Mental Health

Agitation Episode 1: Differentiating organic versus psychiatric

Most children who present to Pediatric Emergency Departments these days with mental health concerns – including agitation – have a known psychiatric problem or diagnosis. Furthermore, the connection between physical and functional symptoms is inextricably linked in many patients. Why then do we persist with the “is it medical/organic or psych” question? Ultimately, this episode hosted by Brad Sobolewski (@PEMTweets) and co-authored by Dennis Ren (@DennisRenMD) is less about “is it psych or not” and more about not missing something because you assumed the patient had a mental or behavioral problem. It is also episode 1 in a 5 episode series focused on agitation in children and adolescents.

After listening to this episode you will be able to:

  • Describe the findings on history and physical examination that differentiate organic vs psychiatric causes of agitation and altered mental status.
  • Develop a strategy to differentiate organic from psychiatric causes of altered mental status, including using ancillary studies

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 – 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 2: Non-pharmacologic management of agitated children (Coming May 24, 2023)

Episode 3: Pharmacologic management of agitated children (Coming May 31, 2023)

Episode 4: Safe pre-hospital transport of the agitated child (Coming June 7, 2023)

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


To learn more about the Emergency Medical Services for Children Innovation and Improvement Center visit


Follow on Twitter @EMSCImprovement

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

PEAK Agitation resources

Brad’s stuff


@PEMTweets on Twitter

My Mastodon account @bradsobo

My Educator Portfolio


Hua LL, COMMITTEE ON ADOLESCENCE. Collaborative Care in the Identification and Management of Psychosis in Adolescents and Young Adults. Pediatrics 2021; 147.

Sedel F, Baumann N, Turpin JC, et al. Psychiatric manifestations revealing inborn errors of metabolism in adolescents and adults. J Inherit Metab Dis 2007; 30:631.

Chun TH, Sargent J, Hodas GR. Psychiatric emergencies. In: Textbook of Pediatric Emergency Medicine, 5th, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. P.1820.

Cunqueiro A, Durango A, Fein DM, et al. Diagnostic yield of head CT in pediatric emergency department patients with acute psychosis or hallucinations. Pediatr Radiol 2019; 49:240.

Gerson R, Malas N, Feuer V, Silver GH, Prasad R, Mroczkowski MM. Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the American Association for Emergency Psychiatry. West J Emerg Med. 2019 Mar;20(2):409-418. doi: 10.5811/westjem.2019.1.41344. Epub 2019 Feb 19. Erratum in: West J Emerg Med. 2019 May;20(3):537. Erratum in: West J Emerg Med. 2019 Jul;20(4):688-689. PMID: 30881565; PMCID: PMC6404720.


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

Advocacy and Injury Prevention

Gun Violence and Safety (2023)

Dr. Kit Carney and Dr. Kristen Humphrey discuss gun violence, its impact on our patients and their families, as well as practical tips on advocating for safe storage of firearms, and how we can support victims of violence.


@PEMTweets on Twitter

My Mastodon account @bradsobo

Advocacy and education resources

Be SMART Campaign
Be SMART emphasizes the importance of responsible gun ownership and secure gun storage. Ultimately, secure gun storage prevents kids from accessing guns. When we protect our kids from the dangers of gun violence, the whole community stands to benefit.

Brady: Asking Saves Kids (ASK)
ASK (Asking Saves Kids) is a simple way to help keep kids safe and a fundamental part of our End Family Fire campaign. Parents and guardians ask all sorts of questions before they allow their children to visit other homes; they ask about pets in the house, discuss allergies and Internet access, and ask questions about supervision. As part of our End Family Fire campaign, ASK encourages parents and guardians to add one more question to this conversation: “Is there an unlocked gun in your house?” 

AAP Gun Safety Toolbox

Resources for gun violence survivors


Sandy Hook Promise

Moms Demand Action

Giffords: Courage to Fight Gun Violence

Talking to children about gun violence

Cincinnati Children’s Blog: Tips for Talking to Kids About Violence in the News

National Association of School Psychologists: Talking to Children About Violence: Tips for Parents and Teachers How to Talk With Kids About Tragedies & Other Traumatic News Events

Ohio specific resources

Ohio coalition against gun violence

Ohio coalition against gun violence resource list


Council on injury, violence, and poison prevention executive committee, M. Denise Dowd, Robert D. Sege, H. Garry Gardner, Kyran P. Quinlan, Michele Burns Ewald, Beth E. Ebel, Richard Lichenstein, Marlene D. Melzer-Lange, Joseph O’Neil, Wendy J. Pomerantz, Elizabeth C. Powell, Seth J. Scholer, Gary A. Smith; Firearm-Related Injuries Affecting the Pediatric Population. Pediatrics November 2012; 130 (5): e1416–e1423. 10.1542/peds.2012-2481

Haasz, M., Boggs, J. M., Beidas, R. S., & Betz, M. E. (2022). Firearms, physicians, families, and kids: Finding words that work. The Journal of Pediatrics247, 133–137. 

Gifford. (2022, August 10). Child Access & Safe Storage. Giffords. Retrieved October 7, 2022, from

Goldstick, J. E., Cunningham, R. M., & Carter, P. M. (2022). Current causes of death in children and adolescents in the United States. New England Journal of Medicine386(20), 1955–1956. 

Gun violence prevention. Children’s Defense Fund. (2022, March 18). Retrieved October 7, 2022, from

Episode Transcript

[Kit] Hello! I’m Dr. Carney and I am a pediatric resident at Cincinnati Children’s Hospital Medical Center. I’m here with my co-resident, Dr. Humphrey. Today, we are going to discuss firearm safety and ways to screen for it in both the ED and clinic settings. Thank you for hosting us, Brad!

The goals of this episode are to:

  1. Report updated statistics about pediatric firearm-related injuries and deaths in the US
  2. Discuss and review the updated American Academy of Pediatrics’ recommendations on firearm safety
  3. Discuss updated strategies for counseling your patients and families on firearm safety, and 
  4. Talk about how we can support patients and families who are victims of gun violence 

[ Kit ] To best understand how prevalent firearm-related injuries are, let’s discuss some statistics:

  • Firearms are now the leading cause of death among children 0-19 years old in the United States. While gun violence is a global issue, the United States houses a disproportionate amount of these gun violence instances. 
  • While the United States accounts for just 4% of the world’s population, it accounts for 35% of firearm suicides and 9% of firearm homicides.
  • Each year, 3200 children die from firearm-related injuries. This means that a child dies from a firearm every 2 hours and 45 minutes. Unfortunately, this number has continued to rise as gun sales have soared. 
  • From 2019 to 2020, the rate of firearm related deaths among children increased by 30%. When we look more closely at these numbers, we note that prominent racial disparities exist regarding firearm injury, as well. 
  • Black children and teens are 4 times more likely than their white peers to die by firearms.

[ Kristen ] These fire-arm related fatalities among children are due not only to homicide or accident, but also suicide. 

  • Firearms account for the greatest number of suicide deaths. Guns are by far the greatest risk for completed suicide, because they are so lethal. Guns have a 90% mortality rate when used for suicide. 
  • Unfortunately, of the weapons used in these suicides, as well as in school shootings and unintentional homicides, 70-90% of them came from unsecured weapons at the child’s home. 
  • Research demonstrates that fewer than half of all gun owners store their firearms safely, and that many children have access to these guns. 
  • Of the estimated 4.6 million children in the US who live with at least one unsecured firearm in their home, 75% of those know where guns are stored in their home and 22% have handled guns without their caregivers’ knowledge. 

[ Kit ] To help address these harrowing statistics, the American Academy of Pediatrics has released updated recommendations concerning safe firearm storage practices.      

  • The most effective measure caregivers can take to prevent fire-arm related injuries is to remove them from the home. 
  • For those families who do have guns in the home, these firearms should be unloaded and locked, with ammunition stored and locked separately.
  • Cable locks, trigger locks, and lockboxes are all safe ways to store firearms. 
  • A Cable lock is a looped wire that works similarly to a bike lock. This mechanism allows you to loop one end of the wire through the handgun to prevent the gun from being fired or loaded, and then connect that end of the wire to the lock at the end of the loop. You can purchase these for about $10 at local retailers.  
  • A trigger lock is a two-piece mechanism. The two pieces fit over the trigger guard so that the gun’s trigger cannot be released and allow the gun to fire. These trigger locks come with either a key and lock; a keypad, or a combination lock. One can purchase these for about $10 at local retailers. 
  • Finally, a Gun lock box is a combination-protected box that is similar to a safe but is small enough to house just a gun. You can purchase these for about $25-100. 
  • Studies demonstrate that utilizing one of these storage methods can reduce the suicide and unintentional gun deaths in children by up to 54%. 

[ Kristen ] Great question. 

  • In our current environment, it can feel overwhelming as a healthcare provider to discuss firearms. The encouraging news is that the majority of parents report that they would feel comfortable discussing firearm safety with their pediatrician. Nonjudgmental communication is key to this conversation. Healthcare providers need to be aware of and manage their biases concerning this topic, and that starts by ensuring that we ask all families about it.
  • Firearm safety can be discussed in any setting, but ideally it is a preventative, rather than a reactionary, conversation. 
  • It helps to first frame this conversation as one about safety, perhaps in the context of discussing car seats, water safety, or bike helmets because optimizing a patient’s safety is often a common goal of both caregivers and healthcare providers. 
  • For example, you might say “I like to talk about firearm safety with all of my patients because we know firearms can pose a safety risk to children. Research has shown that the safest way to store firearms is to store them locked, unloaded, and separately from ammunition.” 
  • While the AAP continues to emphasize that the most effective measure to prevent firearm-related injuries is their absence in the home.

New studies demonstrate that families respond best to a normative statement. This means that the clinician normalizes that many people have firearms in the home. An example of this normative statement would be “for any firearms in the home, or other homes your child may visit, are they stored locked and unloaded?” Asking about both their home and other homes they visit allows families to talk about this subject without having to disclose a gun in their own house. 

  • After asking this question, you can also ask if families would like to hear more information about safe storage practices, such as cable locks and lockboxes.
  • When discussing firearms, it is important to keep in mind the age of the patient.  
    • In younger children (ages 1-9), firearm injuries are typically related to unintentional injury, as children as young as 2-3 are capable of pulling a trigger. 
    • However, In adolescents, (ages 10-19), nearly 97% of firearm injuries are related to intentional homicide or suicide. In this patient population, especially if there are significant mental health concerns, discussion about removing firearms from the home temporarily and voluntarily may help promote the patient’s safety. 

[ Kit ] 

  • It is important that both the adolescent and the parent be engaged in these discussions, as adolescents are prone to more impulsivity and need to understand the dangers for themselves, as they are able to get access even without a caregiver’s knowledge.  
  • To help caregivers keep their adolescents and younger children safe, I often refer families to the ASK (or asking saves kids) campaign to provide them with the tools to ask their children about the presence of firearms in both new and familiar circumstances. These new circumstances can include a new babysitting job, a new roommate, or a new playmate. 
  • The Be SMART campaign is another excellent resource for both parents and healthcare providers for modeling firearm safety conversations. S stands for secure all guns  in the home and vehicles; M stands for model responsible behavior around guns; A stands for ask about presence of unsecured firearms in other locations; R stands for recognize the role of guns in suicide T stands for tell peers to be SMART. Check out the references section of this PEM currents episode for links to the ASK and Be SMART websites, as well as for other links for learning how to talk to children about gun violence. 

[ Kristen]

  • Because those impacted by gun violence often experience trauma and are at higher risk for suicide, we as healthcare providers need to ensure that families get early access to mental health support. National support groups for families and patients who have experienced gun violence include: Trauma Survivors Network, Survivors Empowered, and the Gun Violence Survivors Foundation. There are also local survivors groups through Cincinnati’s chapter of Mom’s Demand Action and Every Town.

[Kit] Let’s review what we talked about today:

  • [Kit] Gun sales and violence have increased since 2020, and firearms are now the leading cause of death for those aged 0-19 
  • [Kit] While younger children are more likely to become injured 2/2 unintentional use, adolescents are more likely to become injured due to intentional homicide or suicide attempts
  • [Kit] Many caregivers are open to discussing firearm safety with their healthcare provider in the context of other anticipatory guidance 
  • [Kristen] The American Academy of Pediatrics states that discussing with ALL families that firearms should be unloaded and locked, with locked ammunition stored separately, would significantly decrease the rate of firearm-related injury among children
  • [Kristen] Victims of firearm related injury and their families are at higher risk for mental health crises; providing them with support is essential to ensuring their ongoing well-being 

[Kristen] If you are interested in becoming involved at a legislative level, Moms Demand Action is a national organization that provides information for local, state, and national advocacy around gun safety.

Infectious Diseases


The epiglottis is the toilet seat of the airway. That’s a useful function. But what if becomes so swollen and inflamed that it leads to airway obstruction and respiratory failure. That’s bad. That’s also what epiglottitis is. You can also call it supraglottitis. Either way you need to recognize this potentially life threatening malady and secure a definitive airway in the sickest patients ASAP.


@PEMTweets on Twitter

My Mastodon account @bradsobo


Rafei K, Lichenstein R. Airway infectious disease emergencies. Pediatr Clin North Am 2006; 53:215.

Sobol SE, Zapata S. Epiglottitis and croup. Otolaryngol Clin North Am 2008; 41:551.

Richards AM. Pediatric Respiratory Emergencies. Emerg Med Clin North Am. 2016 Feb;34(1):77-96. PMID: 26614243.

Faden H. The dramatic change in the epidemiology of pediatric epiglottitis. Pediatr Emerg Care. 2006 Jun;22(6):443-4. PMID: 16801849

Infectious Diseases


Norovirus is the leading cause of viral gastroenteritis worldwide and is also a major cause of food borne illness. It spreads rapidly and causes vomiting and diarrhea that lead to many ED visits. Hopefully this brief episode will enrich the discussions that you have with patients and their families when making the diagnosis of viral gastroenteritis.


@PEMTweets on Twitter

My Mastodon account @bradsobo


O’Ryan ML, Peña A, Vergara R, Díaz J, Mamani N, Cortés H, Lucero Y, Vidal R, Osorio G, Santolaya ME, Hermosilla G, Prado VJ. Prospective characterization of norovirus compared with rotavirus acute diarrhea episodes in chilean children. Pediatr Infect Dis J. 2010 Sep;29(9):855-9. doi: 10.1097/INF.0b013e3181e8b346. PMID: 20581736.

King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep 2003; 52:1.

Wilhelmi I, Roman E, Sánchez-Fauquier A. Viruses causing gastroenteritis. Clin Microbiol Infect 2003; 9:247.


Agitation in Neurodivergent Children

“Neurodivergent” is a term used to describe brain functionality and how it differs in some people. These individuals perceive, interpret and interact with the world in ways that are different than what we typically encounter. The Emergency Department is a potentially challenging and stressful place for Neurodivergent children, and this episode discusses strategies to help make their experience just a little bit better.

This episode features the talents of Ilene Claudius, MD, the Director of Quality and Process Improvement for the Emergency Department at and Alice Kuo, MD, Professor and Chief of Medicine-Pediatrics and Preventive Medicine – both at UCLA.

It is also 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 EMS for children continuum.

To learn more about the Emergency Medical Services for Children Innovation and Improvement Center visit


Follow @EMSCImprovement on Twitter

Contact Ilene Claudius, MD

Contact Alice Kuo, MD


@PEMTweets on Twitter

My Mastodon account @bradsobo


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

De-escalation tips for pediatric agitation: EMSC Innovation & Improvement Center


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 $3 million with zero 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


Commotio Cordis

Commotio cordis is caused by the blunt impact of a hard object directly over the heart occurring during a specific window of ventricular repolarization leading to immediate collapse, ventricular fibrillation, and cardiac arrest. This episode focuses on risk factors and management of this rare but catastrophic injury.


@PEMTweets on Twitter

My Mastodon account @bradsobo

American Heart Association CPR and AED Training


Link MS. Commotio cordis: ventricular fibrillation triggered by chest impact-induced abnormalities in repolarization. Circ Arrhythm Electrophysiol. 2012 Apr;5(2):425-32. doi: 10.1161/CIRCEP.111.962712. PMID: 22511659.

Madias C, Maron BJ, Weinstock J, et al. Commotio cordis–sudden cardiac death with chest wall impact. J Cardiovasc Electrophysiol 2007; 18:115.

Maron BJ, Gohman TE, Kyle SB, et al. Clinical profile and spectrum of commotio cordis. JAMA 2002; 287:1142.

Maron BJ, Estes NA 3rd. Commotio cordis. N Engl J Med 2010; 362:917.

Otolaryngology Procedures

Peritonsillar Abscesses

Peritonsillar Abscesses are the most common deep neck infection in adolescents and young adults. You will see them in grade schoolers as well. Learn about the diagnosis and management, including making the choice between needle aspiration versus wielding a scalpel for incision and drainage.


@PEMTweets on Twitter

My Mastodon account @bradsobo


Ungkanont K, Yellon RF, Weissman JL, et al. Head and neck space infections in infants and children. Otolaryngol Head Neck Surg 1995; 112:375.

Schraff S, McGinn JD, Derkay CS. Peritonsillar abscess in children: a 10-year review of diagnosis and management. Int J Pediatr Otorhinolaryngol 2001; 57:213.

Sumpter, R, Bridwell, R. emDOCs: Emergency Medicine @3AM: Peritonsillar Abscess. March 7, 2020. Accessed December 8, 2022.

Dental Procedures

Tongue Lacerations

Tongue lacerations are surprisingly common in the Emergency Department. Fortunately most of them don’t require any specific interventions. You just let them go and they heal on their own. Really. But if you do have to repair I offer advice in this brief episode.


@PEMTweets on Twitter

My Mastodon account @bradsobo

Resource from the British Dental Journal that has EXCELLENT pictures of healing tongue lacerations to share with patients and families.


Das UM, Gadicherla P1. Lacerated tongue injury in children. Int J Clin Pediatr Dent. 2008 Sep;1(1):39-41. PMID: 25206087.

Kazzi MG, Silverberg M. Pediatric tongue laceration repair using 2-octyl cyanoacrylate (dermabond(®)). J Emerg Med. 2013 Dec;45(6):846-8. PMID: 23827167.

Lamell CW, Fraone G, Casamassimo PS, Wilson S. Presenting characteristics and treatment outcomes for tongue lacerations in children. Pediatr Dent. 1999 Jan-Feb;21(1):34-8. PMID: 10029965.

Patel, A. Tongue lacerations. Br Dent J 204, 355 (2008).

Ud-din Z, Aslam M, Gull S. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Should minor mucosal tongue lacerations be sutured in children? Emerg Med J. 2007 Feb;24(2):123-4. PMID: 17251622.

Infectious Diseases

Periorbital Cellulitis

Perioribital cellulitis (AKA Preseptal cellulitis)is a soft tissue infection of the eyelids and skin anterior to the orbit. It must be differentiated from the more invasive and dangerous orbital cellulitis. Treatment varies depending on the original source (sinusitis, local trauma, stye etc,.). Learn all about periorbital cellulitis in this brief episode of PEM Currents: The Pediatric Emergency Medicine Podcast.

The companion blog post is right here!

Follow @PEMTweets on Twitter

Check out the Facebook page


Fox S. Periorbital cellultiis. Pediatric EM Morsels. March 29, 2013. Accessed October 20, 2022.

Andrea Hauser, Simone Fogarasi; Periorbital and Orbital Cellulitis. Pediatr Rev June 2010; 31 (6): 242–249.

Murphy, D.C., Meghji, S., Alfiky, M. and Bath, A.P. (2021), Paediatric periorbital cellulitis: A 10-year retrospective case series review. J Paediatr Child Health, 57: 227-233.

Infectious Diseases Surgery

Neutropenic enterocolitis

Bad things happen when you don’t have enough neutrophils. After getting cytotoxic chemotherapy you tend to have even fewer neutrophils. This can put you at risk for neutropenic enterocolitis which should be suspected in an immunocompromised child with fever and abdominal symptoms. Treatment is broad spectrum antibiotics and the imaging test of choice is CT with contrast. Learn all about this potentially catastrophic condition in this brief podcast episode.

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Check out the Facebook page


Freifeld AG, Bow EJ, Sepkowitz KA, Boeckh MJ, Ito JI, Mullen CA, Raad II, Rolston KV, Young JA, Wingard JR. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of america. Clin Infect Dis. 2011 Feb 15;52(4):e56-93. doi: 10.1093/cid/cir073. PubMed PMID: 21258094.

McQueen A, et al. Oncologic Emergencies. In: Shaw KN, et al. Fleisher & Ludwig’s Textbook of Pediatric Emergency Medicine. 8th ed. 2021:901-935.

Moran H, Yaniv I, Ashkenazi S, Schwartz M, Fisher S, Levy I. Risk factors for typhlitis in pediatric patients with cancer. J Pediatr Hematol Oncol. 2009 Sep;31(9):630-4. doi: 10.1097/MPH.0b013e3181b1ee28. PMID: 19644402.

Kirkpatrick ID, Greenberg HM. Gastrointestinal complications in the neutropenic patient: characterization and differentiation with abdominal CT. Radiology. 2003 Mar;226(3):668-74. doi: 10.1148/radiol.2263011932. Epub 2003 Jan 24. PMID: 12601214.