2, 0.6], P = 0.006). MBH patients transported by EMS and police had significantly higher odds of requiring restraint in the ED and were more likely to have higher BRACHA scores and to be admitted compared to self-transported patients (all comparisons, P < 0.001). CONCLUSIONS: Pediatric MBH ED visits and EMS utilization are increasing. MBH patients transported by EMS and police may represent a more aggressive ED population. Given the rising encounters within this high-risk population, our EDs, EMS, and police need support and resources for safe pediatric MBH patient management.