OBJECTIVES:To describe the historical and current use of recreational drugs by a trial cohort of youth presenting to the emergency department (ED) whilst experiencing acute behavioural disturbance (ABD). METHODS:This was a secondary analysis of a randomised, controlled trial comparing medication management of ABD in children and adolescents aged nine to 17 years who were deemed to require oral sedative medication. RESULTS:Recreational drugs were used by 33% of participants any time prior to enrolment (115/348). Cannabis was the most commonly used (87/348, 25%), followed by amphetamines/methamphetamines (32/348, 9%) and benzodiazepines (26/348, 7%). CONCLUSION:Recreational drug use may be a contributing factor to ABD amongst children and adolescents presenting to EDs.

AIM:To describe the epidemiological characteristics of children and young people presenting to the emergency department (ED) with acute severe behavioural disturbance (ASBD) who were deemed to require oral sedative medication. METHODS:Secondary analysis of a randomised controlled open-label multi-centre trial of oral olanzapine versus oral diazepam for the management of ASBD in children and young people aged nine to 17 years for whom epidemiological data were recorded. RESULTS:There were 348 participants enrolled in the randomised controlled trial (RCT). The majority were female (215/348, 62%) with a mean age of 14.6 years (standard deviation 2.2). The most common pre-existing medical or mental health condition was anxiety (122/299, 35%) followed by attention deficit hyperactivity disorder and autism spectrum disorder (33% and 32%, respectively). Two-thirds of the study population (216/348, 62%) had previously attended the ED for ASBD management and 61% (212/348) reported previous intentional self-harm. Nearly three-quarters (247/348, 71%) were accessing psychiatric care in the community prior to their ED presentation. Half of the study population (178/348, 52%) presented to the ED with emergency services (e.g., ambulance, police). The median length of stay in the ED was 5.7 h (interquartile range 3.9-10.2 h) and 28% (98/348) of study participants required admission to hospital. CONCLUSIONS:For children and young people presenting to the ED with ASBD who were deemed to require oral sedative medication to assist with behavioural containment, pre-existing mental health disorders were common. There is a need for focussed management procedures for more targeted, trauma-focussed care for children and young people presenting to the ED with ASBD and for support and education in the pre-hospital setting. TRIAL REGISTRATION:The primary study (PEAChY-O) was registered with the Australian and New Zealand Clinical Trials Registry (ANZCTR) (ACTRN12621001236886) prior to commencement.

Objective To describe the frequency and nature of non-pharmacological de-escalation methods used for children and adolescents presenting to emergency departments (EDs) with acute severe behavioural disturbance (ASBD).Design Secondary analysis of a randomised, controlled, open-label, multicentre trial of oral olanzapine versus oral diazepam for the management of ASBD.Setting Nine EDs in Australia between October 2021 and November 2023.Participants Children aged 9-17 years, for whom information on non-pharmacological de-escalation attempts was recorded, who ultimately required oral sedative medication to manage their ASBD.Main outcome measures The frequency and nature of the use of non-pharmacological de-escalation methods for children and adolescents presenting to EDs in a state of ASBD.Results There were 348 participants enrolled in the randomised controlled trial. This study reports on the 337 of 348 participants (97%) for whom information was recorded regarding non-pharmacological de-escalation attempts during the trial period. Verbal de-escalation was the most commonly attempted technique (96%) followed by active listening (75%). The frequency and nature of de-escalation techniques used were similar across the nine participating sites.Conclusions A variety of non-pharmacological de-escalation strategies are used among patients who require oral sedative medication. There is a need for studies to investigate whether there are optimal first-line de-escalation strategies and to determine their effectiveness and order of use in children and adolescents presenting to EDs with ASBD.

OBJECTIVE:To compare the total direct healthcare costs of nasal high flow (NHF) therapy and standard oxygen therapy (SOT) as first-line treatments for paediatric acute hypoxaemic respiratory failure (AHRF) and to identify what factors explain variations in these costs. DESIGN:Cost analysis following a randomised controlled trial. SETTING:14 hospitals across Australia and New Zealand. PATIENTS:1517 children aged 1-4 years admitted with AHRF between 18 December 2017 and 18 March 2020, enrolled in the Paediatric Acute Respiratory Intervention Study 2(PARIS-2) trial. INTERVENTIONS:Patients were randomised to receive either NHF or SOT. MAIN OUTCOME MEASURES:Total and average cost per patient admission for the two first-line treatments of AHRF. RESULTS:The total cost of treating the trial cohort was $A10 788 793 (US$7 660 143; €6 689 052; £6 041 724), corresponding to an average of $A7112 (US$5050; €4409; £3983) per patient. Average cost per patient admission was significantly higher in the NHF group at $A7815 (US$5549; €4845; £4376) compared with the SOT group at $A6419 (US$4557; €3980; £3595), with a mean difference of $A1396 (US$991; €866; £782, 95% CI $A419 to $A2372). Subgroup analyses showed that NHF non-responders, particularly those presenting with wheeze, incurred greater costs due to higher likelihood of intensive care admission and longer hospital stays. CONCLUSION:NHF costs more than SOT and does not lead to better clinical outcomes. Although NHF remains an important respiratory support modality for paediatric AHRF, its higher costs, particularly among those not responding to NHF, emphasise the need for more targeted use. TRIAL REGISTRATION NUMBER:ACTRN12618000210279.

Study objective: To determine whether oral olanzapine or oral diazepam was more effective at achieving behavioral containment for young people presenting to the emergency department with acute severe behavioral disturbance. Methods: We conducted an open-label, multicenter, randomized controlled trial from October 22, 2021, to November 6, 2023. We enrolled young people aged between 9 and 17 years with acute severe behavioral disturbance deemed to require oral medication across 9 Australian emergency departments. We randomly assigned participants to a single weight-based oral dose of olanzapine or diazepam. The primary outcome was successful sedation (Sedation Assessment Tool score less than or equal to 0) without the need for additional sedatives one hour postrandomization. Secondary outcomes included adverse events; length of stay; aggression toward staff, participants, or parent/guardians; disposition; and satisfaction with care. Results: We recruited 348 participants, with 176 assigned to olanzapine and 172 to diazepam. Successful sedation without the requirement for additional sedatives occurred in 103/168 (61%) in the olanzapine group and 90/158 (57%) in the diazepam group (adjusted risk difference 3.6%, 95% confidence interval-6.7% to 14.0%). No serious adverse events were reported in either group. Conclusions: There was no evidence that oral olanzapine resulted in a greater proportion of participants with acute severe behavioral disturbance achieving successful sedation at one hour postrandomization than oral diazepam. Neither medication resulted in any serious adverse events; however, approximately 40% of participants in each group did not achieve successful sedation.

Introduction Acute severe behavioural disturbance (ASBD) is a condition seen with increasing frequency in emergency departments (EDs) in adults and young people. Despite the increasing number of presentations and significant associated risks to patients, families and caregivers, there is limited evidence to guide the most effective pharmacological management in children and adolescents. The aim of this study is to determine whether a single dose of intramuscular olanzapine is more effective than intramuscular droperidol at successfully sedating young people with ASBD requiring intramuscular sedation. Methods and analysis This study is a multicentre, open-label, superiority randomised controlled trial. Young people aged between 9 and 17 years and 364 days presenting to an ED with ASBD who are deemed to require medication for behavioural containment will be recruited to the study. Participants will be randomised in a 1:1 allocation between a single weight-based dose of intramuscular olanzapine and intramuscular droperidol. The primary outcome is the proportion of participants who achieve successful sedation at 1-hour post randomisation without the need for additional sedation. Secondary outcomes will include assessing for adverse events, additional medications provided in the ED, further episodes of ASBD, length of stay in the ED and hospital and satisfaction with management. Effectiveness will be determined using an intention-to-treat analysis, with medication efficacy determined as part of the secondary outcomes using a per-protocol analysis. The primary outcome of successful sedation at 1hour will be presented as a percentage within each treatment group, with comparisons presented as a risk difference with its 95% CIs. Ethics and dissemination Ethics approval was received from the Royal Children's Hospital Human Research Ethics Committee (HREC/69948/RCHM-2021). This incorporated a waiver of informed consent for the study. The findings will be disseminated in a peer-reviewed journal and at academic conferences. Trial registration number ACTRN12621001238864.

AimsHigh‐flow is increasingly used in children with acute hypoxaemic respiratory failure (AHRF), despite limited evidence. The primary feasibility endpoint for this pilot‐study was the proportion of treatment failure, secondary outcomes being intensive care unit (ICU) admissions and proportion of patients requiring escalation of care. We measured duration of hospital stay, duration of oxygen therapy and rates of ICU admission.MethodsAn open‐labelled randomised controlled trial feasibility design was used in two tertiary children's hospitals in the emergency department and general wards. Children aged 0–16 years with AHRF were randomised (1:1) to either high‐flow or standard‐oxygen. Children on standard‐oxygen received rescue high‐flow in general wards if failure criteria were met.ResultsOf 563 randomised, 283 received high‐flow and 280 standard‐oxygen with no adverse events. The proportion of children who failed treatment and receiving escalation of care was 11.7% (32/283 children) on high‐flow and 18.1% (50/280 infants) on standard‐oxygen (odds ratio 0.68, 95% confidence interval 0.38–1.00). In children with obstructive airway disease, 9.7% on high‐flow and 17.4% on standard‐oxygen required escalation (risk‐difference −7.7% percentage points; 95% confidence interval −14.3, −1.1); in children with non‐obstructive disease no difference was observed. Neither difference in ICU admissions nor any difference in length of hospital stay was observed. Sixty percent of children who failed standard‐oxygen responded to rescue high‐flow.ConclusionHigh‐flow outside ICU appears to be feasible in children with AHRF and the required proportion of escalation was lower compared to standard‐oxygen. The trial design can be applied in a future large randomised controlled trial.

Introduction Acute hypoxaemic respiratory failure (AHRF) in children is the most frequent reason for non-elective hospital admission. During the initial phase, AHRF is a clinical syndrome defined for the purpose of this study by an oxygen requirement and caused by pneumonia, lower respiratory tract infections, asthma or bronchiolitis. Up to 20% of these children with AHRF can rapidly deteriorate requiring non-invasive or invasive ventilation. Nasal high-flow (NHF) therapy has been used by clinicians for oxygen therapy outside intensive care settings to prevent escalation of care. A recent randomised trial in infants with bronchiolitis has shown that NHF therapy reduces the need to escalate therapy. No similar data is available in the older children presenting with AHRF. In this study we aim to investigate in children aged 1 to 4 years presenting with AHRF if early NHF therapy compared with standard-oxygen therapy reduces hospital length of stay and if this is cost-effective compared with standard treatment. Methods and analysis The study design is an open-labelled randomised multicentre trial comparing early NHF and standard-oxygen therapy and will be stratified by sites and into obstructive and non-obstructive groups. Children aged 1 to 4 years (n=1512) presenting with AHRF to one of the participating emergency departments will be randomly allocated to NHF or standard-oxygen therapy once the eligibility criteria have been met (oxygen requirement with transcutaneous saturation <92%/90% (dependant on hospital standard threshold), diagnosis of AHRF, admission to hospital and tachypnoea ≥35 breaths/min). Children in the standard-oxygen group can receive rescue NHF therapy if escalation is required. The primary outcome is hospital length of stay. Secondary outcomes will include length of oxygen therapy, proportion of intensive care admissions, healthcare resource utilisation and associated costs. Analyses will be conducted on an intention-to-treat basis. Ethics and dissemination Ethics approval has been obtained in Australia (HREC/15/QRCH/159) and New Zealand (HDEC 17/NTA/135). The trial commenced recruitment in December 2017. The study findings will be submitted for publication in a peer-reviewed journal and presented at relevant conferences. Authorship of all publications will be decided by mutual consensus of the research team. Trial registration number ACTRN12618000210279