Categories
Surgery

Meckel Diverticulum

Meckel diverticulum is a congenital anomaly of the small intestine that can present with various clinical manifestations, including rectal bleeding and obstruction. Recognizing the characteristic features and understanding the differential diagnosis is crucial in managing patients with lower gastrointestinal bleeding. This episode will help you recognize and diagnose this surgical condition that you probably remember because the “rule of twos.”

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References

Dixon P & Nolan D. The Diagnosis of Meckel’s Diverticulum: A Continuing Challenge. Clin Radiol. 1987;38(6):615-9

Ghahremani G. Radiology of Meckel’s Diverticulum. Crit Rev Diagn Imaging. 1986;26(1):1-43

Weerakkody Y, Ranchod A, Yap J, et al. Meckel diverticulum. Reference article, Radiopaedia.org (Accessed on 26 Oct 2023) https://doi.org/10.53347/rID-17174

Sagar J, Kumar V, Shah DK. Meckel’s diverticulum: a systematic review. J R Soc Med. 2006 Oct;99(10):501-5.

An J, Zabbo CP. Meckel Diverticulum. [Updated 2023 Jan 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499960/#

Transcript

Note: This transcript was partially completed with the use of the Descript AI

Welcome to PEMCurrents: The Pediatric Emergency Medicine Podcast. As always, I’m your host, Brad Sobolewski. Your time is valuable and so is mine. And that’s why I release these brief, succinct episodes focused on a single clinical topic, get you in, get you out, teach you something. Today I’m going to talk about Meckel diverticulum. If you haven’t seen it clinically, you have seen it on a test and it is absolutely something that you should be thinking about when you see a patient with bloody stools in the emergency department.

So Meckel diverticulum is a congenital abnormality of the small intestine and it’s the most common cause of significant lower GI bleeding in children. It arises from an incomplete involution of the vitelline duct during embryonic development. You didn’t think I’d say that during this podcast.

Typically occurring during the seventh week of gestation. It’s characterized by a blind ending true diverticulum, a pouch, that contains all of the layers typically found in the ileum. So especially relevant to board exams, Meckel diverticulum follows the rule of twos. So it affects approximately 2 percent of the population.

It’s located about two feet from the ileocecal valve. It’s usually about two inches long. Only about 2 percent of cases actually become symptomatic. It is most commonly diagnosed by the age of two years, with 45 percent of symptomatic cases occurring in this age group. It is two times as common in boys, and there are two types of epithelium found in the meckle diverticulum, gastric and pancreatic.

So the clinical presentation of Meckel can vary depending on the complications that arise. The most common presentation in children Under the age of five years is rectal bleeding, which may be intermittent or just massive, but the bleeding is usually painless. Other complications include obstruction due to intussusception or volvulus, which can lead to bowel ischemia or shock.

Diverticulitis and umbilical fistula can also occur, but that might typically be seen later in life. In approximately a third of cases, Meckel diverticulum may perforate, and traumatic rupture of one could actually occur following blunt trauma. Let’s move briefly into the differential diagnosis of GI bleeding in children.

So, upper GI bleeding is typically not bright red. Now you could have a briskly bleeding ulcer and a liver transplant patient, but that’s not something we typically see in pediatrics. So generally lower GI bleeding is bright red, hematochezia, whereas the upper GI bleeding is maroon or dark black, diverticular disease.

which is rare in children, could cause bright red bleeding. A vascular ectasia or angio dysplasia, which is really hard to diagnose unless you’re an endoscopist. You could have bright red blood from inflammatory bowel disease, infectious colitis, mesenteric ischemia or ischemic colitis, colorectal cancer or polyps, hemorrhoids, both internal and external.

Aortoenteric fistula, or vascular fistulas, which are pretty darn rare in children, and generally a complication of inflammatory bowel disease or previous surgery, a rectal foreign body, a rectal ulcer, which is often associated with HIV, syphilis, or other sexually transmitted infections, or an anal fissure.

So all of these things are on the differential for lower GI bleeding. It’s important to note that if you see diarrhea with blood, as opposed to just frank blood, you should be thinking about infectious problems, like STEC causing organisms, like E. coli 0157:H7 which can lead to hemolytic uremic syndrome, or inflammatory bowel disease, or other problems.

So the diagnosis of Meckel diverticulum is called a meckle scan. I wonder how it got its name. It’s a technetium 99 pertectinate scan, and it’s the classic test of choice for diagnosis. It’s a nuclear medicine study, and the radioactive tracer is taken up by the gastric mucosa, which is in the Meckel diverticulum.

Therefore, it’ll show up on the radiology picture. The sensitivity is reported to be about 60 percent in adults, but 85 90 percent in children. The uptake of the dye can be increased by giving cimetidine or glucagon. So the feeding artery of the Meckel diverticulum is an anomalous branch of the superior mesenteric artery.

It has a long and non branching course and it ends generally towards the right lower quadrant. So the MEKL scan will help you pick up where that gastric mucosa is and then the surgeons can figure out how the blood supply gets there. Ultrasound and CT are not really good at differentiating a Meckel diverticulum from normal bowel.

So, if you think that somebody has a Meckel diverticulum, Here are some following management steps. If the patient has signs of obstruction, insert a nasogastric tube for GI decompression. Give broad spectrum antibiotics to cover potential bacterial infection, especially if the patient is ill appearing.

Give IV fluids packed red blood cells to resuscitate. A CBC and type and screen are great lamps to get. If there’s brisk bleeding or the patient’s unstable, consider COAGs. And yeah, you’re gonna want to consult a surgeon because that is how you deal with asymptomatic Meckel diverticulum. So if you’ve got complications such as significant bleeding, bowel obstruction or perforation, emergent surgical removal is warranted.

This can be done via a laparoscopic or open approach. So I’m going to wrap this up here. Again, this is a brief episode. A Meckle diverticulum is a congenital anomaly of the small intestine that can present with various clinical manifestations, including rectal bleeding. and bowel obstruction. Recognizing the characteristic features and understanding the differential diagnosis is crucial in managing patients with lower GI bleeding.

The Meckel scan is the preferred diagnostic modality. It’s a nuclear medicine scan and prompt surgical consultation is necessary for symptomatic cases. All right, so that’s it for this brief episode. If there’s other topics you want to see me tackle, send them my way. I’ll take your suggestions via email. Direct message on X or Twitter, Facebook, Instagram, telepathy. Any feedback is good feedback. Until next time, for PEMCurrents: The Pediatric Emergency Medicine Podcast, this has been Brad Sobolewski. See you later. 

Categories
Choosing Wisely Infectious Diseases

Respiratory viral panels

Just because you can test for dozens of viruses with a single swab should you? Is this actually measuring a current infection, or a recent virus from which the child has since recovered. And what about the cost? Are these tests expensive (spoiler alert: They are!). Learn about the situations when we should get these panels, and how we can avoid overusing them when we shouldn’t in this tremendous discussion with Dr. Olivia Ostrow and Dr. Kelly Levasseur.

This podcast episode is designed to disseminate the important work of Choosing Wisely, an initiative of the the American Board of Internal Medicine Foundation, the goal of which is the spark conversations between clinicians and patients about what tests, treatments, and procedures are needed – and which ones are not.

The Choosing Wisely recommendation: Do not obtain comprehensive viral panel testing for patients who have suspected respiratory viral illnesses

The Choosing Wisely Pediatric Emergency Medicine Recommendations

The Choosing Wisely Campaign Toolkit


Bonus Resource: The Dialogue Around Respiratory Illness Treatment (DART) program which is designed to support antibiotic stewardship


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References

  1. Gill, PJ, Richardson, SE, Ostrow O. Testing for respiratory viruses in children: to swab or not to swab. JAMA Pediatr. 2017;171(8):798-804
  1. Noël KC, Fontela PS, Winters N, et al. The clinical utility of respiratory viral testing in hospitalized children: a meta-analysis. Hosp Pediatr. 2019;9(7):483-494
  1. Parikh K, Hall M, Mittal V, et al. Establishing benchmarks for the hospitalized care of children with asthma, bronchiolitis, and pneumonia. Pediatrics. 2014;134(3):555-562
  1. Innis K, Hasson D, Bodilly L, et al. Do I need proof of the culprit? Decreasing respiratory viral testing in critically ill patients. Hosp Pediatr. 2021;11(1):e1-e5
Categories
Choosing Wisely

Constipation: Diagnosis, X-Rays, and more

Where else is the poop going to be? Constipation is by and large a clinical diagnosis. This episode reviews how to make the diagnosis, red flags, and why X-Rays don’t necessarily help assess stool burden adequately in most children.

This podcast episode is designed to disseminate the important work of Choosing Wisely, an initiative of the the American Board of Internal Medicine Foundation, the goal of which is the spark conversations between clinicians and patients about what tests, treatments, and procedures are needed – and which ones are not.

The Choosing Wisely recommendation: Do not obtain abdominal radiographs for suspected constipation

The Choosing Wisely Pediatric Emergency Medicine Recommendations

The Choosing Wisely Campaign Toolkit


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References

Anwar Ul Haq MM, Lyons H, Halim M. Pediatric Abdominal X-rays in the Acute Care Setting – Are We Overdiagnosing Constipation?. Cureus. 2020;12(3):e7283. Published 2020 Mar 15. doi:10.7759/cureus.7283

Beinvogl B, Sabharwal S, McSweeney M, Nurko S. Are We Using Abdominal Radiographs Appropriately in the Management of Pediatric Constipation?. J Pediatr. 2017;191:179-183. doi:10.1016/j.jpeds.2017.08.075

Berger MY, Tabbers MM, Kurver MJ, Boluyt N, Benninga MA. Value of abdominal radiography, colonic transit time, and rectal ultrasound scanning in the diagnosis of idiopathic constipation in children: a systematic review. J Pediatr. 2012;161(1):44–50.e502. DOI: https://doi.org/10.1016/j.jpeds.2011.12.045

Freedman SB, Rodean J, Hall M, et al. Delayed diagnoses in children with constipation: multicenter retrospective cohort study. J Pediatr. 2017;186:87-94.e16. DOI: https://doi.org/10.1016/j.jpeds.2017.03.061

Freedman SB, Thull-Freedman J, Manson D, et al. Pediatric abdominal radiograph use, constipation, and significant misdiagnoses. J Pediatr. 2014;164(1):83-88.e2

Hoskins B, Marek S. Things We Do for No Reason: Obtaining an Abdominal X-ray to Assess for Constipation in Children. J Hosp Med. 2020;15(9):557-559. doi:10.12788/jhm.3387

Kearney R, Edwards T, Braford M, Klein E. Emergency provider use of plain radiographs in the evaluation of pediatric constipation. Pediatr Emerg Care. 2019;35(9):624-629. DOI: 10.1097/PEC.0000000000001549

McSweeney ME, Chan Yuen J, Meleedy-Rey P, Day K, Nurko S. A Quality Improvement Initiative to Reduce Abdominal X-ray use in Pediatric Patients Presenting with Constipation. J Pediatr. 2022;251:127-133. doi:10.1016/j.jpeds.2022.07.016

NICE. Constipation in children and young people: diagnosis and management.  NICE. Clinical guideline [CG99] Published: 26 May 2010 Last updated: 13 July 2017. Available online at https://www.nice.org.uk/guidance/cg99 

Pensabene L, Buonomo C, Fishman L, Chitkara D, Nurko S. Lack of utility of abdominal x-rays in the evaluation of children with constipation: Comparison of different scoring methods. J Pediatr Gastroenterol Nutr. 2010;51(2):155-159. DOI: https://doi.org/10.1097/MPG.0b013e3181cb4309

Reuchlin-Vroklage LM, Bierma-Zeinstra S, Benninga MA, Berger MY. Diagnostic value of abdominal radiography in constipated children: a systematic review. Arch Pediatr Adolesc Med. 2005;159(7):671-678. doi:10.1001/archpedi.159.7.671

Rome IV Criteria: https://theromefoundation.org/rome-iv/rome-iv-criteria/

Rothrock SG, Green SM, Hummel CB. Plain abdominal radiography in the detection of major disease in children: a prospective analysis. Ann Emerg Med. 1992;21(12):1423-1429. doi:10.1016/s0196-0644(05)80053-8

Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and treatment of functional constipation in infants and children: Evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014;58(2):258-274. DOI: https://doi.org/10.1097/mpg.0000000000000266

Categories
Choosing Wisely Neurology

Do we need labs or a head CT after simple febrile or unprovoked seizures?

Labs or CT scans are not necessary to provide additional diagnostic information or reassurance for most children who recover completely following simple febrile seizures or unprovoked first time generalized seizures. The rate of abnormalities on these studies is very low, and the cost and downsides are too high to justify ordering them on a regular basis.

This podcast episode is designed to disseminate the important work of Choosing Wisely, an initiative of the the American Board of Internal Medicine Foundation, the goal of which is the spark conversations between clinicians and patients about what tests, treatments, and procedures are needed – and which ones are not.

The Choosing Wisely recommendation: Do not order laboratory testing or a CT scan of the head for a patient with an unprovoked, generalized seizure or a simple febrile seizure who has returned to baseline mental status

The Choosing Wisely Pediatric Emergency Medicine Recommendations

The Choosing Wisely Campaign Toolkit


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References

American Academy of Pediatrics, Subcommittee on Febrile Seizures. Neurodiagnostic evaluation of the children with a simple febrile seizure. Pediatrics. 2011;127(2):389-394. DOI: https://doi.org/10.1542/peds.2010-3318

Brugman J, Solomons RS, Lombard C, Redfern A, Du Plessis AM. Risk-Stratification of Children Presenting to Ambulatory Paediatrics with First-Onset Seizures: Should We Order an Urgent CT Brain?. J Trop Pediatr. 2020;66(3):299-314. doi:10.1093/tropej/fmz071

Expert Panel on Pediatric Imaging, Trofimova A, Milla SS, et al. ACR Appropriateness Criteria® Seizures-Child. J Am Coll Radiol. 2021;18(5S):S199-S211. doi:10.1016/j.jacr.2021.02.020

Fine A, Wirrell EC. Seizures in Children. Pediatr Rev. 2020;41(7):321-347. doi:10.1542/pir.2019-0134

Hirtz D, Ashwal S, Berg A, et al. Practice parameter: Evaluating a first nonfebrile seizure in children. Report of the Quality Standards Subcommittee of the American Academy of Neurology, the Child Neurology Society, and the American Epilepsy Society. Neurology. 2000; 55(5):616-623. Reaffirmed October 17, 2020

Jaffe M, Bar-Joseph G, Tirosh E. Fever and convulsions: indications for laboratory investigations. Pediatrics. 1981;67(5):729 –731

Maytal J, Krauss JM, Novak G, Nagelberg J, Patel M. The role of brain computed tomography in evaluating children with new onset of seizures in the emergency department. Epilepsia. 2000;41(8):950-954. doi:10.1111/j.1528-1157.2000.tb00277.x

McKenzie KC, Hahn CD, Friedman JN; Canadian Paediatric Society, Acute Care Committee. Emergency management of the paediatric patient with convulsive status epilepticus. Paediatr Child Health. 2021;26(1):50-57

NICE. Epilepsies in children, young people and adults; Evidence reviews underpinning recommendations. NICE guideline NG217. 2022. Accessed online at https://www.nice.org.uk/guidance/ng217/evidence/b-computed-tomography-scan-performance-in-people-with-epilepsy-pdf-398366282811 

NICE. Epilepsies in children, young people and adults. NICE guideline NG217. 2022. Accessed online at https://www.nice.org.uk/guidance/ng217 

Reinus WR, Wippold FJ, 2nd, Erickson KK. Seizure patient selection for emergency computed tomography. Ann Emerg Med 1993;22:1298-303.

Riviello JJ Jr, Ashwal S, Hirtz D, et al; American Academy of Neurology Subcommittee; Practice Committee of the Child Neurology Society. Practice parameter: Diagnostic assessment of the child with status epilepticus (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2006;67(9):1542-1550 

Royal Children’s Hospital Melbourne. Afebrile Seizures. 2020. Accessed online at https://www.rch.org.au/clinicalguide/guideline_index/afebrile_seizures/ 

Sawires R, Buttery J, Fahey M. A Review of Febrile Seizures: Recent Advances in Understanding of Febrile Seizure Pathophysiology and Commonly Implicated Viral Triggers. Front Pediatr. 2022;9:801321. Published 2022 Jan 13. doi:10.3389/fped.2021.801321

Shah SS, Alpern ER, Zwerling L, Reid JR, McGowan KL, Bell LM. Low Risk of Bacteremia in Children With Febrile Seizures. Arch Pediatr Adolesc Med. 2002;156(5):469–472. doi:10.1001/archpedi.156.5.469

Subcommittee on Febrile Seizures; American Academy of Pediatrics. Neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics. 2011;127(2):389-394. doi:10.1542/peds.2010-3318

Veerapandiyan A, Aravindhan A, Takahashi JH, Segal D, Pecor K, Ming X. Use of Head Computed Tomography (CT) in the Pediatric Emergency Department in Evaluation of Children With New-Onset Afebrile Seizure. J Child Neurol. 2018;33(11):708-712. doi:10.1177/0883073818786086

Young AC, Costanzi JB, Mohr PD, Forbes WS. Is routine computerised axial tomography in epilepsy worth while?. Lancet. 1982;2(8313):1446-1447. doi:10.1016/s0140-6736(82)91340-x
Yousefichaijan P, Dorreh F, Abbasian L, Pakniyat AG. Assessing the prevalence distribution of abnormal laboratory tests in patients with simple febrile seizure. J Pediatr Neurosci. 2015;10(2):93-97. doi:10.4103/1817-1745.159180

Categories
Choosing Wisely Psychiatry

Do we need labs to medically clear a patient for psych admission?

For most children requiring admission to an inpatient psychiatric facility laboratory studies are generally not required. Many of the children and adolescents being admitted already have an established mental or behavioral diagnosis, and a reassuring history and exam. The heterogeneity of clinical settings makes it challenging to establish processes that account for the needs of our patients while limiting the use of unnecessary resources broadly.

This podcast episode is designed to disseminate the important work of Choosing Wisely, an initiative of the the American Board of Internal Medicine Foundation, the goal of which is the spark conversations between clinicians and patients about what tests, treatments, and procedures are needed – and which ones are not.

The Choosing Wisely recommendation: Do not obtain screening laboratory tests in the medical clearance process of pediatric patients who require inpatient psychiatric admission unless clinically indicated

The Choosing Wisely Pediatric Emergency Medicine Recommendations

The Choosing Wisely Campaign Toolkit


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References

Thrasher TW, Rolli M, Redwood RS, et al. ‘Medical clearance’ of patients with acute mental health needs in the emergency department: a literature review and practice recommendations. WMJ. 2019;118(4):156-163

Donofrio JJ, Horeczko T, Kaji A, Santillanes G, Claudius I. Most routine laboratory testing of pediatric psychiatric patients in the emergency department is not medically necessary. Health Aff (Millwood). 2015;34(5):812-818

Chun TH. Medical clearance: time for this dinosaur to go extinct. Ann Emerg Med. 2014;63(6):676-677

Donofrio JJ, Santillanes G, McCammack BD, et al. Clinical utility of screening laboratory tests in pediatric psychiatric patients presenting to the emergency department for medical clearance. Ann Emerg Med. 2014;63(6):666-675.e663.

Santillanes G, Donofrio JJ, Lam CN, et al. Is medical clearance necessary for pediatric psychiatric patients? J Emerg Med. 2014;46(6):800-807

Santiago LI, Tunik MG, Foltin GL, Mojica MA. Children requiring psychiatric consultation in the pediatric emergency 

Berg JS, Payne AS, Wayra T, Morrison S, Patel SJ. Implementation of a Medical Clearance Algorithm for Psychiatric Emergency Patients. Hosp Pediatr (2023) 13 (1): 66–71

Categories
Choosing Wisely Radiology Respiratory

Do children with bronchiolitis, croup, asthma, or first-time wheezing need a Chest X-Ray?

For most children with children with bronchiolitis, croup, asthma, or first-time wheezing chest X-Rays are not necessary. These X-Rays are often obtained due to the possibility of missing pneumonia. But, these radiographs are hard to interpret, increase length of stay and the cost of care, and expose children to excess radiation.

This podcast episode is designed to disseminate the important work of Choosing Wisely, an initiative of the the American Board of Internal Medicine Foundation, the goal of which is the spark conversations between clinicians and patients about what tests, treatments, and procedures are needed – and which ones are not.

The Choosing Wisely recommendation: Do not obtain radiographs in children with bronchiolitis, croup, asthma, or first-time wheezing

The Choosing Wisely Pediatric Emergency Medicine Recommendations

The Choosing Wisely Campaign Toolkit


PEMBlog

@PEMTweets on… sigh “X” (Twitter)

My Instagram

My Mastodon account @bradsobo

References

Shah SN, Bachur RG, Simel DL, Neuman MI. Does this child have pneumonia? The rational clinical examination systematic review. JAMA. 2017;318(5):462-471. PMID: 28763554.

Schuh S, Lalani A, Allen U, et al. Evaluation of the utility of radiography in acute bronchiolitis. J Pediatr. 2007;150(4):429-433. PMID: 17382126.

Ramgopal S, Ambroggio L, Lorenz D, Shah SS, Ruddy RM, Florin TA. A Prediction Model for Pediatric Radiographic Pneumonia. Pediatrics. 2022 Jan 1;149(1):e2021051405. doi: 10.1542/peds.2021-051405. PMID: 34845493

Florin TA, Carron H, Huang G, Shah SS, Ruddy R, Ambroggio L. Pneumonia in Children Presenting to the Emergency Department with an Asthma Exacerbation. JAMA Pediatr. 2016;170(8):803-805. https://doi:10.1001/jamapediatrics.2016.0310

Categories
Nephrology Rheumatology

Henoch–Schönlein Purpura (HSP)

Henoch–Schönlein Purpura (HSP) is a common vasculitis seen in younger children. The classic skin finding is palpable purpura in gravity dependent areas of the body (buttocks and legs). Children can also have arthralgias, abdominal pain and intussusception, and even nephritis. Learn about the diagnosis and management of Henoch–Schönlein Purpura (HSP) in this brief podcast episode.

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References

Chen JY et al. Henoch-Schönlein purpura nephritis in children: incidence, pathogenesis and management. World J Pediatr. 2015 Feb;11(1):29-34.

Saulsbury, FT (1999) Henoch-Schönlein purpura in children. Report of 100 patients and review of the literature. Medicine (Baltimore) 78: pp. 395-409

Saulsbury FT. Henoch-Schonlein Purpura. Current Opinion in Rheummatology. Jan. 2001;13(1):35-40.

Little KJ, Danzl DF. Intussusception associated with Henoch-Schonlein Purpura. The Journal of Emergency Medicine: 1991;9(1):29-32.

Chamberlain RS, Greenberg LW. Scrotal involvement in Henoch-Schonlein Purpura: A case report and review of the literature. Pediatric Emergency Care;8(4):213-215.

Saulsbury FT. Henoch-Schonlein Purpura. Current Opinion in Rheummatology: Jan. 2001; Vole 13(1). Pp.35-40.

Categories
Toxicology

Stings and Envenomations

It is summertime, so the bees and bugs are out! In this episode, Dr. Ben Grebber, a pediatric resident at Boston Children’s Hospital/Tufts Children’s Hospital, discusses Bee Stings and Spider Bites. A very common pediatric summer complaint in emergency departments, urgent cares, and primary care offices, this episode covers common signs and symptoms, some pathophysiology, and recommended treatments.

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References

Arif F, Williams M. Hymenoptera Stings. [Updated 2022 Jun 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK518972/

Bond, G. R. (1999). Snake, spider, and scorpion envenomation in North America. Pediatrics in review, 20(5), 147-151.

Pansare, M., Seth, D., Kamat, A., & Kamat, D. (2020). Summer buzz: All you need to know about insect sting allergies. Pediatrics in Review, 41(7), 348-356.

Shireen Banerji, PharmD, Alvin C. Bronstein, MD, 2016. “Envenomations”, American Academy of Pediatrics Textbook of Pediatric Care, Thomas K. McInerny, MD, FAAP, Henry M. Adam, MD, FAAP, Deborah E. Campbell, MD, FAAP, Thomas G. DeWitt, MD, FAAP, Jane Meschan Foy, MD, FAAP, Deepak M. Kamat, MD, PhD, FAAP, Rebecca Baum, MD, FAAP, Kelly J. Kelleher, MD, MPH, FAAP

Categories
Mental Health

Agitation Episode 5: The boarded ED patient

We are in the midst of a staggering mental health crisis. Thousands of children and adolescents spend days at time in Emergency Departments waiting for definitive mental health disposition. This podcast episode hosted by Brad Sobolewski (@PEMTweets) and co-authored by Dennis Ren (@DennisRenMD) is all about what we should consider when boarding children in the ED for mental health reasons. It is also the final episode in a 5 episode series focused on agitation in children and adolescents.

After listening to this episode you will be able to:

  • Identify some of the reasons why we are boarding so many children in the ED and which children are the highest priority
  • Describe the challenges these patients face as they await inpatient psychiatric care
  • Describe best practices and what we should be doing for them 
  • Discuss some of the stresses that these children place on the healthcare system, and possible alternative strategies.

This episode is a co-production of the Emergency Medical Services for Children Innovation and Improvement Center whose mission is to minimize morbidity and mortality of acutely ill and injured children across the emergency continuum.

EMDocs Collaboration

EMDocs.net – the excellent Emergency Medicine site will also be contributing a supplementary article for each episode that will be posted each Friday following the release of the podcast episode. These articles will take another look at the content included in this episode.

Special thanks to Manpreet Singh, MD (@MprizzleER) for helping to put this collaboration together. 

Other Episodes in the Agitation Series

Episode 1: Differentiating organic versus psychiatric causes of agitation and altered mental status | Supplementary EMDocs article

Episode 2: Non-pharmacologic management of agitated children | Supplementary EMDocs article

Episode 3: Pharmacologic management of agitated children | Supplementary EMDocs article

Episode 4: Safe prehospital transport of the agitated patient | Supplementary EMDocs.net article

EMSC IIC

To learn more about the Emergency Medical Services for Children Innovation and Improvement Center visit https://emscimprovement.center

Email km@emscimprovement.center

Follow on Twitter @EMSCImprovement

EMSC IIC: Pediatric Education and Advocacy Kit (PEAK): Agitation

PEAK Agitation resources

Brad’s stuff

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My Educator Portfolio

References

Fiona B. McEnany, Olutosin Ojugbele, Julie R. Doherty, Jennifer L. McLaren, JoAnna K. Leyenaar; Pediatric Mental Health Boarding. Pediatrics October 2020; 146 (4): e20201174. 10.1542/peds.2020-1174

AAP-AACAP-CHA Declaration of a National Emergency in Child and Adolescent Mental Health

Jennifer A. Hoffmann, Polina Krass, Jonathan Rodean, Naomi S. Bardach, Rachel Cafferty, Tumaini R. Coker, Gretchen J. Cutler, Matthew Hall, Rustin B. Morse, Katherine A. Nash, Kavita Parikh, Bonnie T. Zima; Follow-up After Pediatric Mental Health Emergency Visits. Pediatrics March 2023; 151 (3): e2022057383. 10.1542/peds.2022-057383

Nordstrom K, Berlin JS, Nash SS, Shah SB, Schmelzer NA, Worley LLM. Boarding of Mentally Ill Patients in Emergency Departments: American Psychiatric Association Resource Document. West J Emerg Med. 2019 Jul 22;20(5):690-695. doi: 10.5811/westjem.2019.6.42422. PMID: 31539324; PMCID: PMC6754202.

Cushing AM, Liberman DB, Pham PK, et al. Mental Health Revisits at US Pediatric Emergency Departments. JAMA Pediatr. 2023;177(2):168–176. doi:10.1001/jamapediatrics.2022.4885

Nash  KA, Zima  BT, Rothenberg  C,  et al.  Prolonged emergency department length of stay for US pediatric mental health visits (2005-2015).   Pediatrics. 2021;147(5):e2020030692. doi:10.1542/peds.2020-030692

Lo CB, Bridge JA, Shi J, Ludwig L, Stanley RM. Children’s Mental Health Emergency Department Visits: 2007-2016. Pediatrics. 2020 Jun;145(6):e20191536. doi: 10.1542/peds.2019-1536. Epub 2020 May 11. PMID: 32393605.

Parent/Professional Advocacy League: Best Practices: Pediatric Emergency Department Psychiatric Boarding

Kraft CM, Morea P, Teresi B, et al. Characteristics, Clinical Care, and Disposition Barriers for Mental Health Patients Boarding in the Emergency Department. American Journal of Emergency Medicine. Nov. 2020. Doi.org/10.1016/j.ajem.2020.11.021

Disclaimer

The Emergency Medical Services for Children Innovation and Improvement Center is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award (U07MC37471) totaling $3M with 0 percent financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

Categories
Mental Health

Agitation Episode 4: Safe prehospital transport

There are protocols in place that assist highly trained Emergency Medical Service providers in assuring that agitated children are safely transported to their destination. This podcast episode hosted by Brad Sobolewski (@PEMTweets) and co-authored by Dennis Ren (@DennisRenMD) is all about what pre-hospital providers should do to get these agitated children safely to the ED. It is also episode 4 in a 5 episode series focused on agitation in children and adolescents.

After listening to this episode you will be able to:

  • Identify unique aspects of the pre-hospital environment that impact assessment and treatment of agitated children
  • Describe the role of EMS personnel and EMS director in the care of agitated children.
  • Describe the role of medical control in determining destination and goals of safe transport

This episode is a co-production of the Emergency Medical Services for Children Innovation and Improvement Center whose mission is to minimize morbidity and mortality of acutely ill and injured children across the emergency continuum.

EMDocs Collaboration

EMDocs.net – the excellent Emergency Medicine site will also be contributing a supplementary article for each episode that will be posted each Friday following the release of the podcast episode. These articles will take another look at the content included in this episode.

Special thanks to Manpreet Singh, MD (@MprizzleER) for helping to put this collaboration together. 

Other Episodes in the Agitation Series

Episode 1: Differentiating organic versus psychiatric causes of agitation and altered mental status | Supplementary EMDocs article

Episode 2: Non-pharmacologic management of agitated children | Supplementary EMDocs article

Episode 3: Pharmacologic management of agitated children | Supplementary EMDocs article

Episode 5: Management of the child with mental health problems who is boarded in the Emergency Department (Coming June 14, 2023)

EMSC IIC

To learn more about the Emergency Medical Services for Children Innovation and Improvement Center visit https://emscimprovement.center

Email km@emscimprovement.center

Follow on Twitter @EMSCImprovement

EMSC IIC: Pediatric Education and Advocacy Kit (PEAK): Agitation

PEAK Agitation resources

Brad’s stuff

PEMBlog

@PEMTweets on Twitter

My Mastodon account @bradsobo

My Educator Portfolio

References

Kupas D et al. NASEMSO: Clinical care and restraint of agitated or combative patients by emergency medical service practitioners. https://nasemso.org/wp-content/uploads/Clinical-Care-and-Restraint-of-Agitated-or-Combative-Patients-by-Emergency-Medical-Services-Practitioners.pdf

Patient restraint in emergency medical services [Position Statement]. Prehosp Emerg Care. 2017;21(3):395-396.

Disclaimer

The Emergency Medical Services for Children Innovation and Improvement Center is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award (U07MC37471) totaling $3M with 0 percent financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.