A Growing Crisis: Adults with Autism Spectrum Disorder in the ED

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By: Kayla Mays, DNP, APRN, PMHNP-BC
Email: Mays-Kayla.Mays@choa.org

In the state of Georgia, none of the existing acute inpatient psychiatric hospitals will accept an adult with Autism Spectrum Disorder, who has limited communication abilities and/or is needing any assistance with activities of daily living. The current prevalence of adults with ASD is estimated to be 2.21% (5,437,988) of the US population (1). Adults with ASD are typically seen in the ED 2.3 times higher than adults without ASD (2). As we know, when kids and young adults with ASD become adults they are not cured of their symptoms. They continue to need ongoing behavioral and psychiatric care. Unfortunately, when the patient is unable to access primary mental health care the emergency departments become the safety net for this population when they have a behavioral health crisis.

For adult patients with severe ASD, the chaotic and urgent environment of most ED’s can be particularly distressing. The combination of exposure to a novel environment, exposure to increased stimuli, and increased demands on the patient during a time of crisis (ex. needing to draw blood, enter the exam room, talk to doctor, etc.) can result in worsening of aggressive behaviors. At Children’s Healthcare of Atlanta Emergency Departments, our teams have attempted to modify the environment to help reduce this risk through the use of: individualized Coping Plans, therapeutic visits from the behavioral and mental health nursing team, and assistance from the behavioral specialists from the Marcus Autism Center (3). The Consultation-Liaison Psychiatry service is also available to discuss medication recommendations and available community resources. Since there are no psychiatric facilities that can accept these adult ASD patients, they must be stabilized in the ED and transitioned to community outpatient care. 

Anaphylaxis: It’s all about the Epi

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By: Dr. John Cheng
Email: ChCheng-john.cheng@pemaweb.com

Allergic reactions are common complaints in the ED. Often they are mild (e.g., urticaria without any other symptoms) and can be easily managed by antihistamines alone.  They can be caused by many things; but in pediatrics, allergic reactions are usually due to foods (in all ages) and insect stings (in older kids). 

Anaphylaxis, by definition, is a life-threatening allergic reaction with severe respiratory or cardiovascular compromise or involving at least 2 organ systems (e.g., skin, pulmonary, cardiovascular, neurologic, gastrointestinal). Typically, patients present during the “acute” phase when symptoms first occur.  In some cases, there is a “late” phase to the reaction that can occur 12-24 hours later, sometimes even later (up to 72 hours) in some case series. It may take several hours after an exposure to an allergen before symptoms develop. The risk of a biphasic response is greater in those patients who have a severe initial presentation or require more than one dose of epinephrine.

Children should not be shot: Child access prevention laws are just as important as child restraint laws!

By Kiesha Fraser Doh

kiesha.fraser@emory.edu

In 2019, there were 563 emergency department visits for unintentional shootings involving children and teens in Georgia. Early 2020 estimates show that a total of 22 children gained access to a gun and unintentionally shot themselves or someone else. The youngest child was two years old when he shot his father in the back and killed him

In 2020, there was an increase in firearm injuries and deaths of children nationwide. During the first six months, there was a 1.9 times increased risk of firearm injury in children under 12 and an 1.4 times increased risk of children under 12 shooting someone else with a gun compared to pre-COVID period.

There are numerous ways to secure firearms safely by utilizing cable locks, trigger locks, lockboxes, and gun safes. Public policy that encourages gun owners to secure their weapons could potentially reduce the impact of this injury, similar to the impact that child passenger restraint laws have had on our society.  In 1975, many kids died in motor vehicle collisions (MVCs) due to inadequate and less sophisticated car design and lack of child and passenger restraints. Since 1975, the rate of pediatric passenger motor vehicle deaths has decreased by 56%.  

In the early 1980s, only 14% of American adults used seat belts, and only 7% of American children were restrained in seat belts or car seats. Starting in the ’70s and ‘80s, numerous public safety campaigns promoted car restraints, and the National Highway Transportation Association pushed for improved car design. Since the first child restraint law was enacted in our neighboring state of Tennessee in 1985, child restraint laws have been enacted in all 50 states and DC; these laws have encouraged parents to restrain 90% of children nationwide. In fact, since the passage of Georgia’s seat belt restraint law, 97% of Georgians now wear a seat belt

Since 1963 the child and teen firearm fatality rate has increased by 72%. From March-December 2020, there was a 30% increase in unintended shooting deaths by kids. One-third of children in the US live in homes with guns, and 85% of fatal pediatric firearm deaths in children 12 and under occur in their own homes. In addition, a recent survey in Georgia found that 53% of parents report storing their firearms insecurely: unlocked, loaded, or not separate from ammunition. 

Fifteen states plus the District of Columbia have laws that make it illegal to store your firearm negligently (Child Access Prevention-CAP laws).  Just 4 of those states require some or all guns to be locked up, and only one state, Massachusetts, requires all firearms to be locked up. CAP laws that require gun owners to store their firearms safely have been shown to reduce suicide and unintentional death and injury by up to 54%. In addition, the CAP law in Massachusetts has potentially impacted the number of children killed by guns; for example: in 2019, 163 children and teens died from firearm injuries in Georgia, while Massachusetts had 18 deaths. Georgia’s CAP law is considered a negligence law as it states that it’s illegal to knowingly give a gun to a minor for an unlawful purpose but Ga has no law that makes it illegal for gun owners to store their firearms insecurely. 

Motor vehicle collisions used to be the number one cause of death in children and teens, but now firearms injury has surpassed MVCs as the leading cause of death. By utilizing similar injury prevention approaches to those that enabled us to reduce the frequency of MVCs as a preventable cause of death in children and teens, we can reduce the rate of firearm injury. Medical organizations, public health agencies, gun owners’ associations, and public safety personnel all support safe firearm storage practices in homes with children and youth

“What can healthcare workers and Georgians do?” 

   We can lead by example: securely storing firearms unloaded, locked up, and separate from ammunition.

   We can talk to children and teens in our lives about the dangers of unsecured firearms and what steps to take if they find an unsecured firearm: “STOP! Don’t touch. Leave the area. Tell an Adult.”  

   We can ask if any firearms in the home are stored, unloaded, and locked before sending our child to someone else’s home. 

   We can have respectful, informed conversations with patients, parents, and caregivers about the risk of unsecured firearms and how to reduce that risk.

   We can work collaboratively with lawmakers and stakeholders to craft thoughtful, evidenced-based CAP laws.

   We can partner with community partners, families, and gun owners to advocate for safe gun storage in our communities.

Georgia Stay SAFE! Georgia Stay SAFE is a coalition of healthcare workers involved in injury prevention who came together to form a partnership based on our shared interest in promoting the prevention of firearm injuries in children.Georgia Stay SAFE Coalition is excited to announce the launch of Georgia Stays SAFE campaign this current week from June 20th-June 25th.

Georgia Stays SAFE stands for:

1.     Secure Firearm Storage

2.     Ask Before Play

3.     Focus on Safety

4.     End Firearm Injury

Skin and Soft Tissue Guideline

By Preeti Jaggi

Preeti.jaggi@choa.org

Most antibiotics are prescribed in the outpatient setting and there are many opportunities for optimizing antimicrobial prescribing in this setting. Skin and soft tissue infections (SSTIs) are common presenting complaints in emergency department.  Infectious Disease Society of America guidelines recommend 5 days of initial treatment for non-purulent SSTI. In addition, randomized controlled trials have shown that cephalexin vs. both trimethoprim/sulfamethoxazole and cephalexin (to treat for presumed methicillin resistant Staphylococcus aureus as well as Group A streptococcus) are equally effective for non-purulent SSTI. This implies that cephalexin alone can be used for patients without abscesses. For patients presenting with purulent SSTIs, recent studies have shown comparable cure rates when trimethoprim/sulfamethoxazole or clindamycin are used for 7 instead of 10 days following I&D. 

In our system, we have found a wide range of variation in the outpatient management of SSTIs for both antibiotic choice and duration of treatment. For both purulent and non-purulent SSTIs, clindamycin or trimethoprim/sulfamethoxazole were generally being prescribed for 10 days, a longer duration than recommended. In a recent quality improvement project, we were able to improve antibiotic prescribing for both purulent and non-purulent SSTIs. Exclusion criteria were patients with impetigo, paronychia, preseptal and orbital cellulitis, cephalosporin allergy, and inpatient admission. 

Submersion Injury Guidelines

By Sarah Lazarus

Sarah.lazarus@pemaweb.com

Every summer, there are many articles and news reports of drownings. Some of these reports use terms that are outdated, such as delayed drowning, “dry” drowning, and near-drowning. The World Health Organization (WHO) defines drowning as the process of experiencing respiratory impairment from submersion/immersion in liquid.

  Any submersion or immersion incident without evidence of respiratory impairment should be considered a water rescue and not a drowning. Drowning remains a large cause of morbidity and mortality in children. Drowning is the leading cause in ages 1-4.  At least 10 people die from drowning daily. 

From the Armchair: Tips for school return from a Child Psychologist

Betsy Gard, Ph.D.

  Drbetsy5151@comcast.net

In April 2020, schools were suspended in 188 countries and over 2.5 billon young people worldwide were not in school. As of February 2021, school systems are reopening, but with tremendous variability in policies.  Almost all children and youth have missed at least 25% of teacher-led instruction.  Some children are actually “missing” and have rarely attended virtually. This is more common in those who come from disadvantaged environments or have special learning needs.  These youngsters will need to be reconnected to their school system. In addition, children have missed being in a social structure,  have not been monitored for academic progress, and in many situations, may not be receiving adequate nutrition,  sleep, or exercise.  They also may not be receiving services such as speech, physical, occupational therapy, or educational assistance as specified in their Individualized Education Plans (IEPs).

Although returning to school may be a relief for many children and their families, the impact of the stressors families and children have experienced over the duration of COVID may be exacerbated, for some, by returning to school. Stress affects physiological, psychological and behavioral reactions but can vary by child. It is common that parents and teachers may be distressed by the child’s externalizing behaviors- irritability, oppositionality, anger outbursts, talking back, quarreling with siblings, or unwillingness to cooperate in the family. They may not realize that these behaviors may be due to their child’s fear, anxiety or depression.

Firearm Injury Prevention: The Importance of Safe Firearm Storage

Sofia Chaudhary

sofia.s.chaudhary@emory.edu

A 12-year-old boy with a gunshot wound (GSW) to the chest is wheeled into the trauma bay, unresponsive, pulseless and undergoing CPR and subsequently dies. The patient’s 6-year old brother found their father’s gun while playing and pointed it at him. The parents now face the shattering loss of their older son and also the psychological impacts for their younger son, the second victim. Tragedies such as this have become too familiar for emergency departments across the US as the number of pediatric firearm deaths continue to climb annually

Firearms are the second leading cause of pediatric death in the US taking the lives of over 1,700 and injuring more than 6,500 children and teens (ages 0-17) in 2019.1 Homicide accounted for a majority of these deaths, but 40% were from firearm-assisted suicide and 5% from unintentional injuries. Middle schoolers and high schoolers in the US are now more likely to die from a gun than from any other cause, including motor vehicle collisions.2 Additionally, 4.6 million children in the US live in a home with at least one unlocked and loaded gun, double the rates of firearm exposure from a decade earlier.3 Access to an improperly stored firearm in the home increases the risk of both pediatric unintentional firearm injury and firearm assisted-suicide (by 2-5x).4-7

Childrens’ (CHOA) ED COVID-19/Flu Testing Algorithm

by Thuy Bui

thuy.bui@pemaweb.com

According to the Centers for Disease Control and Prevention (CDC), COVID-19 cases, hospitalizations, and deaths across the United States are rising.  With the socialization that comes with the holiday season and the arrival of cold weather driving more people indoors, this rise in COVID cases will not likely improve any time soon.  Due to the concern of a worsening COVID surge, the possibility of a “twindemic” with the arrival of influenza, and continued limited testing capacity at our hospitals and EDs, medical leadership from Emergency Medicine and Infection Prevention at Children’s Healthcare of Atlanta created an algorithm to help determine how to best utilize available tests for SARS-CoV-2.  

This testing algorithm, which takes into account CDC recommendations, provides a general framework for testing in our emergency departments.  Basic considerations of the algorithm include:

  1. Has the patient had a recent positive COVID PCR or antigen test?
  2. Does the patient exhibit symptoms of COVID-19?
  3. Will the results of the COVID test directly impact acute clinical care or medical management of this patient?
  4. Will the results of the COVID test help in management of a child with a chronic or underlying medical condition?
  5. Will testing impact a child or parent’s ability to return to school or work?

These are the questions our ED providers will have in mind if a child presents or is referred to any of our emergency departments with a concern of COVID-19.

The first consideration is whether or not the child has had a positive COVID PCR or antigen test in the past 3 months.  Since it has been shown that patients may test positive for up to 3 months after recovering from an acute COVID infection and not be contagious to others, COVID testing is not routinely recommended during this time frame.  Testing for other etiologies including influenza and Multisystem Inflammatory Syndrome in Children (MIS-C) may need to be considered.

Adolescent Mental Health During COVID-19 Pandemic and Beyond

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by Kristin Weinschenk kristin.weinschenk@choa.org
By Becky Burger
BeckyBurger@emory.edu

The year 2020 has presented tremendous challenges and changes to all fields of medicine.  As this pandemic has grown in size and impact, there has been growing concern about the impact of social, economic and political stressors on mental health (MH).  Early data from the CDC has shown rising prevalence of symptoms of anxiety, substance abuse, suicidal ideations, and depressive disorders across all ages, with a disproportionate prevalence amongst young adults (62.9% in 18-24yo vs 30.9% in all ages) and racial minorities.1 Data on children and teens is still being collected, but thus far points to similar increases in children and teens. As COVID continues to affect our communities, physicians must be on alert for these growing psychiatric concerns.  

One of the major changes for youth has been the closure of schools and subsequent shift to online education. Children of all ages across the state are now learning virtually and screen time is surpassing the limits recommended by AAP.  While public opinion often considers social media as having a negative impact on MH, the data around this is mixed.4,5   Rather than focusing on social media use itself, it may be more helpful to look at specific exposures to negative aspects of social media, such as online bullying, sexual exploitation, and trauma exposure.5,6  An example that has received considerable media attention this year is the prevalence across social media platforms of videos depicting police brutality of minorities.  The American Academy of Child and Adolescent Psychiatry (AACAP) recommends parents have an active, hands on role in helping children process information they have learned from the news about tragedies. When children view these images on social media, they often lack the parental support and context, and may experience higher stress related responses.7   As screen time increases, parents should be advised to remain engaged in what their children are viewing and how they are processing that information.  Physicians should also be ready to discuss in detail how patients are using their screen time and how it may be affecting their mood and thoughts. 

THE HIGH AND LOWS OF CANNABIS

Ricardo Jimenez, MD

Cannabis, also known as Marijuana, remains the most used illegal drug in the United States. National estimates suggest that 22.2 million people 12 years or older are current users of Cannabis. The primary cannabinoids in cannabis are 9-Tetrahydrocannabinol (THC) and cannabinol (CBD). THC is primarily responsible for the psychoactive properties of cannabis. Cannabinoids are thought to exert their pharmacological activity via several mechanisms. The most studied  is the receptor mediated mechanism that includes two receptors, Cannabinoid-binding receptor 1 (CB1) and Cannabinoid-binding receptor 2 (CB2). CB1 receptors are located throughout the central nervous system (CNS) and CB2 are only found in the peripheral tissues. Stimulation of the receptors in the CNS produces hallucinations, memory loss, dyskinesia, and sedation. The actions of CB2 are receptors are not yet clear. 

            The increase in legalization, availability, and marketing of cannabis, correlates to an increase in unintentional pediatric exposures. Pediatric exposures to cannabis rose from 148% from 2006 to 2013. Since the decriminalization of cannabis, there has been an explosion of dispensaries that have catapulted cannabis to be a major industry generating $ 2.3 billion dollars in sales in Colorado alone. Part of this growth has included expansion in the available forms of cannabis, including edible products, concentrated tinctures, and e-cigarettes. Many commercial cannabis-infused edibles are produced in the form of cookies, cakes, candy bars, and even drinks, which are indistinguishable to children from their non-cannabis counterparts. Edibles have become the most common form of unintentional cannabis exposure in pediatrics.