Recreational cannabis legalization and pediatric exposures in Massachusetts, United States.

INTRODUCTION: In Massachusetts, US, medical cannabis legalisation was associated with increased paediatric cannabis exposure cases, including emergency department (ED) visits and hospitalizations. The impact of recreational cannabis legalisation (RCL) on paediatric exposures in Massachusetts has yet to be studied. METHODS: To compare the incidences before and after RCL in Massachusetts, US, we queried the data on paediatric cannabis exposure cases in 2016-2021 from the Centre for Healthcare and Analysis and Injury Surveillance Programme at the Massachusetts Department of Public Health. The pre-and post-legalisation phases comprised the periods between 2016-2018 and 2019-2021, respectively. Cannabis-related exposure cases included ED visits and hospitalizations among children and young adolescents of 0-19 years old. RESULTS: During the 6-year period (2016-2021), 2357 ED visits and 538 hospitalizations related to cannabis exposure among children and teenagers (0-19 years) were reported in Massachusetts. The incidence of ED visits for all age groups increased from 18.5 per 100 000 population before RCL to 31.0 per 100 000 population (incidence rate ratio (IRR), 1.6; 95% CI, 1.5 to 1.8). Children in the age groups of 0-5 and 6-12 years experienced the highest increase in cannabis-related ED visits. Additionally, the incidence of hospitalisation due to cannabis intoxication substantially increased following RCL (IRR, 2.2; 95% CI, 1.8 to 2.7), a 126% increase. CONCLUSIONS: Cannabis-related ED visits and hospitalizations among children and teenagers increased after recreational cannabis became legal in Massachusetts, US. Further efforts are warranted to prevent the unintentional impact of RCL, especially considering substantial increases in cannabis exposure cases among young children.

Ventricular tachycardia after naloxone administration in an adolescent.

Naloxone is a medication with a largely benign safety profile that is frequently administered in the emergency department to patients presenting with altered mental status. Ventricular tachycardia has been reported after naloxone administration in adult patients with prior use of opiate or sympathomimetic medications. However, no such reports exist in the pediatric population or in patients who have no known history of opiate or sympathomimetic medication use. We describe a case of ventricular tachycardia after naloxone administration in a 17-year-old male with no known prior use of opiate or sympathomimetic agents who presented to the emergency department with altered mental status of unknown etiology. Emergency physicians may wish to prepare for prompt treatment of ventricular arrythmias when administering naloxone to pediatric patients presenting with altered mental status.

Firearm-related injuries in children and adolescents: an emergency and critical care perspective.

PURPOSE OF REVIEW: Firearms are a leading cause of death and injury in children, especially in the United States. Many of these injuries present to emergency departments and pediatric ICUs, prompting a need for updated prevention, interventions, and trauma-informed care. This review explores the evidence for prevention and screening for access to firearms, types of injuries, and considerations for mass casualty events. RECENT FINDINGS: Firearm-related injuries lead to over 20 000 emergency department visits annually in children and carry a higher risk of severe injury or death. Screening high-risk patients for access to firearms is suboptimal, despite evidence showing reduction in suicide deaths and increased safe storage. While mass casualty shootings represent a low proportion of all firearm-related morbidity, they have brought heightened attention to focus on quality research. SUMMARY: Firearm-related injury is a public health crisis and presents a unique risk to children and adolescents. A firearm in the home, especially one with children, significantly increases the risk of death by homicide or suicide. Research on gun violence is leading to important national conversations on gun control and the role of physicians in the prevention of injury and advocacy for effective interventions and legislation.

Impact of a State Law on Physician Practice in Sports-Related Concussions.

OBJECTIVE: To determine physician-reported adherence to and support of the 2010 Massachusetts youth concussion law, as well as barriers to care and clinical practice in the context of legislation. STUDY DESIGN: Primary care physicians (n = 272) in a large pediatric network were eligible for a cross-sectional survey in 2014. Survey questions addressed key policy and practice provisions: concussion knowledge, state regulations and training, practice patterns, referrals, patient characteristics, and barriers to care. Analyses explored relationships between practice and policy, adjusting for physician demographic and practice characteristics. RESULTS: The survey response rate was 64% among all responders (173 of 272). A total of 146 respondents who had evaluated, treated, or referred patients with a suspected sports-related concussion in the previous year were eligible for analysis. The vast majority (90%) of providers agreed that the current Massachusetts laws regarding sports concussions are necessary and support the major provisions. Three-quarters (74%) had taken a required clinician training course on concussions. Those who took training courses were significantly more likely to develop individualized treatment plans (OR, 3.6; 95% CI, 1.1-11.0). Physician training did not improve screening of youth with concussion for depression or substance use. Most physicians (77%) advised patients to refrain from computer, telephone, or television for various time periods. Physicians reported limited communication with schools. CONCLUSIONS: Primary care physicians report being comfortable with the diagnosis and management of concussions, and support statewide regulations; however, adherence to mandated training and specific legal requirements varied. Broader and more frequent training may be necessary to align current best evidence with clinical care and state-mandated practice.

Helmet Use in Preventing Head Injuries in Bicycling, Snow Sports, and Other Recreational Activities and Sports.

Bicycling, snow sports, and other recreational activities and sports are important activities to keep children and youth active as part of a healthy lifestyle. These activities can be associated with serious and fatal head and facial injuries. Helmets, when worn correctly, are effective in decreasing head injuries and fatalities related to these activities. Legislation for helmet use is effective in increasing helmet use in children and, ultimately, in decreasing deaths and head and facial injuries. A multipronged strategy employing legislation, enforcement of laws, and medical clinicians and community programs is important for increasing helmet use to decrease deaths and injuries from recreational sports.

Helmet Use in Preventing Head Injuries in Bicycling, Snow Sports, and Other Recreational Activities and Sports.

Recreational activities and sports are a common and popular way for youth to enjoy physical activity; however, there are risks related to physical injury. Injuries can potentially result in death and long-term disability, especially from traumatic brain injury. Helmet use can significantly decrease the risk of fatal and nonfatal head injury, including severe traumatic brain injury and facial injuries when participating in recreational sports. The most robust evidence of helmet effectiveness has been demonstrated with bicycling and snow sports (eg, skiing, snowboarding). Despite this evidence, helmets are not worn consistently with all recreational sports. A multipronged approach is necessary to increase helmet use by children and youth participating in recreational sports. This approach includes legislation and enforcement, public educational campaigns, child education programs, and anticipatory guidance from clinicians. This policy statement guides clinicians, public health advocates, and policymakers on best practices for increasing helmet use in recreational sports, including bicycling and snow sports.

Implementation of a Nurse-Driven Asthma Pathway in the Pediatric Intensive Care Unit.

Asthma is one of the most common conditions requiring admission to a pediatric intensive care unit. Dosing and weaning medications, particularly bronchodilators, are highly variable, and evidence-based weaning algorithms for clinicians are lacking in this setting. METHODS: Patients admitted to a quaternary pediatric intensive care unit diagnosed with acute severe asthma were evaluated for time spent receiving continuous albuterol therapy, the length of stay in the intensive unit care unit, and the length of stay in the hospital. We developed an asthma pathway and continuous bronchodilator weaning algorithm to be used by bedside nurses. We then implemented two major Plan-Do-Study-Act cycles to facilitate the use of the pathway. They included implementing the algorithm and then integrating it as a clinical decision support tool in the electronic medical record. We used standard statistics and quality improvement methodology to analyze results. RESULTS: One-hundred twenty-six patients met inclusion criteria during the study period, with 32 during baseline collection, 60 after weaning algorithm development and implementation, and 34 after clinical decision support implementation. Using quality improvement methodology, hours spent receiving continuous albuterol decreased from a mean of 43.6 to 28.6 hours after clinical decision support development. There were no differences in length of stay using standard statistics and QI methodology. CONCLUSION: Protocolized asthma management in the intensive care unit setting utilizing a multidisciplinary approach and clinical decision support tools for bedside nursing can reduce time spent receiving continuous albuterol and may lead to improved patient outcomes.

Improving Pediatric Residents' Screening for Access to Firearms in High-Risk Patients Presenting to the Emergency Department.

BACKGROUND/OBJECTIVE: Access to a firearm is a significant risk for completed suicide or homicide. We sought to increase the rate of screening for access to firearms in patients who presented to the emergency department with suicidal or homicidal ideation or suicide attempt through the use of quality improvement methodology. METHODS: Patient records were eligible for inclusion if the child was under the age of 19 and presented to the emergency room of our tertiary medical center with a diagnosis of suicidal ideation, homicidal ideation, or suicide attempt. Records were manually reviewed for demographic information and documentation of screening for access to firearms. A baseline survey of the pediatric residents was completed to identify perceived barriers to screening for access to firearms. Subsequently, three "Plan, Do, Study, Act" (PDSA) cycles consisting of a noon conference, a dedicated grand rounds, and an electronic health record template were completed. RESULTS: During the baseline and study period, 501 patients met inclusion criteria. Forty-one of sixty-six (62.1%) residents completed a baseline survey and identified barriers to screening. There was no significant increase in screening following the first or second PDSA cycles. Following the third PDSA cycle, screening rates increased from 4% to 34%. CONCLUSIONS: Quality improvement methodology can be used to increase the rates of screening for access to firearms in high-risk patients. Further work is necessary to identify additional strategies to further increase screening rates.

Unintentional Window Falls in Children and Adolescents.

OBJECTIVE: Unintentional window falls represent a preventable source of injury and death in children. Despite major campaigns in some larger cities, there continue to be unintentional falls from windows throughout the United States. We aimed to identify risk factors and trends in unintentional window falls in the pediatric population in a national and regional sample. METHODS: A retrospective analysis of annual emergency department (ED) visits from the National Electronic Injury Surveillance System using product codes specific to windows, as well as patient encounters for unintentional window falls from January 2007 to August 2017 using site-specific trauma registries from 10 tertiary care children's hospitals in New England. National and state-specific census population estimates were used to compute rates per 100,000 population. RESULTS: There were 38,840 ED visits and 496 regional patients who unintentionally fell from a window across the study period between 0 and 17 years old. The majority of falls occurred in children under the age of 6 and were related to falls from a second story or below. A decreased trend in national ED visits was seen, but no change in rates over time for regional trauma center encounters. A high number of falls was found to occur in smaller cities surrounding metropolitan areas and from single family residences. CONCLUSIONS: Falls from windows represent a low proportion of overall types of unintentional sources of injury in children but are a high risk for severe disability. These results provide updated epidemiologic data for targeted intervention programs, as well as raise awareness for continued education and advocacy.

Going green: decreasing medical waste in a paediatric intensive care unit in the United States.

The healthcare industry generates significant waste and carbon emissions that negatively impact the environment. Intensive care units (ICU) are a major contributor to the production of waste, due to patient complexity and needs requiring extensive equipment, cleaning practices and pre-emptive supplies. To quantify the extent of the problem, health care professionals collected all unused medical supplies destined to be discarded over three one-week periods in a paediatric intensive care unit, weighed the items, and created an inventory. This article argues for greener hospital standards and provides a specific example of a project framework to reduce disposable waste with the hope that others can embark on similar initiatives for a more ethical and sustainable future for hospitals. Healthcare facilities must not just meet short-sighted safety standards of the now. In order to be a virtuous organization, one must consider all implications of daily decisions, including disposable supplies and cleaning.

Distracted Driving Laws and Motor Vehicle Crash Fatalities.

BACKGROUND: Motor vehicle crashes (MVCs) continue to be the leading cause of death in youth 16 to 24 years old in the United States. Distracted driving has been shown to increase the risk of MVCs in all drivers, particularly teenagers. We aimed to determine the association between fatal MVC rates involving 16- to 19-year-old drivers and state distracted driving laws. METHODS: We conducted a retrospective time series analysis of fatal MVCs in the United States involving drivers and passengers 16 to 19 years old from 2007 to 2017 using the Fatality Analysis Reporting System. Multivariable negative binomial regression analysis was performed to compare MVC rates across states on the basis of different types and strengths of distracted driving laws. RESULTS: There were 38 215 drivers 16 to 19 years old involved in fatal MVCs from 2007 to 2017. Incidence of fatal MVCs was highest for 19-year-old drivers (27.2 out of 100 000 19-year-old persons) and lowest for 16-year-olds (10.7 out of 100 000). States with primarily enforced texting bans had lower MVC fatality rates overall involving 16- to 19-year-old drivers (adjusted incidence rate ratio: 0.71; 95% confidence interval: 0.67-0.76). Texting bans and handheld bans for all drivers were associated with decreased MVC fatalities in all age groups. CONCLUSIONS: In the United States, primarily enforced distracted driving laws are associated with a lower incidence of fatal MVCs involving 16- to 19-year-old drivers. Bans on all handheld device use and texting bans for all drivers are associated with the greatest decrease in fatal MVCs. Adoption of universal handheld cellphone bans in all states may reduce the incidence of distracted driving and decrease MVC fatalities.

Fire Pit-Related Burn Injuries in Children and Adolescents.

Thermal burns are a leading cause of preventable injury in children and adolescents. Fire pits have become increasingly popular outdoor fixtures in U.S. homes. We aimed to identify trends in pediatric burn injuries related to fire pits that presented to a representative sample of United States Emergency Departments (EDs). A retrospective analysis of annual ED visits from the National Electronic Injury Surveillance System (NEISS) from January 1, 2006 through December 31, 2017 using product codes specific to fire pits. U.S. Census population estimates were used to compute rates per 100,000 population. SAS and Joinpoint weighted regression analyses were used to analyze annual estimates and rate trends across the study period. There were 10,951 (95% CI = 8535-13,367) ED visits for burn injuries secondary to outdoor fire pits in patients 19 years of age and younger across the study period. The majority of injuries occurred in children under the age of 5, and were related to falls into or on a hot fire pit. The annual modeled rate change showed an overall significant increase in burn injuries of 7.16 per 100,000 annually from 2006 to 2017 (P = .02). Outdoor fire pits represent an increasing hazard to young children who are particularly susceptible to burn injuries from falls in or around lit recreational fires. Product modifications and public awareness campaigns are necessary to prevent future life-altering injuries in pediatric patients.

Screening for Access to Firearms by Pediatric Trainees in High-Risk Patients.

OBJECTIVE: Access to firearms is an independent risk factor for completed suicide and homicide, and the American Academy of Pediatrics recommends that pediatricians screen and counsel about firearm access and safe storage. This study investigates how often pediatric residents screen for access to firearms or counsel about risk-reduction in patients with suicidal or homicidal ideation. METHODS: Retrospective chart review of visits by patients younger than the age of 19 years presenting to the pediatric emergency department (ED) of a tertiary academic medical center from January to December 2016. Visits were eligible if there was an ultimate ED discharge diagnosis of "suicidal ideation," "suicide attempt," or "homicidal ideation" as identified by International Statistical Classification of Diseases and Related Health Problems, 10th revision codes and the patient was seen by a pediatric resident before evaluation by psychiatry. Descriptive statistics were used to analyze results. RESULTS: Ninety-eight patients were evaluated by a pediatric resident for medical assessment before evaluation by a psychiatry team during the study period and were therefore eligible for inclusion. Screening for firearm access was documented by a pediatric resident in 5 of 98 (5.1%) patient encounters. Twenty-five patients (25.5%) had no documented screening for firearm access by any provider during the ED visit, including in 5 cases when patients were discharged home. CONCLUSIONS: Pediatric residents rarely document screening for firearm access in patients with known suicidal or homicidal ideation who present to the ED. Additional understanding of the barriers to screening and potential strategies for improving screening and counseling are critical to providing appropriate care for high-risk pediatric patients.

Age Legislation and Off-Road Vehicle Injuries in Children.

BACKGROUND AND OBJECTIVES: In 2010, the Massachusetts Legislature passed a comprehensive law that restricted off-road vehicle (ORV) use by children <14 years old and regulated ORV use by children up to the age of 18 years. We aimed to examine the impact of the 2010 Massachusetts law on the rates of ORV-related injuries. METHODS: A retrospective analysis was performed of Massachusetts emergency department (ED) and inpatient discharges between 2002 and 2013 as found in the Center for Health Information and Analysis database by using external causes of injury codes specific to ORV-related injuries. Yearly population-based rates were compared before and after the implementation of the law (2002-2010 vs 2011-2013) by using Poisson regression analysis and segmented regression. RESULTS: There were 3638 ED discharges and 481 inpatient discharges for ORV-related injuries in children across the 12-year study period. After the implementation of the law, the rate of ED discharges declined by 33% in 0- to 9-year-olds, 50% in 10- to 13-year-olds, and 39% in 14 to 17-year-olds (P < .0001). There was no significant decline in ED discharges for 25- to 34-year-olds. Inpatient hospital discharges were also reduced by 41% in 0- to 17-year-olds after implementation (P < .001). CONCLUSIONS: As compared with adults (ages 25-34 years), the population-based ORV-related injury rate of residents <18 years old significantly declined after the passage of legislation that imposed age restrictions and other safeguards for youth riders.