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


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


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.