Thomas H. Chun

Point-of-care ultrasonography by pediatric emergency medicine physicians

Emergency physicians have used point-of-care ultrasonography since the 1990s. Pediatric emergency medicine physicians have more recently adopted this technology. Point-of-care ultrasonography is used for various scenarios, particularly the evaluation of soft tissue infections or blunt abdominal trauma and procedural guidance. To date, there are no published statements from national organizations specifically for pediatric emergency physicians describing the incorporation of point-of-care ultrasonography into their practice. This document outlines how pediatric emergency departments may establish a formal point-of-care ultrasonography program. This task includes appointing leaders with expertise in point-of-care ultrasonography, effectively training and credentialing physicians in the department, and providing ongoing quality assurance reviews.

Effects of naltrexone on adolescent alcohol cue reactivity and sensitivity: an initial randomized trial

Adolescent alcohol use is associated with myriad adverse consequences and contributes to the leading causes of mortality among youth. Despite the magnitude of this public health problem, evidenced‐based treatment initiatives for alcohol use disorders in youth remain inadequate. Identifying promising pharmacological approaches may improve treatment options. Naltrexone is an opiate receptor antagonist that is efficacious for reducing drinking in adults by attenuating craving and the rewarding effects of alcohol. Implications of these findings for adolescents are unclear; however, given that randomized trials of naltrexone with youth are non‐existent. We conducted a randomized, double‐blinded, placebo‐controlled cross‐over study, comparing naltrexone (50 mg/daily) and placebo in 22 adolescent problem drinkers aged 15–19 years (M = 18.36, standard deviation = 0.95; 12 women). The primary outcome measures were alcohol use, subjective responses to alcohol consumption, and alcohol–cue‐elicited craving assessed in the natural environment using ecological momentary assessment methods, and craving and physiological reactivity assessed using standard alcohol cue reactivity procedures. Results showed that naltrexone reduced the likelihood of drinking and heavy drinking (Ps ≤ 0.03), blunted craving in the laboratory and in the natural environment (Ps ≤ 0.04), and altered subjective responses to alcohol consumption (Ps ≤ 0.01). Naltrexone was generally well tolerated by participants. This study provides the first experimentally controlled evidence that naltrexone reduces drinking and craving, and alters subjective responses to alcohol in a sample of adolescent problem drinkers, and suggests larger clinical trials with long‐term follow‐ups are warranted.

Policy statement - Consent for emergency medical services for children and adolescents

Parental consent generally is required for the medical evaluation and treatment of minor children. However, children and adolescents might require evaluation of and treatment for emergency medical conditions in situations in which a parent or legal guardian is not available to provide consent or conditions under which an adolescent patient might possess the legal authority to provide consent. In general, a medical screening examination and any medical care necessary and likely to prevent imminent and significant harm to the pediatric patient with an emergency medical condition should not be withheld or delayed because of problems obtaining consent. The purpose of this policy statement is to provide guidance in those situations in which parental consent is not readily available, in which parental consent is not necessary, or in which parental refusal of consent places a child at risk of significant harm.

Biobehavioral mechanisms of topiramate's effects on alcohol use: an investigation pairing laboratory and ecological momentary assessments

Topiramate reduces drinking, but little is known about the mechanisms that precipitate this effect. This double‐blind randomized placebo‐controlled study assessed the putative mechanisms by which topiramate reduces alcohol use among 96 adult non‐treatment‐seeking heavy drinkers in a laboratory‐based alcohol cue reactivity assessment and in the natural environment using ecological momentary assessment methods. Topiramate reduced the quantity of alcohol heavy drinkers consumed on drinking days and reduced craving while participants were drinking but did not affect craving outside of drinking episodes in either the laboratory or in the natural environment. Topiramate did not alter the stimulant or sedative effects of alcohol ingestion during the ascending limb of the blood alcohol curve. A direct test of putative mechanisms of action using multilevel structural equation mediation models showed that topiramate reduced drinking indirectly by blunting alcohol‐induced craving. These findings provide the first real‐time prospective evidence that topiramate reduces drinking by reducing alcohols priming effects on craving and highlight the importance of craving as an important treatment target of pharmacotherapy for alcoholism.

The Significance of Marijuana Use Among Alcohol-using Adolescent Emergency Department Patients

OBJECTIVES The objective was to determine if adolescents presenting to a pediatric emergency department (PED) for an alcohol-related event requiring medical care differ in terms of substance use, behavioral and mental health problems, peer relationships, and parental monitoring based on their history of marijuana use. METHODS This was a cross-sectional comparison of adolescents 13-17 years old, with evidence of recent alcohol use, presenting to a PED with a self-reported history of marijuana use. Assessment tools included the Adolescent Drinking Inventory, Adolescent Drinking Questionnaire, Young Adult Drinking and Driving Questionnaire, Center for Epidemiologic Studies Depression Scale, Behavioral Assessment System for Children, and Peer Substance Use and Tolerance of Substance Use Scale. RESULTS Compared to adolescents using alcohol only (AO), adolescents who use alcohol and marijuana (A+M) have higher rates of smoking (F = 23.62) and binge drinking (F = 11.56), consume more drinks per sitting (F = 9.03), have more externalizing behavior problems (F = 12.53), and report both greater peer tolerance of substance use (F = 12.99) and lower parental monitoring (F = 7.12). CONCLUSIONS Adolescents who use A+M report greater substance use and more risk factors for substance abuse than AO-using adolescents. Screening for a history of marijuana use may be important when treating adolescents presenting with an alcohol-related event. A+M co-use may identify a high-risk population, which may have important implications for ED clinicians in the care of these patients, providing parental guidance, and planning follow-up care.

Withholding or Termination of Resuscitation in Pediatric Out-of-Hospital Traumatic Cardiopulmonary Arrest

This multiorganizational literature review was undertaken to provide an evidence base for determining whether recommendations for out-of-hospital termination of resuscitation could be made for children who are victims of traumatic cardiopulmonary arrest. Although there is increasing acceptance of out-of-hospital termination of resuscitation for adult traumatic cardiopulmonary arrest when there is no expectation of a good outcome, children are routinely excluded from state termination-of-resuscitation protocols. The decision to withhold resuscitative efforts in a child under specific circumstances (decapitation or dependent lividity, rigor mortis, etc) is reasonable. If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary arrest, under the current status of limiting termination of resuscitation in the field to persons older than 18 years in most states, resuscitation should be initiated and continued until arrival to the appropriate facility. If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis on family-centered care because the evidence suggests that either death or a poor outcome is inevitable.

Alcohol-Related Visits to the Emergency Department by Injured Adolescents: A National Perspective

PURPOSE Alcohol use is a risk factor for injury in adolescents. Many injured adolescents require treatment in emergency departments (EDs). The present study was intended to explore this association between adolescent alcohol use and injury-related ED visits using the National Hospital Ambulatory Medical Care Survey (NHAMCS), a nationally representative probability sample of visits to EDs. METHODS This was a retrospective, cross-sectional study using data from NHAMCS for 2001 through 2004. ED visits by injured adolescents aged 13-20 years whose visits were determined by NHAMCS coders to be related to alcohol were compared with visits by those whose visits were determined not related to alcohol. Specific variables of interest included demographic and medical characteristics of visits. RESULTS Our analyses indicated that there were several visit-related characteristics that were associated with alcohol-related ED visits, including time of visit, type of health insurance, and geographic location of the ED. Similarly, there were a number of patient-related characteristics that were also associated with alcohol-related visits to the ED, including patient acuity and injury intentionality. CONCLUSIONS Our findings suggest that injured adolescents are more likely to present to the ED with an alcohol-related visit during the early hours of the morning, that the injury is more likely to be assault related and of higher acuity than non-alcohol-related visits. These findings suggest the ED as a potential site for alcohol prevention interventions with younger adolescents. However, these interventions will need to take into account when such adolescents will present to the ED and will need also to recognize that factors such as violence and aggression, in addition to alcohol use, may be important issues to address in the intervention.

Challenges of managing pediatric mental health crises in the emergency department

Children with mental health problems are increasingly being evaluated and treated in pediatric clinical settings. This article focuses on the epidemiology, evaluation, and management of the 2 most common pediatric mental health emergencies, suicidal and homicidal/aggressive patients, as well as the equally challenging population of children with autism or other developmental disabilities.

Point-of-Care Ultrasonography by Pediatric Emergency Physicians

Point-of-care ultrasonography is increasingly being used to facilitate accurate and timely diagnoses and to guide procedures. It is important for pediatric emergency physicians caring for patients in the emergency department to receive adequate and continued point-of-care ultrasonography training for those indications used in their practice setting. Emergency departments should have credentialing and quality assurance programs. Pediatric emergency medicine fellowships should provide appropriate training to physician trainees. Hospitals should provide privileges to physicians who demonstrate competency in point-of-care ultrasonography. Ongoing research will provide the necessary measures to define the optimal training and competency assessment standards. Requirements for credentialing and hospital privileges will vary and will be specific to individual departments and hospitals. As more physicians are trained and more research is completed, there should be one national standard for credentialing and privileging in point-of-care ultrasonography for pediatric emergency physicians.

Translation of alcohol screening and brief intervention guidelines to pediatric trauma centers.

BACKGROUND As part of the American College of Surgeons verification to be a Level 1 trauma center, centers are required to have the capacity to identify trauma patients with risky alcohol use and provide an intervention. Despite supporting scientific evidence and national policy statements encouraging alcohol Screening, Brief Intervention and Referral to Treatment (SBIRT), barriers still exist, which prevent the integration of SBIRT into clinical care. Study objectives of this multisite translational research study were to identify best practices for integrating SBIRT services into routine care for pediatric trauma patients, to measure changes in practice with adoption and implementation of a SBIRT policy, and to define barriers and opportunities for adoption and implementation of SBIRT services at pediatric trauma centers. METHODS This translational research study was conducted at seven US pediatric trauma centers during a 3-year period. Changes in SBIRT practice were measured through self-report and medical record review at three different study phases, namely, adoption, implementation, and maintenance phases. RESULTS According to medical record review, at baseline, 11% of eligible patients were screened and received a brief intervention (if necessary) across all sites. After completion of the SBIRT technical assistance activities, all seven participating trauma centers had effectively developed, adopted, and implemented SBIRT policies for injured adolescent inpatients. Furthermore, across all sites, 73% of eligible patients received SBIRT services after both the implementation and maintenance phases. Opportunities and barriers for successful integration were identified. CONCLUSION This model may serve as method for translating SBIRT services into practice within pediatric trauma centers. LEVEL OF EVIDENCE Therapeutic/prevention study, leve IV.