Acute agitation in youth is a challenging presentation to the emergency department. In many cases, however, youth can be behaviorally de-escalated using a combination of environmental modification and verbal de-escalation. In cases where additional strategies such as pharmacologic de-escalation or physical restraint are needed, using the least restrictive means possible, including the youth in the decision-making process, and providing options are important. This paper reviews specific considerations on the approach to a youth with acute agitation and strategies and techniques to successfully de-escalate agitated youth who pose a danger to themselves and/or others.

In this multicenter, cross-sectional, secondary analysis of 4042 low-risk febrile infants, nearly 10% had a contaminated culture obtained during their evaluation (4.9% of blood cultures, 5.0% of urine cultures, and 1.8% of cerebrospinal fluid cultures). Our findings have important implications for improving sterile technique and reducing unnecessary cultures.

Importance:Febrile infants at low risk of invasive bacterial infections are unlikely to benefit from lumbar puncture, antibiotics, or hospitalization, yet these are commonly performed. It is not known if there are differences in management by race, ethnicity, or language. Objective:To investigate associations between race, ethnicity, and language and additional interventions (lumbar puncture, empirical antibiotics, and hospitalization) in well-appearing febrile infants at low risk of invasive bacterial infection. Design, Setting, and Participants:This was a multicenter retrospective cross-sectional analysis of infants receiving emergency department care between January 1, 2018, and December 31, 2019. Data were analyzed from December 2022 to July 2023. Pediatric emergency departments were determined through the Pediatric Emergency Medicine Collaborative Research Committee. Well-appearing febrile infants aged 29 to 60 days at low risk of invasive bacterial infection based on blood and urine testing were included. Data were available for 9847 infants, and 4042 were included following exclusions for ill appearance, medical history, and diagnosis of a focal infectious source. Exposures:Infant race and ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White, and other race or ethnicity) and language used for medical care (English and language other than English). Main Outcomes and Measures:The primary outcome was receipt of at least 1 of lumbar puncture, empirical antibiotics, or hospitalization. We performed bivariate and multivariable logistic regression with sum contrasts for comparisons. Individual components were assessed as secondary outcomes. Results:Across 34 sites, 4042 infants (median [IQR] age, 45 [38-53] days; 1561 [44.4% of the 3516 without missing sex] female; 612 [15.1%] non-Hispanic Black, 1054 [26.1%] Hispanic, 1741 [43.1%] non-Hispanic White, and 352 [9.1%] other race or ethnicity; 3555 [88.0%] English and 463 [12.0%] language other than English) met inclusion criteria. The primary outcome occurred in 969 infants (24%). Race and ethnicity were not associated with the primary composite outcome. Compared to the grand mean, infants of families that use a language other than English had higher odds of the primary outcome (adjusted odds ratio [aOR]; 1.16; 95% CI, 1.01-1.33). In secondary analyses, Hispanic infants, compared to the grand mean, had lower odds of hospital admission (aOR, 0.76; 95% CI, 0.63-0.93). Compared to the grand mean, infants of families that use a language other than English had higher odds of hospital admission (aOR, 1.08; 95% CI, 1.08-1.46). Conclusions and Relevance:Among low-risk febrile infants, language used for medical care was associated with the use of at least 1 nonindicated intervention, but race and ethnicity were not. Secondary analyses highlight the complex intersectionality of race, ethnicity, language, and health inequity. As inequitable care may be influenced by communication barriers, new guidelines that emphasize patient-centered communication may create disparities if not implemented with specific attention to equity.

Suicide is a leading cause of death among youth, and emergency departments (EDs) play an important role in caring for youth with suicidality. Shortages in outpatient and inpatient mental and behavioral health capacity combined with a surge in ED visits for youth with suicidal ideation (SI) and self-harm challenge many EDs in the United States. This review highlights currently identified best practices that all EDs can implement in suicide screening, assessment of youth with self-harm and SI, care for patients awaiting inpatient psychiatric care, and discharge planning for youth determined not to require inpatient treatment. We will also highlight several controversies and challenges in implementation of these best practices in the ED. An enhanced continuum of care model recommended for youth with mental and behavioral health crises utilizes crisis lines, mobile crisis units, crisis receiving and stabilization units, and also maximizes interventions in home- and community-based settings. However, while local systems work to enhance continuum capacity, EDs remain a critical part of crisis care. Currently, EDs face barriers to providing optimal treatment for youth in crisis due to inadequate resources including the ability to obtain emergent mental health consultations via on-site professionals, telepsychiatry, and ED transfer agreements. To reduce ED utilization and better facilitate safe dispositions from EDs, the expansion of community- and home-based services, pediatric-receiving crisis stabilization units, inpatient psychiatric services, among other innovative solutions, is necessary.

AbstractBackgroundArtificial intelligence (AI) has transformative potential to support prehospital clinicians, emergency physicians, and trauma surgeons in acute traumatic injury care. This scoping review examines the literature evaluating AI models using prehospital features to support early traumatic injury care.MethodsWe conducted a systematic search in August 2023 of PubMed, Embase, and Web of Science. Two independent reviewers screened titles/abstracts, with a third reviewer for adjudication, followed by a full‐text analysis. We included original research and conference presentations evaluating AI models—machine learning (ML), deep learning (DL), and natural language processing (NLP)—that used prehospital features or features available immediately upon emergency department arrival. Review articles were excluded. The same investigators extracted data and systematically categorized outcomes to ensure consistency and transparency. We calculated kappa for interrater reliability and descriptive statistics.ResultsWe identified 1050 unique publications, with 49 meeting inclusion criteria after title and abstract review (kappa 0.58) and full‐text review. Publications increased annually from 2 in 2007 to 10 in 2022. Geographic analysis revealed a 61% focus on data from the United States. Studies were predominantly retrospective (88%), used local (45%) or national level (41%) data, focused on adults only (59%) or did not specify adults or pediatrics (27%), and 57% encompassed both blunt and penetrating injury mechanisms. The majority used machine learning (88%) alone or in conjunction with DL or NLP, and the top three algorithms used were support vector machine, logistic regression, and random forest. The most common study objectives were to predict the need for critical care and life‐saving interventions (29%), assist in triage (22%), and predict survival (20%).ConclusionsA small but growing body of literature described AI models based on prehospital features that may support decisions made by dispatchers, Emergency Medical Services clinicians, and trauma teams in early traumatic injury care.

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This panel brings together a diverse set of experts to discuss training for high-stakes domains such as emergency medicine, law enforcement, combat medicine, and others. Work in these domains typically involves managing uncertainty, time pressure, and often life and death risk. These high-stakes domains are often leaders in simulation-based training, creating virtual environments and seeking the right types of fidelity to prepare personnel to develop the perceptual, sensemaking, and stress management skills needed to perform in some of the toughest situations. Panelists will discuss some of the challenges for training and evaluating the effectiveness of training in these complex domains. They will share examples of successful strategies and lessons learned from less-than-successful strategies.

OBJECTIVES:We evaluated prehospital professionals' accuracy, speed, interrater reliability, and impression in a pediatric disaster scenario both without a tool ("No Algorithm"-NA) and with 1 of 5 algorithms: CareFlight (CF), Simple Triage and Rapid Treatment (START) and JumpSTART (J-START), Pediatric Triage Tape (PTT), Sort, Assess, Life-saving interventions, Treatment/Transport (SALT), and Sacco Triage Method (STM).METHODS:Prehospital professionals received disaster lectures, focusing on 1 triage algorithm. Then they completed a timed tabletop disaster exercise with 25 pediatric victims to measure speed. A predetermined criterion standard was used to assess accuracy of answers. Answers were compared to one another to determine the interrater reliability.RESULTS:One hundred and seven prehospital professionals participated, with 15-28 prehospital professionals in each group. The accuracy was highest for STM (89.3%; 95% confidence interval [CI] 85.7% to 92.2%) and lowest for PTT (67.8%; 95% CI 63.4% to 72.1%). Accuracy of NA and SALT tended toward undertriage (15.8% and 16.3%, respectively). The remaining algorithms tended to overtriage, with PTT having the highest overtriage percentage (25.8%). The 3 fastest algorithms were: CF, SALT, and NA, all taking 5 minutes or less. STM was the slowest. STM demonstrated the highest interrater reliability, whereas CF and SALT demonstrated the lowest interrater reliability.CONCLUSIONS:This study demonstrates the most common challenges inherent to mass casualty incident (MCI) triage systems: as accuracy and prehospital professional interrater reliability improve, speed slows. No triage algorithm in our study excelled in all these measures. Additional investigation of these algorithms in larger MCI drills requiring collection of vital signs in real time or during a real MCI event is needed.

ObjectivesPrehospital protocols vary across local emergency medical service (EMS) agencies in California. We sought to develop evidence-based recommendations for the out-of-hospital evaluation and treatment of pediatric respiratory distress, and we evaluated the protocols for pediatric respiratory distress used by the 33 California local EMS agencies. MethodsEvidence-based recommendations were developed through an extensive literature review of the current evidence regarding out-of-hospital treatment of pediatric patients with respiratory distress. The authors compared the pediatric respiratory distress protocols of each of the 33 California local EMS agencies with the evidence-based recommendations. Our focus was on the treatment of 3 main pediatric respiratory complaints by presentation: stridor (croup), wheezing < 24 months (bronchiolitis), and wheezing > 24 months (asthma). ResultsProtocols across the 33 California local EMS agencies varied widely. Stridor (croup) had the highest protocol variability of the 3 presentations we evaluated, with no treatment having uniform use among all agencies. Only 3 (9.1%) of the local EMS agencies differentiated wheezing in children < 24 months of age, referencing this as possible bronchiolitis. All local EMS agencies included albuterol and epinephrine (intravenous/intramuscular) in their pediatric wheezing (asthma) treatment protocols. The least common treatments for wheezing (asthma) included nebulized epinephrine (3/33) and magnesium (2/33). No agencies included steroids in their treatment protocols (0/33). ConclusionProtocols for pediatric respiratory distress vary widely across the state of California, especially among those for stridor (croup) and wheezing in < 24 months (bronchiolitis). The evidence-based recommendations that we present for the prehospital treatment of these conditions may be useful for EMS medical directors tasked with creating and revising these protocols.

BACKGROUNDIn November and December 2012, 6 patients at a hemodialysis clinic were given a diagnosis of new hepatitis C virus (HCV) infection.OBJECTIVETo investigate the outbreak to identify risk factors for transmission.METHODSA case patient was defined as a patient who was HCV-antibody negative on clinic admission but subsequently was found to be HCV-antibody positive from January 1, 2008, through April 30, 2013. Patient charts were reviewed to identify and describe case patients. The hypervariable region 1 of HCV from infected patients was tested to assess viral genetic relatedness. Infection control practices were evaluated via observations. A forensic chemiluminescent agent was used to identify blood contamination on environmental surfaces after cleaning.RESULTSEighteen case patients were identified at the clinic from January 1, 2008, through April 30, 2013, resulting in an estimated 16.7% attack rate. Analysis of HCV quasispecies identified 4 separate clusters of transmission involving 11 case patients. The case patients and previously infected patients in each cluster were treated in neighboring dialysis stations during the same shift, or at the same dialysis station on 2 consecutive shifts. Lapses in infection control were identified. Visible and invisible blood was identified on multiple surfaces at the clinic.CONCLUSIONSEpidemiologic and laboratory data confirmed transmission of HCV among numerous patients at the dialysis clinic over 6 years. Infection control breaches were likely responsible. This outbreak highlights the importance of rigorous adherence to recommended infection control practices in dialysis settings.Infect. Control Hosp. Epidemiol. 2016;37(2):125–133

OBJECTIVE: To describe the circumstances, characteristics, and trends of emergency department (ED) visits for nonfatal, playground-related traumatic brain injury (TBI) among persons aged ≤14 years. METHODS: The National Electronic Injury Surveillance System–All Injury Program from January 1, 2001, through December 31, 2013, was examined. US Census bridged-race population estimates were used as the denominator to compute rates per 100 000 population. SAS and Joinpoint linear weighted regression analyses were used to analyze the best-fitting join-point and the annual modeled rate change. These models were used to indicate the magnitude and direction of rate trends for each segment or period. RESULTS: During the study period, an annual average of 21 101 persons aged ≤14 years were treated in EDs for playground-related TBI. The ED visit rate for boys was 39.7 per 100 000 and 53.5 for persons aged 5–9 years. Overall, 95.6% were treated and released, 33.5% occurred at places of recreation or sports, and 32.5% occurred at school. Monkey bars or playground gyms (28.3%) and swings (28.1%) were the most frequently associated with TBI, but equipment involvement varied by age group. The annual rate of TBI ED visits increased significantly from 2005 to 2013 (P < .05). CONCLUSIONS: Playgrounds remain an important location of injury risk to children. Strategies to reduce the incidence and severity of playground-related TBIs are needed. These may include improved adult supervision, methods to reduce child risk behavior, regular equipment maintenance, and improvements in playground surfaces and environments.

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Background The objectives of this study were to evaluate racial misclassification in a statewide trauma registry and to describe the epidemiology of trauma among the Washington American Indian and Alaska Native (AI/AN) population.Methods We performed probabilistic record linkage between the Washington Trauma Registry (2005-2009) and Northwest Tribal Registry, a dataset of known AI/AN. AI/AN patients were compared with caucasians on demographic, injury and clinical outcome factors. A multivariable model estimated odds of mortality.Results Record linkage increased ascertainment of AI/AN cases in the trauma registry 71%, from 1777 to 3039 cases. Compared with caucasians, AI/AN trauma patients were younger (mean age=36 vs 47 years, p<0.001) and more commonly male (66.5% vs 61.2%, p<0.001). AI/AN experienced more intentional injuries (suicide or homicide: 20.1% vs 6.7%, p<0.001), a higher proportion of severe traumatic brain injury (20.7% vs 16.8%, p=0.004) and were less likely than caucasians to use safety equipment such as seat belts/airbags (53.9% vs 76.7%, p<0.001). ISSs were similar (ISS > 15: 21.4% vs 20.5%, p=0.63), and no difference was observed in mortality after adjustment for covariates (p=0.58).Conclusions Linkage to a state trauma registry improved data quality by correcting racial misclassification, allowing for a comprehensive description of injury patterns for the AI/AN population. AI/AN sustained more severe injuries with similar postinjury outcomes to caucasians. Future efforts should focus on primary prevention for this population, including increased use of seat belts and child safety seats and reduction of interpersonal violence and suicide.

IMPORTANCE:Sports- and recreation-related traumatic brain injuries (SRR-TBIs) are a growing public health problem affecting persons of all ages in the United States.OBJECTIVE:To describe the trends of SRR-TBIs treated in US emergency departments (EDs) from 2001 to 2012 and to identify which sports and recreational activities and demographic groups are at higher risk for these injuries.DESIGN:Data on initial ED visits for an SRR-TBI from the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) for 2001-2012 were analyzed.SETTING:NEISS-AIP data are drawn from a nationally representative sample of hospital-based EDs.PARTICIPANTS:Cases of TBI were identified from approximately 500,000 annual initial visits for all causes and types of injuries treated in EDs captured by NEISS-AIP.MAIN OUTCOME MEASURE(S):Numbers and rates by age group, sex, and year were estimated. Aggregated numbers and percentages by discharge disposition were produced.RESULTS:Approximately 3.42 million ED visits for an SRR-TBI occurred during 2001-2012. During this period, the rates of SRR-TBIs treated in US EDs significantly increased in both males and females regardless of age (all Ps < .001). For males, significant increases ranged from a low of 45.8% (ages 5-9) to a high of 139.8% (ages 10-14), and for females, from 25.1% (ages 0-4) to 211.5% (ages 15-19) (all Ps < .001). Every year males had about twice the rates of SRR-TBIs than females. Approximately 70% of all SRR-TBIs were reported among persons aged 0 to 19 years. The largest number of SRR-TBIs among males occurred during bicycling, football, and basketball. Among females, the largest number of SRR-TBIs occurred during bicycling, playground activities, and horseback riding. Approximately 89% of males and 91% of females with an SRR-TBI were treated and released from EDs.CONCLUSION AND RELEVANCE:The rates of ED-treated SRR-TBIs increased during 2001-2012, affecting mainly persons aged 0 to 19 years and males in all age groups. Increases began to appear in 2004 for females and 2006 for males. Activities associated with the largest number of TBIs varied by sex and age. Reasons for the reported increases in ED visits are unknown but may be associated with increased awareness of TBI through increased media exposure and from campaigns, such as the Centers for Disease Control and Prevention's Heads Up. Prevention efforts should be targeted by sports and recreational activity, age, and sex.