Autism

Autism

The Emergency Department is appealing to many of us because of the speed at which it occurs.  We evaluate rapidly.  We get results quickly (relatively anyway… often we get cranky because they aren’t rapid enough).  We make decisions expeditiously.  Our environment is loud and fast.  The chaos and cacophony can be appealing to many, but can also be terrifying to others.  Children with Autism, particularly, may not respond well to this environment and it is our job to adjust to them, otherwise everyone may end up having a bad day.

 

Autism: Basics

  • Autism is a “neurobehavioral disorder”
  • Affects children’s Social Communications and has Restricted Behaviors
    • Large spectrum of disordered behaviors
    • Social skills and behaviors can vary greatly between individuals.
      • Many prefer well defined daily routines.
      • Can lead to some being very anxious when placed in unfamiliar situations (like the ED)
    • Cognitive ability can range from severe delay to gifted.
  • Prevalence:
    • Most prevalent childhood neurodevelopmental disorder.
    • Increasing over the past several decades
      • Possibly due to awareness and altered definitions
    • Estimates range from 1 in 50 to 1 in 500

 

Autism in the ED

  • Often have concomitant medical conditions:
    • 79% of patients presenting to ED in one study had more multiple chronic medical conditions.
    • Abdominal Complaints
    • Seizure Disorders (prevalence of ~30% in one study)
    • Behavioral Problems 
  • Children with autism have demonstrated an increased risk for head, face, and neck injury. [McDermott, 2008]
  • There is evidence that children with Autism do not come to the ED frivolously. [Cohen-Silver, 2014]
    • 71% of visits were deemed to have higher triage acuity levels.
    • 15% presented for Neurologic Concerns and Seizures
    • 15-25% presented for Gastrointestinal issues
    • Dental issues are also another common reason for ED visits.
  • Time measures: [Cohen-Silver, 2014]
    • Patients with autism spent an average of 6 hours in the ED.
    • They were placed in rooms in 1 hour.
    • It took the provider almost 2 hours to do initial assessment.
    • These may be typical numbers for your ED… maybe even better… but for a child who does not do well with new environments and alterations to schedule, this can cause significant distress.

 

Autism: Some Basic Tips

  • Despite your desire to be expedient and quick, SLOW DOWN!
    • Your typical pace of evaluation may be, in fact, counterproductive.
    • Do not rush in and expect to examine the child.
    • Enter slowly. Approach only after understanding the dynamic well.
    • Taking your time early will potentially save time later.
  • Parents know the chid best!  Ask them!!
    • The parents’ input in how to approach, speak with, and examine the patient is extremely valuable!
    • Often they appreciate your understanding of this and will be very helpful to you!
    • Asking about what has worked well previously (from simple examinations to full sedations) will save everyone time and frustration.
      • I once cared for a child who was vigorously resisting examination of her laceration.  I asked the mother what we should do to try to calm the child.  Simply placing a band-aid on the child’s knee (which was not injured) was her signal that all was safe.  We would have never of thought of this and it calmed her immediately.  ALWAYS ASK FIRST!

  • Ask about stressors and triggers. [Shellenbarger, 2004]
    • Some items and issues that you may not perceive as being alarming, may be to the patient with autism.
    • Ask the family about this and try to eliminate and avoid them if possible.
    • If unable to eliminate or avoid, ask the family how they typically deal with them.
  • Ask what calms the child. [Shellenbarger, 2004]
    • Obviously, this can be very valuable.
  • Speak clearly and concisely.
    • Should do this more for all patients… and family and friends too.
    • Simple words work best.
  • Do not assume that poor eye contact indicates poor attention. [Shellenbarger, 2004]
    • The child may use different social cues and interactions.

 

Autism & Sedation

  • Again, first ask the parents what has worked best for their child!
    • Many will, unfortunately, already have had negative experiences with medicines.
    • No need repeating the mistakes of the past.
  • Know that children with neurodevelopmental disorders are at increased risk for airway compromise during sedations.
  • Some advocate for the use of:
    • Clonidine [Mehta, 2004]
      • Mean time to achieve sedation = 58 min; Recover = 105 min
      • May decrease BP and HR, but no instability seen.
    • Dexmedetomidine [Lubisch, 2009]
      • 7-fold greater affinity for alpha 2 vs alpha 1 receptors than clonidine.
      • Elimination 1/2-life of 2-3 hours.
      • Highly efficacious with good safety
      • It is costly.
  • No perfect solution…
    • Tailor the therapy to the individual and the specific situation.
    • Maybe a band-aid on the knee is all you will need.

 

References

Cohen-Silver JH1, Muskat B2, Ratnapalan S3. Autism in the emergency department. Clin Pediatr (Phila). 2014 Oct;53(12):1134-8. PMID: 25031320. [PubMed] [Read by QxMD]

McDermott S1, Zhou L, Mann J. Injury treatment among children with autism or pervasive developmental disorder. J Autism Dev Disord. 2008 Apr;38(4):626-33. PMID: 17690968. [PubMed] [Read by QxMD]

Mehta UC1, Patel I, Castello FV. EEG sedation for children with autism. J Dev Behav Pediatr. 2004 Apr;25(2):102-4. PMID: 15083132. [PubMed] [Read by QxMD]

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MEdIC Series | The Case of the Financial Fiasco – Expert Review and Curated Commentary

The Case of the Financial Fiasco has stimulated interesting  discussion over the past week. We are now proud to present to you the Curated Community Commentary and our two expert opinions. Thank-you again to all our experts and participants for contributing again this week to the ALiEM MEdIC series.

This follow-up post includes:

  • The responses of our experts, Dr. Gus Garmel and Dr. Edwin Leap
  • A summary of insights from the ALiEM community derived from the blog discussions
  • Freely downloadable PDF versions of the case and expert responses for use in continuing medical education activities
Expert Response 1: Dr. Gus Garmel
Expert Response 2: Dr. Edwin Leap
Community Commentary: Dr. Tamara McColl

MEdIC Series Case and Responses for Download

Download the case (143 kb PDF)

2.07 Mini

Author information

Eve Purdy, BHSc

Eve Purdy, BHSc

Medical student

Queen's University in Kingston, Ontario, Canada

Student editor at BoringEM.org

Founder of manuetcorde.org

The post MEdIC Series | The Case of the Financial Fiasco – Expert Review and Curated Commentary appeared first on ALiEM.

Red Hot Emergency Intubation

Making Emergency Intubation Safer

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The ideal emergency intubation should have first pass success, no desaturation (as far as possible) and minimal haemodynamic compromise as the result of the use of drugs or the trauma of laryngoscopy.

Training, procedural technique and standardisation of the process can all help with achieving safe intubation.

So, how do we SAFELY go from this:

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To this?

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Answer – Prioritise the Basics in the ED:

The Basics

Intubation Priority

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Use an Intubation Checklist

Here is the current Westmead Intubation Checklist which we have developed based on the ‘best of’ other checklists for local use.  A checklist should be ideally a team ‘event’, short, sharp and focus on key steps.  It should be part of training in a standardised approach to a team based procedure such as Rapid Sequence Intubation.  An intubation checklist can be omitted in patients in Cardiac Arrest but in the chaotic critically unwell patient it is if anything more important to avoid missing crucial steps.  Not everyone likes a checklist as it is “prescriptive” but we think it is a useful cognitive aid to help the team achieve success in this important emergency procedure:

2015 Airway Algorithm

Post Intubation Checklists are also available and can be useful to prevent the phenomenon of post intubation inertia.


Tasty Morsels of EM 045 – Parvovirus B19

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure.

Everyone knows the slapped cheek syndrome that runs in epidemics in kids. Hopefully you’ll be aware of the risk to pregant mothers with this infection.

There are however other complications that you need to know about that just might appear in your ED or in your FCEM

Arthralgia/arthritis

  • keep parvovirus in your differential for someone presenting with an acute poly arthritis, especially if there’s a recent flu like illness in the back ground
  • usually symmetric and in the small joints (something that might make you think rheumatoid but you probably shouldn’t head that direction until symptoms have been present for more than 6 weeks)
  • most will have a rash but in adults don’t expect the classic slapped cheek
  • should resolve within 3 weeks and there shouldn’t be any joint destruction

Transient Aplastic crisis

  • typically someone with some kind of haematologic problems eg sickle or iron def anaemia
  • the scenario you should think of this is when you get the FBC back and there an unexpected anaemia
  • usually it’s only red cells involved. If checked reticulocytes should be low

References:

  • UpToDate
  • Rosen’s 8th Chapter 116

[Featured image CC license, via Wikipedia]

 

The post Tasty Morsels of EM 045 – Parvovirus B19 appeared first on Emergency Medicine Ireland.

Nanoneedles Help Build New Blood Vessels

nanoneedles-for-angiogenesis

nanoneedles-microscope

Optical microscopy image of human cells (green) on the nanoneedles (orange). The nanoneedles have injected DNA into the cells’ nuclei (blue).

A team of scientists from Imperial College London and Houston Methodist Research Institute have developed a new technique that helps promote the growth of new blood vessels. This angiogenesis relies on a specially designed bed of porous nanoneedles loaded with nucleic acids. When cells are placed on top of this structure, the needles penetrate their membranes, delivering the nucleic acids into their nuclei, which in turn promotes rapid growth.

The silicon needles actually remain within the cells, degrading within days without a trace, save for a bit of harmless orthosilicic acid. The team tested the new technology on human cells and on living mice, delivering the nucleic acids into their back muscles. A week following treatment, the muscles that were subject to the loaded nanoneedles showed a six-fold increase in angiogenesis that continued to generate another week later. Notably, there was no apparent increase in inflammation or any other noticeable side effects.

The researchers are looking at moving this technology forward to help repair damaged tissues, as well as in aiding with organ transplants.

Source: Imperial College London…

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Episode 26 – The Spinal Cord

(ITUNES OR Listen Here) The Free Open Access Medical Education (FOAM) In January 2015, ACEP recommended against the use of long backboards by EMS, “Backboards should not be used as a therapeutic intervention or as a precautionary measure either inside or outside the hospital or for inter-facility transfers.” We review the use of longboards and cervical […]