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]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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2 Responses

  1. If you have them on site a Child Life Specialist is often (along with parents of course) the MVP when it comes to assessing the autistic patient. I also never sedate until I’m certain I have only a single problem to deal with (abscess, laceration). Consider that “minor” procedures may be better performed with anesthesiology and surgery in the OR if it’s safer for the child.

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