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LIN Session - Pediatric Code Grey

Michelle Lin, MD and Dina Wallin, MD
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31:28

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN
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05:36

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EMRAP 2018 07 July Vol.18 V2 Written Summary 390 KB - PDF

LIN Sessions - Peds Code Gray

Michelle Lin MD and Dina Wallin MD

Take Home Points 

  • Children with mental health issues need different evaluation and management compared to adults. You can make a difference. Your words and actions matter.
  • Take a really thorough psycho-social history.
  • There are many downsides to obtaining routine psychiatric screening labs and they are unlikely to provide any additional benefit.
  • Emergency physicians can provide outstanding care to our pediatric mental health patients in the emergency department.
  • Pediatric psychiatric emergencies. This is a common problem. The experience of providers varies depending on their setting. Pediatric mental health can present to the emergency department in a variety of manners. A teenage girl with increasing cutting behavior. A child presenting with a suicide attempt. A teenage boy who punched a wall after his mother took away his cellphone who arrives in a spit hood and four-point restraints. A child with crippling anxiety who is unable to leave the house.
  • The management and how we evaluate these children differs from how we manage and evaluate adults. We have dual goals in children with a primary mental health chief complaint. Our first goal is to recognize and treat emergencies, which we are outstanding at. We also need to make sure that everyone feels heard, not stigmatized and helped by their visit to the emergency department. This is more difficult. Emergency physicians frequently say they aren’t experts in this and don’t have time. You can provide better care to the next pediatric mental health patient that comes through your door.
  • You are not only dealing with the child in front of you but also an entire family system that is in an acute crisis situation. It is up to us to rapidly identify the crisis and start putting out fires immediately. There might be one or two parents, guardians, siblings, friends, boyfriends, girlfriends, etc. All of these factor into how the child is doing in life overall and our disposition.
  • Check your biases before you even walk into the room. Is this a chief complaint that makes you feel uncomfortable? If so, it is important to remind yourself that our goal as emergency physicians is to ensure health and safety of all of our patients. When you bring yourself back to that core value, it is easier to approach these patients with an open mind.
  • Try to establish rapport with the child and family.This can be very difficult because this is a family system in crisis. Everyone is nervous, angry, frustrated and freaking out.
    • There are multiple age-specific ways of trying to establish rapport with a child.
    • In a school age child, you want to make sure the child feels safe and is kept busy. Bringing them toys, a movie or something to occupy them and provide familiarity in your sterile ED.
    • In an adolescent, you want to talk to them before you talk to the parents to show that you trust them with their own health. You want to explain exactly what is happening in very concrete terms because adolescents have an underdeveloped frontal lobe and don’t understand abstract concepts very well.
    • For young adults and older teens, you don’t want to become defensive. Be on their side, be open, fully transparent and explain where you are going.
  • Managing anxiety is important. It is on us to manage their anxiety. Keep your speech calm and even and quiet. Choose your words carefully. It is really important for us to make sure that we keep positive, forward-thinking language. “I’m really glad that you’re here. It is really brave of you to talk with me about these issues and together we are going to figure this out.” rather than what you might be tempted to say such as, “You are overreacting to this. All kids do that.” “I get why you are mad at your dad. He is the worst.”
  • Frequently these patient and families fail to recognize strengths that they already have. This can be a way to expedite your care. “Wow, you have already been through so much, your resilience is remarkable and that resilience is going to carry you through this time.” “Your honesty is impressive. I really appreciate you sharing that. It is very brave of you to share what is going on in your head.” Showing you like them and care about them is helpful going forward.
  • How can you use food and drinks in your favor? Wallin walks in the room. She introduces herself and her staff. She lets everyone know what is going on including the fact that this process will take time. “Hi! My name is Dina. I’m the emergency physician who will be taking care of you today. I’m going to ask you, the patient, some questions alone. I’m going to ask you, the guardian, some questions alone. Then I am going to talk with my mental health partner which may be a social worker, crisis worker or psychiatrist and then we will all come up with a plan together. This will take at least 3 hours. Are you hungry? Do you want anything to eat or drink before we get going?” Just offering food and drinks can be soothing and comforting.
  • It is important to ask about patient requests or preferences? “Do you want to watch a movie right now? What can I do to make you feel more comfortable while you are waiting?” Your facility may have policies on what may be offered to mental health patients. If the patient has a reasonable and safe request, it is fair to try to honor reasonable requests.
  • We need to reassure the patient that they are safe with us. Remember, you have a child from a scary and stressful environment entering an even scarier environment, the busy emergency department. “You are safe here with me. I’m on your side. I’m here to protect you and you are going to be all right. You might be waiting for a while but while you are, you are safe here with me.” This goes a long way.
  • Data-gathering in this situation is different from the history and physical that we do in our adult psych patients. Often in adult psych patients, we evaluate vital signs, do a cursory head to toe exam, review the triage note of what happened and move on. This will not work with a pediatric patient.
    • What happened today?” “What happened leading up to today?” “Is this the first time the child has had these symptoms?” If not, what are they doing about it? Are they going to counseling? Is the child on medications? Do they feel comfortable talking with their counselor about these problems?
  • Do a thorough medical history including any medications the child is taking with specific doses. Do a detailed review of systems to make sure we aren’t missing a medical cause of psychiatric symptoms.
  • A detailed psycho-social history can be difficult if the wrong questions are being asked.  It is important to ask about things that we don’t always think of. Children have a very different home environment and different needs compared to our adult patients. There are a lot of validated screening tools to remind you of important questions to ask. It doesn’t matter which tool you use as long as you are systematic every time about asking the important types of questions.
    • Cappelli, M et al. The HEADS-ED: a rapid mental health screening tool for pediatric patients in the emergency department. 2012 Aug;130(2):e321-7.PMID: 22826567
    • This was really designed more to predict disposition. However, it is a useful tool to remind you of the questions you need to ask.

 

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  • We often forget to ask about home and education resources. Who lives at home? What type of housing do they live in? What is their neighborhood like? Are they safe at home? This is important. The child has no control over where they live and their safety. This lack of control can absolutely influence their behavior.
  • What type of school does the child go to? What grade are they in? Are they having a lot of absences? How are their grades? Academic performance is the most sensitive indicator of how a child is doing in life overall.
  • On the HEADS ED tool, if the child has a score of greater than 7 out of a maximum of 10 as well as a suicidality score of 2, it is highly predictive of needing inpatient psychiatric admission. For those who have minimal mental health support in your emergency department, this tool can help you determine if the child is likely to need inpatient resources so you can start mobilizing to get the child to definitive management sooner. 
  • It is really important to do a good physical exam. It is our job to determine if the patient has an unstable medical condition or an acute injury that needs immediate treatment. We also need to make sure that we aren’t missing medical causes of psychiatric symptoms.
    • This begins with a full set of vital signs. Only about 50% of adult psychiatric patients presenting to the ED have a full set of vital signs documented.
    • You need to do a good neurologic exam including gait. You can assess this by walking them to the bathroom to obtain a urine sample. 
    • You need to expose their skin and examine them from head to toe.We often tend to dismiss cutting or other signs of self-harm. However, it is a problem because it demonstrates an escalation in active self-harm behavior. Children will frequently cut or burn themselves in spots that are hidden by clothing so that teachers and parents don’t notice. The upper inner thighs are a frequent spot for cutting. We do need to look and document these findings in a mindful way protecting their modesty and comfort.
      • Laboratory testing. It is important to understand the available evidence and what our professional societies say. Both ACEP and the American Psychiatric Association have both released policy statements against routine lab testing in adult patients. Who is more likely to have a chronic undiagnosed medical condition, an adult or a kid? It really doesn’t make sense to obtain routine screening labs. There is a lot of data that shows that routine screening labs rarely change management (about 6% of the time). They rarely change disposition (0-1%). Nearly 100% of these conditions (usually giving antibiotics for a UTI) can be obtained on your history and physical.
    • There are many downsides to obtaining screening labs. There is the discomfort of the lab draw which is especially important in a younger child or agitated patient. It also extends the length of stay in the ED by about 2 hours. There is a much higher cost. Most pediatric mental health patients are publically insured or uninsured. For them and their families, the cost of the ED visit is significant and every choice you make is important to the family.
    • If the child has a normal physical exam including normal vital signs and a negative review of systems, there really aren’t any labs that are indicated.
    • However, urine pregnancy testing is important to do.
  • Try to verbally de-escalate patients. However, this doesn’t always work. Offer oral medications first. “You look a little anxious. Can I get you something to help calm you down while we are waiting?” Patients will often agree.
  • If that doesn’t work, you can give them parenteral injections.
  • Benzodiazepines and diphenhydramine can cause paradoxical agitation in a specific subset of patients. In preschool or early school age patients as well as children with autism or other sensory processing disorders, benzodiazepines or diphenhydramine can cause them to go bonkers.  Ask the family, “Has your child ever had a medicine like _______?” If they haven’t, it doesn’t mean you can’t use it, but you need to be prepared to handle it. If you give IM midazolam and the kid starts bouncing off the walls, you need to have your second option at the ready.
  • What oral medication does Wallin like to use? She prefers olanzapine. It comes in multiple formats including an oral dissolvable tablet, a pill that can be swallowed or intramuscular injection. The patient can be transitioned from IM to oral as they calm down. It is calming without being overly sedating. There are fewer adverse side effects with olanzapine in the pediatric population compared to adults.
  • Hopefully, you work in a place where you have a partner to help you with this. Some sites have a social worker or a child crisis team. If you don’t have a partner, you need to integrate all of the data you have accumulated. Some predictors of inpatient psychiatric admission are not surprising. Have they had a previous emergency department visit for a mental health problem? Have they had a previous psychiatric hospitalization? Are they doing risky behaviors like self-harm or eating disorders? A positive predictor of needing inpatient psychiatric admission is already being on psychotropic medications and receiving counseling. This means they are failing outpatient treatment.
    • Can you come up with a safe outpatient plan for the kid and their family or do you need to pursue inpatient psychiatric admission?

Recent Related Material

EMRAP 2018 June - Peds Psych Policy

 

 

Carlos J. -

Excellent talk! As an EM PA who works both fast track and main ED, we see a large amount of adult and pediatric psych. I couldn't help but laugh when the first step in the management algorithm was "sign out", it's also closely followed by "is there a resident/PA that can see this patient?" The most challenging aspect of managing these cases is making sure you don't ignore the subtle signs despite having already been "screened/triaged" based on their obvious injury or basic complaint without a history: "just a lac, mechanical fall, head injury, extremity injury, panic attack, ect"

I have had more than a few close calls with those cases, and those are the cases that matter most in my opinion. Many patients experiencing a new psychiatric emergency, non accidental trauma or abuse are prone to minimize and obfuscate, you have to pay attention to changes in posture and demeanor when friends or family enter the room, when questions make a patient look away or tear up, or when a story doesn't make sense. I also ask my nurses "was that weird?" after the history or exam if there is something i cant put my finger on, EM nurses live and breathe weird, its their baseline. I've been hit back with "OMG yes! I wanted to say something to you but didn't know what" more times than i can count. It's a clear indication for me when both myself and my nurse are picking up on something, to make sure I do my due diligence in history exam and documentation even if it means asking them the same questions a second time.

Most if not all of what I learned about managing these cases was over 10 years of trial and error, and wanted to offer a few more "sneaky" ways to get a chance to talk alone with your adult or pediatric patient.

Ambulatory Trials: Let the family know were going to take the patient for a short walk to assess for dizziness, nausea, instability, weakness. Works in most cases if you hit a brick wall with not being able to escort the patient to the bathroom. Just have them ambulate out of direct line of sight or past your workstation. If you find new information have someone let the family/friend/spouse know the patient failed and isn't going home yet, and they can wait in the waiting room for a few minutes while we bring the patient back to the room.

Imaging: In the setting of concerns for non accidental trauma where diagnostic imaging is warranted, I give my tech or nurse a heads up before they escort the patient to radiology so I can either meet them there or walk along with them and ask them questions directly

Contact information: A great way of getting parents/spouses out of the room is to have registration "update" their contact information, billing information, whatever information you want, just review and update it. I find that every time i ask my registrars are excited about the chance to play a role in sniffing out the truth, I have never once had them view it as an inconvenience.

Dina W., MD -

Great tips, Carlos! I especially love your technique of involving oft-neglected, yet vital, members of the care team, such as radiology techs and registration workers. We are all working together in the department with the goal of helping our patients be healthy and happy, and 360 degree input is vital to help us reach this goal.

You're also completely correct that it's super important to perform a detailed H&P, including asking certain questions multiple times, in all of these patients-- this can help us pick up on subtle clues that the situation is more serious than we thought.

Thanks again for your engagement and commentary!

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EM:RAP 2018 July Full episode audio for MD edition 229:23 min - 319 MB - M4AEM:RAP 2018 July German Edition Deutsche 120:44 min - 166 MB - MP3EM:RAP 2018 July Spanish Edition Español 90:31 min - 124 MB - MP3EM:RAP 2018 July Australian Edition Australian 35:17 min - 48 MB - MP3EM:RAP 2018 July Canadian Edition Canadian 24:10 min - 33 MB - MP3EM:RAP 2018 July French Edition Français 27:05 min - 37 MB - MP3EM:RAP 2018 07 July Individual MP3 Files 293 MB - ZIPEMRAP 2018 07 July Individual Summaries 742 KB - ZIPEMRAP 2018 07 July Spanish Summary 1 MB - PDFEMRAP Board Review Answers 2018 07 July Vol.18 07 116 KB - PDFEMRAP 2018 07 July Vol.18 V2 Written Summary 390 KB - PDFEMRAP Board Review Questions 2018 07 July Vol.18 07 407 KB - PDF

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