The burden of mental and behavioral health visits to the pediatric ED: A 3-year tertiary care center experience.

BACKGROUND: The shortage of mental health services across the United States has turned pediatric emergency departments (PEDs) into safety-nets for the increasing population of children with mental and behavioral health (MBH) needs. This study provides a descriptive characterization of MBH-related PED visits, the trends in visit, ED length of stay (EDLOS), and admission rate. METHODS: We reviewed electronic health records of children ≤18 years with MBH needs, who visited the PED of a large tertiary hospital from January 2017 to December 2019. We performed descriptive statistics, chi-square (χ2 ), and logistic regression analyses to evaluate trend in visit, EDLOS, admission rate, and predictors of prolonged EDLOS and inpatient admission. RESULTS: Of 10,167 patients, 58.4% were females, median age was 13.8 years, and 86.1% were adolescents. On average, visits increased by 19.7% annually, with a 43.3% increase over 3 years. Common ED diagnoses include, suicidality (56.2%), depression (33.5%), overdose/poisoning, and substance use (18.8%), and agitation/aggression (10.7%). Median EDLOS was 5.3 hr, average admission rate was 26.3%, with 20.7% boarding in the ED for >10 hr. Independent predictors of admission include depression (pOR: 1.5, CI: 1.3-1.7), bipolar disorder (pOR: 3.5, CI: 2.4-5.1), overdose/substance use disorder (pOR: 4.7, CI: 4.0-5.6), psychosis (pOR: 3.3, CI: 1.5-7.3), agitation/aggression (pOR: 1.8, CI: 1.5-2.1), and ADHD (pOR: 2.5, CI: 2.0-3.0). Principal independent driver of prolonged EDLOS was patient admission/transfer status (pOR: 5.3, CI: 4.6-6.1). CONCLUSIONS: Given the study results, MBH-related PED visits, ED length-of-stay, and admission rates continue to rise even in recent years. PEDs lack the resources and capability to provide high-quality care for the increasing population of children with MBH needs. Novel collaborative approaches and strategies are urgently needed to find lasting solutions.

The agitated pediatric patient located in the emergency department: The APPLIED observational study.

Objectives: Focused research on pediatric agitation is lacking despite being a common mental and behavioral health (MBH) emergency. Prevalence of pediatric agitation remains unknown, and prior reports may have underestimated the rate of restraint use for pediatric agitation. This is the largest study to provide a focused evaluation of the prevalence and predictors of pediatric agitation and restraint use as well as the emergency department (ED) length of stay (LOS) and admission rates for agitated patients. Methods: We reviewed records of patients aged ≤18 years with MBH needs who visited the pediatric ED of a tertiary care hospital during a 3-year-period. We identified and ascertained agitated/aggressive patients using documented signs/symptoms, International Classification of Diseases, Tenth Revision codes, and Behavioral Activity Rating Scale scores. We performed descriptive and multivariable analyses using SAS 9.4 (SAS Institute). Results: Of 10,172 patients with MBH needs, 1408 (13.8%) were agitated/aggressive. Of these (n = 1408), 63.7% were boys, and the mean age was 11.9 years. Among agitated patients, the prevalence of restraint use was 28.7%, with a predominance of pharmacologic restraint with atypical antipsychotics. Non-Hispanic Blacks were more likely to be agitated (adjusted odd ratio [aOR], 1.8; 95% CI, 1.2-2.7), but not restrained (aOR, 0.8; 95% CI, 0.3-1.8). Predictors of restraint use include history of attention deficit hyperactivity disorder (aOR, 2.2; 95% CI, 1.5-3.3), autism (aOR, 2.9; 95% CI, 1.9-4.5), conduct disorder (aOR, 1.7; 95% CI, 1.2-2.5), psychosis (aOR, 14.3; 95% CI, 2.5-271.8), and substance use/overdose states (aOR, 1.9; CI, 1.2-3.2). Restrained agitated patients had longer ED LOS (8.4 vs 5.0 hours; P < 0.0001) and higher admission rates (aOR, 2.6; 95% CI, 2.0-3.5). Depression (aOR, 0.4; 95% CI, 0.3-0.5) and suicidality (aOR, 0.2; 95% CI, 0.1-0.3) were protective against agitation and restraint use. Conclusion: Prevalence of acute agitation and restraint use in pediatric EDs may be much higher than previously reported. Predictors of acute agitation and restraint use among MBH patients were consistent with prior reports. Restrained agitated patients had longer ED LOS and higher admission rates.

Injury Rates, Patterns, Mechanisms, and Risk Factors Among Competitive Youth Climbers in the United States.

INTRODUCTION: Competitive rock climbing is a fast-growing sport. Despite comprehensive reviews on adult climbing-related injuries, few pediatric-specific reviews exist, and studies exclusively on competitive youth climbers are needed. Objectives of this study include 1) estimating the injury rate (IR); 2) describing injury patterns and mechanisms; and 3) identifying injury risk factors in competitive youth climbers. METHODS: The study design was cross-sectional. Competitive youth climbers were included. Participants completed an anonymous questionnaire to document climbing injuries over the preceding 12 mo. Demographic data and data regarding injuries were collected. The IR was calculated. Analyses were performed to assess association between injury and multiple variables. Multivariate logistic regression was completed for significant variables to control for exposure time. RESULTS: The IR was 2.7 injuries per 1000 climbing hours. Hand/Finger injuries were most frequent; chronic overuse was the most common etiology. Injury severity was low overall. Risk factors significantly associated with climbing injury were climbing discipline (bouldering > sport/lead climbing), return to climbing while still in pain, finger taping, higher number of hours climbed per session and per year, climbing at higher bouldering difficulties, and unsupervised climbing. CONCLUSIONS: The IR in competitive youth climbers was found to be lower than previously reported but higher than suggested by adult studies or those that exclude chronic injuries. Findings are consistent with types, severity, and mechanisms reported in other studies. Modifiable risk factors, especially return to climbing while still injured, warrant further prospective investigation.

Virtual Interviewing for Pediatric Emergency Medicine Fellowship-A National Survey.

OBJECTIVE: This study aimed to evaluate both applicant and interviewer satisfaction with the virtual interviewing process for pediatric emergency medicine (PEM) fellowship in hopes to improve the fellowship interviewing process. It was proposed that fellowship programs and applicants would prefer virtual interviews over traditional interviews. METHODS: A survey developed in collaboration with UT Southwestern PEM fellowship leaders and national PEM leaders was sent to all PEM fellowship applicants and programs at the conclusion of the 2020 interview season and rank list submission. The applicant survey obtained information on ease of virtual interviews and whether applicants felt that they obtained adequate information from virtual interviews to make informed program selections. Program director surveys collected data on thoughts and feelings about virtual interviews and obstacles encountered during the recruitment season. Both surveys asked about costs for interviews and interview type preference. RESULTS: A response rate of 49% from applicants and 47% from programs was obtained. Virtual interview days were similar in the amount of time and staff hours used compared with traditional days. Applicants spent less on virtual interviews compared with those who underwent traditional interviews (average $725 vs $4312). Programs received more applications than the prior year and spent less money during the virtual cycle. The majority of the applicants (90%) were comfortable with the virtual interview platform, and most (66%) agreed that virtual interviews provided adequate information to determine program rank. Geography was the number 1 rank determining factor. Programs and applicants preferred a form of in-person interviews. CONCLUSIONS: Virtual interviews provide cost savings for both applicants and programs. Despite this, both parties prefer a form of in-person interviews.

Hard as Iron: A Case of Delayed Presentation of Severe Iron Toxicity With Diagnostic and Treatment Dilemmas.

ABSTRACT: Cases of severe iron toxicity have become increasingly rare; most cases are intentional ingestions by late adolescents and adults who present within 12 hours of ingestion. We present a case of an adolescent girl with metabolic acidosis, hypoglycemia, obtundation, and liver and renal failure of undifferentiated etiology who was eventually discovered to have overdosed on ferrous sulfate tablets 4 days before arrival. The diagnosis was made because the patient had an elevated transferrin concentration in the setting of a minimally elevated serum iron concentration and faint radio-opacities on abdominal plain film imaging. This case presents many diagnostic challenges and treatment dilemmas and is a rare report of survival in delayed presentation of severe toxicity.

"That's Not His Regular Formula": A Case of Organophosphate Poisoning in an Infant.

INTRODUCTION: Organophosphates (OPs) are the basis of many insecticides and herbicides and are also used as nerve agents. Approximately 1 million unintentional and 2 million suicidal poisonings as well as more than 300,000 fatalities that are reportedly due to OPs are reported each year worldwide. The mortality rate from OP toxicity is reported as approximately 20%. We present a rare pediatric exposure to OPs. CASE: This is an unintentional OP poisoning in an infant who presented to a pediatric emergency department with obtundation, respiratory distress, and copious secretions. The infant was intubated, treated with atropine and pralidoxime after resuscitation, and eventually recovered with no neurologic sequelae. DISCUSSION: Symptoms from OP toxicity are secondary to effects on muscarinic and nicotinic cholinergic receptors in the autonomic and central nervous systems. Symptoms include diaphoresis, diarrhea, urination, miosis, bradycardia, bronchospasm, bronchorrhea, emesis, lethargy, lacrimation, and salivation. Treatment starts with titrated doses of atropine and oximes (eg, pralidoxime) after resuscitation and decontamination. Severity of toxicity and recovery can be monitored via plasma and whole blood acetylcholinesterase levels, respectively. Once aging has occurred, oximes will not be able to reverse acetylcholinesterase inhibition. Despite early treatment, rare cases may result in delayed neurologic complications associated with sensory and motor axonal degeneration of the peripheral nerves and spinal cord known as OP-induced delayed neuropathy. CONCLUSIONS: This case highlights the importance of safety education for families. It also demonstrates how to recognize and treat OP toxicity in an infant. It emphasizes starting treatment early to avoid complications secondary to aging.

E-cigarette or vaping product use-associated lung injury (EVALI) features and recognition in the emergency department.

Since August 2019, the pulmonary disease termed e-cigarette or vaping product-use associated lung injury (EVALI), has resulted in 2758 hospitalizations and 64 deaths in the United States. EVALI is considered in patients who have vaped or dabbed within 90 days of symptom onset, and have abnormal lung imaging in the absence of any pulmonary infection. The majority of EVALI patients are otherwise healthy adolescents and young adults. The leading etiology of EVALI is contamination of delta-9-tetrahydrocannabinoid (THC) e-liquids with vitamin E acetate. Although the exact pathophysiology of vitamin E acetate-induced lung injury is unknown, vitamin E acetate may lead to pulmonary lipid accumulation and/or interfere with surfactant functioning. EVALI symptoms are vague but consist of a constellation of constitutional, pulmonary, and gastrointestinal symptoms. Patients often present multiple times to healthcare facilities as their clinical condition worsens with a considerable mortality risk. The diagnosis of EVALI hinges on obtaining history leading to the recognition of vaping/dabbing. Physicians need to be persistent, but nonjudgmental, in obtaining vaping histories, especially in THC-prohibited states. Radiographical findings of nonspecific bilateral ground-glass infiltrates are best detected on computed tomography. Management for EVALI requires a multidisciplinary approach focused on supportive respiratory care and ruling-out infectious causes. Corticosteroids may be of benefit. Most patients who are hypoxic, have comorbidities, or lack appropriate follow-up within 24-48 hours should be admitted for monitoring. Patients may benefit from substance abuse counseling and should be instructed to avoid vaping. As the outbreak continues, cases should be reported to local health departments and poison control centers.

Acute Elemental Mercury Poisoning Masquerading as Fever and Rash.

This is a case series of 3 children from a single family who developed symptomatic elemental mercury poisoning requiring hospitalization and chelation. The mercury exposure primarily occurred in the home but the mercury was also tracked to one of their schools requiring environmental cleanup at both the home and school. The clinical assessment and management, as well as public health investigation and response, are discussed. There are many lessons learned in this difficult, often delayed, diagnosis. Early recognition of this environmental toxic exposure is essential. Communication between the clinicians and public health officials played a critical role. Public education prevented panic. Proper environmental sampling, and assessment and management of those exposed, were a few of the many challenges faced in this complicated case series.

Clinical Features of E-cigarette, or Vaping, Product Use-Associated Lung Injury in Teenagers.

BACKGROUND: In the United States in 2019, there was an outbreak of electronic cigarette, or vaping, product use-associated lung injury (EVALI). The manifestations of EVALI in adolescents are not well characterized. We describe the diagnosis, evaluation, and management of EVALI in adolescents hospitalized at a tertiary care, university-affiliated children's hospital. METHODS: A multidisciplinary committee developed an EVALI algorithm on the basis of guidelines from the Centers for Disease Control and Prevention. A retrospective chart review was conducted on patients diagnosed with EVALI. Descriptive analyses included sociodemographic characteristics, clinical presentation, laboratory and imaging results, pulmonary function testing, oxygen requirements, and clinic follow-up. RESULTS: Thirteen hospitalized adolescents were diagnosed with confirmed or probable EVALI. The majority were female (54%) with a mean age of 15.9 years. Sixty-nine percent of patients presented with respiratory symptoms, whereas gastrointestinal symptoms were prominent in 85% of patients. Vaping Δ-9-tetrahydrocannabinol was reported in 92% of patients, and vaping nicotine was reported in 62% of patients. All had bilateral ground-glass opacities on the chest computed tomography (CT) scan. Treatment with glucocorticoids led to clinical improvement in 11 of 12 patients. Treatment with glucocorticoids led to improvement in both forced expiratory volume in 1 second and forced vital capacity (P < .05). Four patients required home oxygen on the basis of 6-minute walk test results. CONCLUSIONS: Diagnosis of EVALI should be suspected on the basis of vaping history and clinical presentation. Glucocorticoid treatment led to an improvement in symptoms and lung function. The 6-minute walk test may help determine oxygen needs at discharge.

Review of Health Consequences of Electronic Cigarettes and the Outbreak of Electronic Cigarette, or Vaping, Product Use-Associated Lung Injury.

Electronic cigarettes (e-cigarettes) are battery-operated devices to insufflate nicotine or other psychoactive e-liquid aerosols. Despite initial claims of e-cigarettes as a nicotine-cessation device, aggressive marketing of e-cigarettes has led to an explosion in adolescents' and young adults' use over the last few years. Coupled with a lack of adequate investigation and regulation of e-cigarettes, the USA is facing an outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI) starting in mid-2019. While little long-term health hazard data are available, the components and constituents of e-cigarettes may adversely impact health. Propylene glycol and glycerin are humectants (water-retaining excipients) that generate pulmonary irritants and carcinogenic carbonyl compounds (e.g., formaldehyde, acetaldehyde, and acrolein) when heated in e-cigarettes. Metals contained in heating coils and cartridge casings may leach metals such as aluminum, chromium, iron, lead, manganese, nickel, and tin. Flavoring agents are considered safe for ingestion but lack safety data for inhalational exposures. Diacetyl, a common buttery flavoring agent, has known pulmonary toxicity with inhalational exposures leading to bronchiolitis obliterans. In 2019, clusters of lung injury associated with e-cigarette use were identified in Wisconsin and Illinois. Patients with EVALI present with a constellation of respiratory, gastrointestinal, and constitutional symptoms. Radiographically, patients have bilateral ground glass opacifications. As of February 18, 2020, the Centers for Disease Control has identified 2807 hospitalized patients diagnosed with either "confirmed" or "probable" EVALI in the US. Currently, vitamin E acetate (VEA) used as a diluent in tetrahydrocannabinol vape cartridges is implicated in EVALI. VEA cuts tetrahydrocannabinol oil without changing the appearance or viscosity. When inhaled, pulmonary tissue lacks the mechanism to metabolize and absorb VEA, which may lead to its accumulation. While most EVALI patients were hospitalized, treatment remains largely supportive, and use of corticosteroids has been associated with clinical improvement. The outbreak of EVALI highlights the need for regulation of e-cigarette devices and e-liquids. Clinicians need to be aware of the health hazards of e-cigarettes and be vigilant in asking about vaping.

Comparison of Unintentional Exposures to Codeine and Hydrocodone Reported to Texas Poison Centers.

BACKGROUND: Hydrocodone has recently been reclassified as a Schedule II drug by the United States Drug Enforcement Administration and Food and Drug Administration in order to curtail prescription drug abuse. There is concern that analgesic substitutes, such as codeine, will not be as safe or effective. OBJECTIVE: The purpose of this study is to compare the demographics, adverse events, and medical outcomes of patients who had unintentional hydrocodone or codeine exposures through the use of a state's poison center database. METHODS: The Texas Poison Center Network's database was utilized to find all reported unintentional ingestions or adverse reactions of products containing codeine or hydrocodone. Comparisons were made between the two medications by calculating the rate ratios (RR) and 95% confidence intervals (CI). RESULTS: Children aged 5 years or younger were more exposed to codeine (51.6%). Hydrocodone exposures had more serious outcomes (11% vs. 9%; RR = 0.82; 95% CI 0.73-0.91) and had more nausea (7.1% vs. 2.8%; RR = 0.4; 95% CI 0.32-0.48) and vomiting (6.5% vs. 3.3%; RR = 0.51; 95% CI 0.43-0.62). Hydrocodone had a higher rate of intravenous fluids administration (2.4% vs. 1.7%; RR = 0.71; 95% CI 0.54-0.92) and antiemetics (0.4% vs. 0.1%; RR = 0.23; 95% CI 0.08-0.64). Codeine was more closely associated with dermal reactions and patients were given antihistamines (2.5% vs. 1.3%; RR = 1.88; 95% CI 1.46-2.41) more frequently. Cardiovascular side effects, ataxia, and headache occurred equally between the groups. CONCLUSIONS: Both drugs had a wide array of reported side effects, but the overall incidence of serious outcomes was low.

Benzonatate toxicity in a teenager resulting in coma, seizures, and severe metabolic acidosis.

We report a benzonatate overdose in a teenager resulting in life-threatening toxicity to increase awareness of this overdose, and discuss recent pediatric warnings and labeling information provided by the US Food and Drug Administration (FDA). After an overdose of benzonatate, a 13-yr-old female presented to our emergency department with coma, seizures, hypotension, prolonged QT interval on electrocardiogram, and metabolic acidosis. Benzonatate is an antitussive medication with sodium channel-blocking properties and local anesthetic effects on the respiratory stretch receptors due to a tetracaine-like metabolite. Overdose is reported to cause coma, seizures, hypotension, tachycardia, ventricular dysrhythmias, and cardiac arrest. The FDA recently issued a Drug Safety Communication warning that accidental benzonatate ingestion in children younger than 10 years of age have increased risk of death and added the new information to the Warnings and Precautions section of benzonatate's label.

Cheese: an old drug in a new wrapper.

BACKGROUND: An unexpected outbreak of "cheese" heroin, which contained diphenhydramine and usually acetaminophen, began in Dallas around 2004. Onset occurred among youths living in neighborhoods populated by first-generation Hispanic immigrants. Little was known about the problem or the social strengths and deficits of these youth, who were primarily inhalers ("snorters") but at risk of transitioning to injection. METHODS: Multiple data sources were used, including surveys, data from emergency departments, law enforcement, treatment programs, and coroner, and interviews with users and key informants. RESULTS: Among heroin users under age 20, overdose deaths peaked in 2006, the school survey responses to using "cheese" heroin peaked in 2007, and treatment admissions peaked in 2008. Hispanic youth entering treatment were less likely to be injectors and report fewer problems than their Anglo counterparts and they were more likely to live with their families and to be supported by them. Sixty percent of the Hispanic youth had been in treatment previously and only 53% completed treatment. Cocaine and/or benzodiazepines were involved in 32% of the adolescent heroin deaths. CONCLUSIONS: The timely use of multiple data sources enabled this outbreak to be quickly identified and monitored, and the Cheese Heroin Task Force used the collected data to help respond to the problem, although retention in treatment and readmissions remained problematic. Cultural problems including immigration status, language, and misunderstandings about the nature of treatment were barriers to successful treatment outcomes. Completion of treatment as an inhaler is critical to reducing the likelihood of transitioning to injection.

Cardiotoxicity associated with the synthetic cannabinoid, K9, with laboratory confirmation.

Synthetic cannabinoids have been popular recreational drugs of abuse for their psychoactive properties. Five of the many synthetic cannabinoids have been recently banned in the United States because of their unknown and potentially harmful adverse effects. Little is known about these substances. They are thought to have natural cannabinoid-like effects but have different chemical structures. Adverse effects related to synthetic cannabinoids are not well known. We provide clinical effects and patient outcome following K9 use. In addition, we briefly review synthetic cannabinoids. We present a 17-year-old adolescent boy with chest pain, tachycardia, and then bradycardia associated with smoking K9. Two synthetic cannabinoids, JWH-018 and JWH-073, were confirmed on laboratory analysis. In addition to the limited current data, we demonstrate harmful adverse effects related to toxicity of 2 synthetic cannabinoids. Further studies are needed.

Crotalidae polyvalent immune Fab for the treatment of pediatric crotaline envenomation.

Crotaline snakebites occur frequently in children, often resulting in significant morbidity. Crotalidae Polyvalent Immune Fab antivenom (FabAV) became available for clinical use in the US in 2000 and is currently the standard of care for the treatment of crotaline envenomation. The pediatric emergency care provider should be familiar with FabAV because its judicious use in affected children can greatly decrease morbidity caused by crotaline snakebites. This article will review the use of FabAV for the treatment of pediatric crotaline envenomation.

Iron bezoar retained in colon despite 3 days of whole bowel irrigation.

Concretion formation is a documented complication of large iron ingestions. The generally accepted treatment is supportive care, whole bowel irrigation, and intravenous deferoxamine for systemic toxicity. Laparotomy and gastrotomy have also been used in patients with a high iron burden and bezoar formation. Though experiments suggest that iron is poorly absorbed in the colon, there are no case reports of iron overdose without systemic toxicity, despite a retained colonic bezoar. We report the case of a 16-month-old who presented to an Emergency Department 19 h after an iron ingestion. Initial laboratory studies revealed an anion gap of 14 mEq/L, and a 20 h serum iron concentration of 429 mcg/dL. An abdominal radiograph revealed multiple pills throughout the stomach and small bowel; whole bowel irrigation was initiated. Deferoxamine was administered at 10 mg/kg/h and then stopped when the serum iron level reached 27 mcg/dL, 36 h later. At this time, the abdominal radiograph showed an iron bezoar remaining in the ascending colon despite a clear rectal effluent from whole bowel irrigation. Despite whole bowel irrigation over the next 36 h, the iron bezoar was not removed and actually migrated proximally in the colon. Treatment was stopped on the third day and a normal diet was instituted with prompt passage of the bezoar.