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Crisis in the Emergency Department: The Evaluation and Management of Acute Agitation in Children and Adolescents
Gerson, Ruth; Malas, Nasuh; Mroczkowski, Megan M
Acute agitation in children and adolescents in the emergency department carries significant risks to patients and staff and requires skillful management, using both nonpharmacologic and pharmacologic strategies. Effective management of agitation requires understanding and addressing the multifactorial cause of the agitation. Careful observation and multidisciplinary collaboration is important. Medical work-up of agitated patients is also critical. Nonpharmacologic deescalation strategies should be first line for preventing and managing agitation and should continue during and after medication administration. Choice of medication should focus on addressing the cause of the agitation and any underlying psychiatric syndromes.
PMID: 29933788
ISSN: 1558-0490
CID: 3158402
Adolescence
Chapter by: Mandel, Rachel; Gerson, Ruth
in: A case-based approach to public psychiatry by Tse, Jeanie [Ed]; Volpp, Serena Yuan [Ed]
New York, NY, US: Oxford University Press, 2018
pp. 77-83
ISBN: 978-0-19-061099-9
CID: 3054562
Utilization Patterns at a Specialized Children's Comprehensive Psychiatric Emergency Program
Gerson, Ruth; Havens, Jennifer; Marr, Mollie; Storfer-Isser, Amy; Lee, Mia; Rojas Marcos, Carolena; Liu, Michelle; Horwitz, Sarah McCue
OBJECTIVE: Most youths experiencing a psychiatric crisis present to emergency departments (EDs) that lack the specialized staff to evaluate them, so youths are often discharged without appropriate mental health assessment or treatment. To better understand the needs of this population, this study described clinical details and disposition associated with visits for psychiatric emergencies to a specialized ED staffed 24/7 by child psychiatrists. METHODS: Through retrospective chart review, 1,180 visits to the ED during its first year of operation were reviewed for clinical characteristics, prior service utilization, and demographic characteristics. Bivariate analyses (chi-square test and Wilcoxon rank sum test) compared differences in disposition (evaluate and release, brief stabilization, and inpatient psychiatric admission) associated with characteristics of the children's first visit (N=885). Measures with bivariate association of p<.10 were further assessed by using multinomial logistic regression analyses. RESULTS: For most visits (59%), children were evaluated and released, 13% were briefly stabilized, and 28% were admitted for psychiatric treatment. Youths with mood or psychotic disorders were more likely to be admitted, as were those with current suicidality or aggression. Many youths who presented with aggression were also identified as having suicidality or self-harm. CONCLUSIONS: Clinical factors, especially suicidality, predicted psychiatric admission. Admission rates for youths with suicidality were significantly higher in this study than previously reported, suggesting the availability of child psychiatrists in this ED allowed greater ascertainment of suicide risk (and thus hospitalization to mitigate that risk) than occurs in EDs without such staffing.
PMID: 28617206
ISSN: 1557-9700
CID: 2595162
Prn medication utilization over five years in a specialized child psychiatric emergency program [Meeting Abstract]
Gerson, R
Objectives: Youths increasingly present to emergency departments (EDs) with agitated behavior or aggression attributed to psychosis, anxiety, mania, or intoxication or related to underlying behavioral disorder. They can be dangerous to themselves, staff, and other patients in the ED and may require restraint. Although reduction of restraint and injury is a priority of every ED, there are little published data on the use and effectiveness of PRN medications to treat or prevent acute agitation. Further work is needed to understand PRN usage and identify efficacy of different PRN medications to guide clinical practice. Methods: This report describes the use of PRN medications during restraint events in a specialized child psychiatric emergency program between the program's opening in 2011 until December 2016. During this period, 8,800 youth (ages 2-17 years) were seen, and 185 experienced restraint. Chart review examined patient demographics, diagnosis, medication utilization, and efficacy. Results: The youth who experienced restraint ranged in age from six to 17 years. Diagnoses included internalizing, externalizing, and developmental disorders, as well as substance intoxication. The medications used predominantly included most commonly diphenhydramine, chlorpromazine, haloperidol, lorazepam, and risperidone, among others, at a range of doses. Documented efficacy of medication varied significantly as we will report. Conclusions: There are currently no published consensus guidelines for the psychopharmacological management of agitation and little published literature comparing effectiveness of different PRN medications or comparing those medications to placebo. A review of PRN prescribing practices in a specialized child psychiatric emergency program, where all patients are treated by child and adolescent psychiatrists, illustrates the range of medication usage and the varying degree of efficacy of these medications. Further research is needed into the effectiveness of PRN medications, as is professional guidance for choice of medication and dose
EMBASE:620081127
ISSN: 1527-5418
CID: 2924202
Consensus guidelines for pro re nata medication for agitation in the emergency department [Meeting Abstract]
Gerson, R
Objectives: More and more youth are presenting to emergency departments (EDs) in psychiatric distress. Many of these youth present with agitated behavior or aggression as a result of psychosis, anxiety, mania, intoxication, or in relation to underlying behavioral disorder. Agitated patients can be dangerous to themselves, staff, and other patients in the ED and may require restraint. Although reduction of restraint and injury is a priority of every ED, there are little published data on the use and efficacy of PRN medications to treat or prevent acute agitation. In the absence of evidence-based guidelines, expert guidance is needed to assist clinicians in choosing effective and appropriate PRN medications for acute agitation. Methods: The Delphi method for consensus guideline development was used by a team of ED-based child and adolescent psychiatrists from across the United States. By use of an iterative, blinded process to reduce bias, participants reviewed existing or published PRN medication algorithms and guidelines for acute agitation and then developed consensus guidelines with identification of areas of dissension and need for further research. Results: There were significant variations in preferred medications across geography and type of ED setting (medical vs. psychiatric ED). Participants emphasized the importance of nonpharmacologic de-escalation strategies; clinical diagnostic assessment, even in the moment of acute agitation; consideration of individual patient factors in choosing medications; and careful monitoring for efficacy and adverse effects. A range of medications, including antipsychotic drugs, antihistamine, benzodiazepine, and a-adrenergic medications, was recommended. Conclusions: There are currently no AACAP Practice Parameters for the psychopharmacological management of agitation, and there is little published literature comparing effectiveness of different PRN medications or comparing those medications to placebo. Expert consensus guidelines such as these provide much-needed guidance to ED clinicians. These guidelines also demonstrate areas where further research is needed, especially into the comparative efficacy of different PRN medications in patients of different ages, clinical presentations, and diagnostic/treatment history
EMBASE:620079165
ISSN: 1527-5418
CID: 2924322
Special Considerations in the Pediatric Psychiatric Population
Santillanes, Genevieve; Gerson, Ruth S
Youth with psychiatric and behavioral complaints commonly present to emergency departments (EDs), which often lack dedicated mental health staff. This article addresses techniques EDs can use to better care for children in need of psychiatric assessment and medical clearance, specifically addressing the evaluation of youth with suicidal ideation and coexisting medical and psychiatric needs. The evaluation and management of youth with agitation and aggression are also discussed. The article concludes with a discussion of systems changes needed to truly improve emergency care for psychiatrically ill youth.
PMID: 28800802
ISSN: 1558-3147
CID: 2664262
Caring for youth with autism in a child and adolescent psychiatric emergency service [Meeting Abstract]
Filton, B; Gerson, R
Objectives: Most staff in a psychiatric emergency service, even CAPs, have little experience with the emergency evaluation, crisis management, and behavioral treatment of patients with autism. This presentation will teach participants about the evaluation and behavioral management of patients with autism in a child/adolescent psychiatric emergency setting through staff training to improve care for these patients. Methods: This presentation will cover autism-specific evaluation strategies and tools geared to a psychiatric emergency setting for children and adolescents. This evaluation, as well as behavioral interventions and staff trainings, part of a larger Autism Clinical Care Pathway, will be described in depth. Results: Knowledge of specific evaluation concepts and strategies can be extremely useful in a child/adolescent psychiatric emergency setting, both in terms of acquiring a better understanding of patients' immediate treatment needs and strategies for behaviorally managing this population. Multidisciplinary staff training on the basics of autism, behavioral management, and staff collaboration is an important part of promoting improved care for youth with autism in a psychiatric emergency service setting. Conclusions: Given the difficulties managing patients with autism in an emergency setting, specific evaluation procedures and behavioral interventions can be beneficial. Moreover, this information can be conveyed through staff training in a way that is feasible and promotes safety
EMBASE:613991193
ISSN: 1527-5418
CID: 2401632
Improving emergency department care for youth with autism spectrum disorder [Meeting Abstract]
Gerson, R
Objectives: Youth with ASD experience complex psychiatric symptoms and medical comorbidities that often lead them and their families to seek care in the emergency department (ED). Yet EDs, including both general medical and pediatric EDs and psychiatric-specific emergency settings, are often poorly equipped to care for youth with autism. Enhanced interdisciplinary collaboration, use of care pathways to address communication and sensory needs, and more comprehensive evaluation can improve both the patient's experience in the ED and the quality of care received. Methods: Speakers will present the following three models for improving collaborative, interdisciplinary care for youth with ASD in different emergency settings: 1) a regional program to improve care for youth with ASD in a network of general hospital EDs; 2) an autism care pathway in a pediatric ED setting; and 3) an autism care pathway in a psychiatric ED setting. Finally, financial and administrative barriers to enhanced care for youth with autism in the ED will be discussed, along with the ways that these barriers can be addressed on an individual institution level and policy level. Results: Participants will gain exposure to models of enhanced care for youth with autism and strategies to implement such models of care. Conclusions: Given the rising prevalence of ASD, improving care for patients with ASD in our EDs is critical. Child psychiatrists can lead efforts to improve care to make a meaningful impact on the ED experience of youth with autism
EMBASE:613991173
ISSN: 1527-5418
CID: 2401652
Command hallucinations to harm self in a child with recurrent right temporal astrocytoma: a case report
Mazgaj, Robert; Gerson, Ruth; Khakoo, Yasmin; Petriccione, Mary; Haque, Sofia; Haddad, Fadi
PMID: 26403523
ISSN: 1099-1611
CID: 1786972
Evaluating and treating children with psychiatric complaints in the emergency department
Chapter by: Gerson, Ruth S; Haddad, Fadi
in: A case-based approach to emergency psychiatry by Maloy, Katherine [Eds]
New York, NY, US: Oxford University Press, 2016
pp. 112-120
ISBN: 978-0-19-025084-3
CID: 2523172