Management of youth with suicidal ideation: Challenges and best practices for emergency departments.

Suicide is a leading cause of death among youth, and emergency departments (EDs) play an important role in caring for youth with suicidality. Shortages in outpatient and inpatient mental and behavioral health capacity combined with a surge in ED visits for youth with suicidal ideation (SI) and self-harm challenge many EDs in the United States. This review highlights currently identified best practices that all EDs can implement in suicide screening, assessment of youth with self-harm and SI, care for patients awaiting inpatient psychiatric care, and discharge planning for youth determined not to require inpatient treatment. We will also highlight several controversies and challenges in implementation of these best practices in the ED. An enhanced continuum of care model recommended for youth with mental and behavioral health crises utilizes crisis lines, mobile crisis units, crisis receiving and stabilization units, and also maximizes interventions in home- and community-based settings. However, while local systems work to enhance continuum capacity, EDs remain a critical part of crisis care. Currently, EDs face barriers to providing optimal treatment for youth in crisis due to inadequate resources including the ability to obtain emergent mental health consultations via on-site professionals, telepsychiatry, and ED transfer agreements. To reduce ED utilization and better facilitate safe dispositions from EDs, the expansion of community- and home-based services, pediatric-receiving crisis stabilization units, inpatient psychiatric services, among other innovative solutions, is necessary.

Review of pediatric emergency care and the COVID-19 pandemic.

The coronavirus disease 2019 (COVID-19) pandemic posed new challenges in health care delivery for patients of all ages. These included inadequate personal protective equipment, workforce shortages, and unknowns related to a novel virus. Children have been uniquely impacted by COVID-19, both from the system of care and socially. In the initial surges of COVID-19, a decrease in pediatric emergency department (ED) volume and a concomitant increase in critically ill adult patients resulted in re-deployment of pediatric workforce to care for adult patients. Later in the pandemic, a surge in the number of critically ill children was attributed to multisystem inflammatory syndrome in children. This was an unexpected complication of COVID-19 and further challenged the health care system. This article reviews the impact of COVID-19 on the entire pediatric emergency care continuum, factors affecting ED care of children with COVID-19 infection, including availability of vaccines and therapeutics approved for children, and pediatric emergency medicine workforce innovations and/or strategies. Furthermore, it provides guidance to emergency preparedness for optimal delivery of care in future health-related crises.

Pediatric diabetes: management of acute complications in the emergency department.

Children with diabetes mellitus are at high risk for acute life-threatening complications of their chronic disease. Identification and management of these emergencies can be complex and challenging. This issue provides guidance for recognizing pediatric patients with new-onset diabetes as well as diabetic crises in established patients. The most recent literature is reviewed and an approach to managing emergent diabetic complications in the pediatric patient is provided, with a focus on initial stabilization and management. Key features in treating pediatric patients with hyperglycemic emergencies are discussed, including rapid fluid resuscitation when indicated, initiation of insulin, and addressing complicating comorbidities.

The role of telehealth in pediatric emergency care.

In 2006, the Institute of Medicine published a report titled "Emergency Care for Children: Growing Pains," in which it described pediatric emergency care as uneven at best. Since then, telehealth has emerged as one of the great equalizers in care of children, particularly for those in rural and underresourced communities. Clinicians in these settings may lack pediatric-specific specialization or experience in caring for critically ill or injured children. Telehealth consultation can provide timely and safe management for many medical problems in children and can prevent many unnecessary and often long transport to a pediatric center while avoiding delays in care, especially for time-sensitive and acute interventions. Telehealth is an important component of pediatric readiness of hospitals and is a valuable tool in facilitating health care access in low resourced and critical access areas. This paper provides an overview of meaningful applications of telehealth programs in pediatric emergency medicine, discusses the impact of the COVID-19 pandemic on these services, and highlights challenges in setting up, adopting, and maintaining telehealth services.

Resources for Improving Pediatric Readiness and Quality of Care in Rural Communities and Emergency Departments.

OBJECTIVES: To share the process and products of an 8-year, federally funded grant from the Health Resources and Services Administration Emergency Medical Services for Children program to increase pediatric emergency readiness and quality of care provided in rural communities located within 2 underserved local emergency medical services agencies (LEMSAs) in Northern California. METHODS: In 2 multicounty LEMSAs with 24 receiving hospital emergency departments, we conducted focus groups and interviews with patients and parents, first responders, receiving hospital personnel, and other community stakeholders. From this, we (a regional, urban children's hospital) provided a variety of resources for improving the regionalization and quality of pediatric emergency care provided by prehospital providers and healthcare staff at receiving hospitals in these rural LEMSAs. RESULTS: From this project, we provided resources that included regularly scheduled pediatric-specific training and education programs, pediatric-specific quality improvement initiatives, expansion of telemedicine services, and cultural competency training. We also enhanced community engagement and investment in pediatric readiness. CONCLUSIONS: The resources we provided from our regional, urban children's hospital to 2 rural LEMSAs facilitated improvements in a regionalized system of care for critically ill and injured children. Our shared resources framework can be adapted by other regional children's hospitals to increase readiness and quality of pediatric emergency care in rural and underserved communities and LEMSAs.

Initiative to Improve Postintubation Sedation in a Pediatric Emergency Department.

BACKGROUND: Previous research has shown that appropriate pediatric postintubation sedation (PIS) after rapid sequence intubation only occurs 28% of the time. Factors such as high provider variability, cognitive overload, and errors of omission can delay time to PIS in a paralyzed patient. PURPOSE: To increase the proportion of children receiving timely PIS by 20% within 6 months. METHODS: A multidisciplinary team identified key drivers and targeted interventions to improve timeliness of PIS. The primary outcome of "sedation in an adequate time frame" was defined as a time to post-Rapid Sequence Intubation sedative administration less than the duration of action of the RSI sedative agent. Secondary outcomes included the proportion of patients receiving any sedation and time to PIS administration. RESULTS: Pediatric postintubation sedation in an adequate time was improved from 27.9% of intubated patients to 55.6% after intervention (p = .001). The number of patients receiving any PIS improved from 74% to 94% (p = .006). The median time from RSI to PIS was reduced from 13 to 9 minutes (p < .001). Process control charts showed a reduction in PIS variability and a centerline reduction from 19 to 10 minutes. CONCLUSIONS: Implementation of an intubation checklist and a multidisciplinary approach improved the rate of adequate pediatric PIS.

Management of pediatric transplant patients in the emergency department.

Transplant patients are at risk for illnesses and complications days, months, or years after transplantation, and they can present complex challenges for emergency clinicians. This review discusses the general approach to the management of pediatric transplant patients in the emergency department, with a focus on general complications and organ-specific complications after solid organ transplantation. Hematopoietic stem cell transplantation and its common complications will also be discussed. A key step in the management of all transplant patients includes consultation with the patient's transplant team to ensure appropriate testing, treatment, and disposition for these patients.

Access to Optimal Emergency Care for Children.

Every year, millions of pediatric patients seek emergency care. Significant barriers limit access to optimal emergency services for large numbers of children. The American Academy of Pediatrics, American College of Emergency Physicians, and Emergency Nurses Association have a strong commitment to identifying these barriers, working to overcome them, and encouraging, through education and system changes, improved access to emergency care for all children.

Multicenter Retrospective Review of Adult Patients Presenting to Pediatric Emergency Departments: Impact of Interfacility Distance.

OBJECTIVE: This descriptive study aimed at evaluating the impact of distance between a general and pediatric emergency department (PED) on adults seeking care at PEDs. METHODS: The Pediatric Health Information Systems database was used to perform a retrospective study of all adult patients presenting to PEDs from 2005 to 2015. Data regarding age, disposition, pregnancy status, insurance status, median household income, all-patients refined diagnosis-related groups, and procedures were gathered. Distances were categorized as PEDs less than 1 mile and 1 mile from a general facility. Data were analyzed for the entire population, in addition to those 45 years old. RESULTS: The majority of patients were discharged from the ED; transfers were more frequent at PEDs 1 mile away from a general facility. Death was rare, with minimal differences noted between interfacility distances (21: 0.25% vs 0.24%; 45: 0.36% vs 0.32%). Cardiopulmonary resuscitation occurred in 0.25% with no differences based on location. Pregnant women visits and childbirth occur more frequently in PEDs closer to general facilities (4.89% vs 2.85%, P < 0.05; 0.07% vs 0.03%, P < 0.05, respectively). Chest pain was seen more frequently at PEDs located farther away from general EDs, the difference more pronounced in those 45 years old (21: 5.12% vs 6.3%; 45: 6.61% vs 13.17%). CONCLUSIONS: Statistically significant differences were seen in the adult population presenting to PEDs based on the interfacility distance between a pediatric and general ED. These data can help PEDs prepare for the adult patients they are more likely to treat.

High-flow nasal cannula and noninvasive ventilation in pediatric emergency medicine.

The use of high-flow nasal cannula and noninvasive ventilation has become increasingly common in emergency medicine as a first-line treatment of pediatric patients with respiratory distress secondary to asthma and bronchiolitis. When implemented in clinical practice, close monitoring of vital signs and ventilation parameters is warranted to identify possible signs of respiratory failure. This issue provides evidence-based recommendations for the appropriate use of noninvasive ventilation modalities in pediatric patients including high-flow nasal cannula, continuous positive airway pressure, and bilevel positive airway pressure in the setting of acute respiratory distress. Contraindications and complications associated with these modalities are also discussed.

Association of Insurance With Use of Emergency Medical Services Among Children.

OBJECTIVE: The use of emergency medical services (EMS) can be lifesaving for critically ill children and should be defined by the child's clinical need. Our objective was to determine whether nonclinical demographic factors and insurance status are associated with EMS use among children presenting to the emergency department (ED). METHODS: In this cross-sectional study using the National Hospital Ambulatory Medical Care Survey, we included children presenting to EDs from 2009 to 2014. We evaluated the association between EMS use and patients' insurance status using multivariable logistic regressions, adjusting for demographic, socioeconomic, and clinical factors such as illness severity as measured by a modified and recalibrated version of the Revised Pediatric Emergency Assessment Tool (mRePEAT) and the presence of comorbidities or chronic conditions. A propensity score analysis was performed to validate our findings. RESULTS: Of the estimated 191,299,454 children presenting to EDs, 11,178,576 (5.8%) arrived by EMS and 171,145,895 (89.5%) arrived by other means. Children arriving by EMS were more ill [mRePEAT score, 1.13; 95% confidence interval (CI), 1.12-1.14 vs mRePEAT score, 1.01; 95% CI: 1.01-1.02] and more likely to have a comorbidity or chronic condition (OR: 3.17, 95% CI: 2.80-3.59). In the adjusted analyses, the odds of EMS use were higher for uninsured children and lower for children with public insurance compared with children with private insurance [OR (95% CI): uninsured, 1.41 (1.12-1.78); public, 0.77 (0.65-0.90)]. The propensity score analysis showed similar results. CONCLUSIONS: In contrast to adult patients, children with public insurance are less likely to use EMS than children with private insurance, even after adjustment for illness severity and other confounders.

Emergency Medical Services Utilization by Children.

OBJECTIVE: The aim of this study was to compare demographic and clinical features of children (0-14 years old) who arrived at general emergency departments (EDs) by emergency medical services (EMS) to those who arrived by private vehicles and other means in a rural, 3-county region of northern California. METHODS: We reviewed 507 ED records of children who arrived at EDs by EMS and those who arrived by other means in 2013. We also analyzed prehospital procedures performed on all children transported to an area hospital by EMS. RESULTS: Children arriving by EMS were older (9.0 vs 6.0 years; P < 0.001), more ill (mean Severity Classification Score, 2.9 vs 2.4; P < 0.001), and had longer lengths of stay (3.6 vs 2.1 hours; P < 0.001) compared with children who were transported to the EDs by other means. Children transported by EMS received more subspecialty consultations (18.7% vs 6.9%; P < 0.05) and had more diagnostic testing, including laboratory testing (22.9% vs 10.6%; P < 0.001), radiography (39.7% vs 20.8%; P < 0.001), and computed tomography scans (16.8% vs 2.9%; P < 0.001). Children arriving by EMS were transferred more frequently (8.8% vs 1.6%; P < 0.001) and had higher mean Severity Classification Scores compared with children arriving by other transportation even after adjusting for age and sex (ß = 0.48; 95% confidence interval, 0.35-0.61; P < 0.001). Older children received more prehospital procedures compared with younger children, and these were of greater complexity and a wider spectrum. CONCLUSIONS: Children transported to rural EDs via EMS are more ill and use more medical resources compared with those who arrive to the ED by other means of transportation.

Nebulized Tranexamic Acid Use for Pediatric Secondary Post-Tonsillectomy Hemorrhage.

Post-tonsillectomy hemorrhage is a frequent occurrence in the emergency department, and management of potentially life-threatening and ongoing bleeding by the emergency physician is challenging. Limited evidence-based guidelines exist, and practice patterns vary widely. We administered nebulized tranexamic acid to achieve hemostasis in a pediatric patient with associated bleeding cessation prior to definitive operative management.

Risk Factors Associated With Emergency Department Return Visits Following Trauma System Discharge.

OBJECTIVES: Little evidence exists in the pediatric trauma literature regarding what factors are associated with re-presentation to the hospital for patients discharged from the emergency department (ED). METHODS: This was a retrospective cohort study of trauma system activations at a pediatric trauma center from June 30, 2007, through June 30, 2013, who were subsequently discharged from the ED or after a brief inpatient stay. Returns within 30 days were reviewed. χ, Student t test, and univariate logistical regression were used to compare predictive factors for those returning and not. RESULTS: One thousand eight hundred sixty-three patient encounters were included in the cohort. Seventy-two patients (3.9%) had at least 1 return visit that was related to the original trauma activation. Age, sex, language, race/ethnicity, ED length of stay, arrival mode, level of trauma activation, and transfer from an outside hospital did not vary significantly between the groups. Patients with public insurance were almost 2 times more likely to return compared with those with private insurance (odds ratio, 1.92; 95% confidence interval, 1.11-3.35). Income by zip code was associated with the risk of a return visit, with patients in neighborhoods at less than the 50th percentile income twice as likely to return to the ED (odds ratio, 2.15; 95% confidence interval, 1.30-3.54). CONCLUSIONS: Patients with public insurance and those from low-income neighborhoods were significantly more likely to return to the ED after trauma system activation. These data can be used to target interventions to decrease returns in high-risk trauma patients.

Persistent Pneumonia: Time to Take a Closer Look.

Primary pulmonary tumors are rare in pediatrics. When they are encountered, they are usually carcinoid tumors or mucoepidermoid carcinomas. We present a patient who presented to both his primary care physician and the pediatric emergency department with recurrent bouts of wheezing and pneumonia, none of which ever completely resolved despite appropriate treatment. The patient had multiple chest films, which demonstrated the persistence of what appeared to be a right-sided infiltrate/atelectasis. Ultimately, the patient underwent a diagnostic workup that included a computed tomography scan and bronchoscopy. These studies revealed the presence of a bronchial mucoepidermoid carcinoma. The patient was successfully treated with photoablation of the lesion through the involvement of multiple subspecialists, including pediatric pulmonology, pediatric surgery, pediatric otolaryngology, and pediatric oncology. We discuss the incidence and epidemiology of pediatric bronchial tumors in general and mucoepidermoid carcinoma in particular as well as diagnosis, treatment options, and prognosis. Emergency physicians must maintain a high index of suspicion for alternate diagnoses in patients whose disease fails to respond to traditionally accepted therapy.

Making the Quick Diagnosis: A Case of Neonatal Shock.

BACKGROUND: The work-up and initial management of a critically ill neonate is challenging and anxiety provoking for the Emergency Physician. While sepsis and critical congenital heart disease represent a large proportion of neonates presenting to the Emergency Department (ED) in shock, there are several additional etiologies to consider. Underlying metabolic, endocrinologic, gastrointestinal, neurologic, and traumatic disorders must be considered in a critically ill infant. Several potential etiologies will present with nonspecific and overlapping signs and symptoms, and the diagnosis often is not evident at the time of ED assessment. CASE REPORT: We present the case of a neonate in shock, with a variety of nonspecific signs and symptoms who was ultimately diagnosed with tachycardia-induced cardiomyopathy secondary to a resolved dysrhythmia. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights the diagnostic and therapeutic approach to the critically ill neonate in the ED, and expands the differential diagnosis beyond sepsis and critical congenital heart disease. Knowledge of the potential life-threatening etiologies of shock in this population allows the Emergency Physician to appropriately test for, and empirically treat, several potential etiologies simultaneously. Additionally, we discuss the diagnosis and management of supraventricular tachycardia and Wolff-Parkinson-White syndrome in the neonatal and pediatric population, which is essential knowledge for an Emergency Physician.

"Paramedics are bringing in a hypotensive gastrointestinal bleeder": an unexpected diagnosis.

BACKGROUND: Acute esophageal rupture is a rare emergency that must be diagnosed quickly and treated aggressively to avoid significant morbidity and mortality. The typical presentation of this disease includes chest pain, and the diagnosis is challenging when cardinal features such as this are absent. OBJECTIVES: This case report discusses an atypical presentation of esophageal rupture in a patient with a predisposing condition and highlights the diagnostic and cognitive difficulties involved in making the appropriate diagnosis. CASE REPORT: We report a case of a 51-year-old woman who presented to the Emergency Department with hypotension and an emergency medical services report of hematemesis. The patient had a documented history of upper gastrointestinal bleeding and Zollinger-Ellison syndrome during her past hospitalizations; however, the patient was not anemic and had a negative stool guiac despite symptoms for 3 days. A subsequent chest radiograph led to the diagnosis of esophageal rupture with a bilateral pneumothorax requiring thoracostomies. She reported no chest pain. CONCLUSIONS: The esophageal rupture and subsequent hypotension was likely secondary to the combination of her Zollinger-Ellison syndrome and recent vomiting episodes. It is important to avoid premature diagnostic closure and think about unusual presentations of emergent conditions such as esophageal rupture.