What We Still Do Not Know About Pediatric Mental Health Emergencies: PECARN Research Agenda

Adolescent sitting on an emergency department bed seen from behind, with a caregiver and clinician nearby in a calm, dimly lit room

Article reviewed: Hoffmann JA, Foster AA, Krass P, et al. A research agenda for acute pediatric mental and behavioral health emergencies. Ann Emerg Med. Published online July 10, 2026
DOI: 10.1016/j.annemergmed.2026.05.015 | PubMed: PMID 42429726

Every emergency physician knows these moments. A 10-year-old with autism is escalating in a hallway bed, and nobody can say which de-escalation approach or which medication is safest for him. A 15-year-old is boarding for a third night after a suicide attempt, receiving no active treatment while she waits for a psychiatric bed. A charge nurse asks whether universal suicide screening is worth the workflow disruption. These are routine clinical decisions, and for most of them the pediatric evidence simply does not exist.

A new consensus statement from the PECARN Mental Health Working Group, A Research Agenda for Acute Pediatric Mental and Behavioral Health Emergencies, published in Annals of Emergency Medicine, maps where those evidence gaps are and which ones matter most [1]. The panel reached consensus on 51 research priorities, 31 of them top tier. Read as a whole, the agenda is an unusually honest inventory of how much of current pediatric behavioral health emergency care runs on extrapolation and local habit.

Background

One in 6 US children has a mental or behavioral health condition, and nearly half receive no treatment from a mental health professional [2]. The ED has become the de facto safety net: visits for self-harm and harm to others have risen substantially over the past decade, boarding times have stretched, and in 2021 the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association jointly declared a national emergency in child and adolescent mental health [3]. What has not kept pace is the evidence for what emergency clinicians should actually do during these visits.

How the Agenda Was Built

The working group used a modified Delphi process with 23 expert partners: 4 parents and 1 young adult with lived experience of pediatric mental health emergency care, general and pediatric emergency physicians, emergency nurses, child and adolescent psychiatrists with emergency expertise, ED social workers, out-of-hospital and EMS-fellowship-trained clinicians, and a research funder. Across 3 survey rounds, 76 literature-informed candidate priorities were modified, expanded, and rated on need and urgency, research impact, and family centeredness. The prespecified retention criteria required agreement from both the family representative group and the clinician and funder group, so family voices could not be outvoted. The result: 51 consensus priorities sorted into 3 tiers.

Where the Gaps Are

Suicide prevention dominates

Suicide prevention questions account for 42% of the top tier. The panel wants to know which suicide risk screening tool best predicts real outcomes such as return visits, attempts, and deaths, including in neurodivergent children and non-English speakers; what universal screening does to those outcomes; and whether safety planning, with or without structured follow-up calls, actually increases mental health follow-up and reduces future attempts in youth. The contrast with adult evidence is striking. In adults, the multicenter ED-SAFE trial showed that universal screening plus a brief intervention reduced post-discharge suicidal behavior [4]. The pediatric equivalent has never been done. The panel also prioritized a practical lethal-means question: which safety devices, from medication lock boxes to firearm safes, do caregivers actually prefer and use after the ED visit?

Agitation: everything is still an open question

Which de-escalation methods best reduce medication use, restraint use, and staff injuries, and how does that differ by age, developmental stage, culture, language, and trauma history? Which medications are safest and most effective, for which children? What works for children with neurodevelopmental disorders such as autism spectrum disorder, who face a higher risk of pharmacologic and physical restraint? None of these have comparative evidence today, even though documented racial disparities in restraint application make the stakes plain [1].

Boarding and ED care

Top-tier questions include whether brief therapy delivered in the ED during boarding improves symptoms, shortens length of stay, and lowers admission rates, and whether home-based care is a safe and acceptable alternative to hospitalization. The panel also flagged care in rural and low-resource EDs, where most of these children are actually seen.

Before and after the ED

Out-of-hospital priorities center on training first responders in de-escalation and trauma-informed care and on testing novel response models, including mental health co-response teams and alternative destinations. A single-county pilot of direct EMS transport to a psychiatric emergency facility found that roughly 2 in 5 encounters met criteria for direct transport, with only 0.5% requiring secondary ED transfer within 24 hours [5]. On the back end, the agenda targets the high-risk post-discharge window: what actually gets youth to mental health care after they leave, and whether stepped-care models using telehealth reduce return visits and future attempts.

Clinical Implications

Nothing in a research agenda changes tomorrow’s orders, and this post will not pretend otherwise. The value for a practicing clinician is different. First, the agenda names how thin the floor is under common practices: medication choice for acute agitation in children, for example, is largely extrapolated from adult psychiatry. Knowing where evidence is absent should make us slower to treat local protocol as settled science. Second, this document signals where PECARN and federal funders will direct pediatric emergency mental health research over the next 5 to 10 years, which is useful for anyone building a QI program, a research career, or a departmental protocol they would prefer not to rewrite twice. Third, the top-tier questions double as an audit checklist: if your ED cannot say how often it restrains children, whether safety planning happens before discharge, or what its mental health boarding times are, the agenda is a reasonable place to start measuring.

One limitation deserves mention because the authors themselves flag it: no expert partners identified as Black or Hispanic, a notable gap given the documented racial disparities in restraint use and in behavioral health triage that PECARN’s own work has described.

Bottom Line

PECARN’s consensus research agenda distills the pediatric mental and behavioral health emergency evidence gap into 51 prioritized questions, with suicide prevention accounting for 42% of the top tier. It will not change your practice today. It tells you something more uncomfortable and more useful: for most of what we do during pediatric behavioral health visits, from de-escalation to safety planning to boarding care, the evidence base has not been written yet, and this is the field’s official to-do list for writing it.

References

Hoffmann JA, Foster AA, Krass P, et al. A research agenda for acute pediatric mental and behavioral health emergencies. Ann Emerg Med. Published online July 10, 2026. PMID: 42429726. doi:10.1016/j.annemergmed.2026.05.015
Bitsko RH, Claussen AH, Lichstein J, et al. Mental health surveillance among children – United States, 2013-2019. MMWR Suppl. 2022;71(2):1-42. PMID: 35202359. doi:10.15585/mmwr.su7102a1
American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, Children’s Hospital Association. AAP-AACAP-CHA declaration of a national emergency in child and adolescent mental health. 2021.
Miller IW, Camargo CA Jr, Arias SA, et al. Suicide prevention in an emergency department population: the ED-SAFE study. JAMA Psychiatry. 2017;74(6):563-570. PMID: 28456130. doi:10.1001/jamapsychiatry.2017.0678
Glomb NW, Trivedi T, Grupp-Phelan J, et al. Safety of a prehospital emergency medical services protocol for an alternative destination for pediatric behavioral emergencies in Alameda County. J Am Coll Emerg Physicians Open. 2023;4(2):e12930. PMID: 37051504. doi:10.1002/emp2.12930

By Michelle Lin, MD|2026-07-13T03:11:42-07:00Jul 13, 2026|Pediatrics, Psychiatry|

Who Gets Mistriaged? Disparities in Pediatric Behavioral Health ED Triage | A PECARN multicenter analysis

mistriaging of pediatric mental health conditions with ESI
A 14-year-old Hispanic girl presents to the Emergency Department with her mother for suicidal ideation after a conflict at home. The girl is quiet and cooperative. Her mother, who speaks primarily Spanish, is trying to explain the situation. The nurse assigns an ESI level 2, the same score given to nearly every child who walks through the door with a behavioral health complaint. But does that score accurately capture this patient’s needs?

A new multicenter PECARN study published this week in JAMA Network Open takes a close look at triage accuracy for pediatric behavioral health ED visits. The findings: mistriaging errors are common, and they are not equally distributed [1].

Hoffmann et al. analyzed 78,411 ED visits by children aged 5 to 17 with behavioral health chief concerns across 15 PECARN Registry EDs from 2021 to 2023 [1]. They classified each visit as appropriately triaged, overtriaged, or undertriaged using vital signs, Glasgow Coma Scale, pain scores, emergency medication use, resource utilization, and disposition. Of the 74,564 visits with complete data:

57% were overtriaged
34% were appropriately triaged
8.5% were undertriaged

How ESI Handles Behavioral Health

The Emergency Severity Index (ESI) is used in over 90% of US EDs [2]. It sorts patients into 5 acuity levels. Level 1 is for patients needing lifesaving interventions. Level 2 is for high-risk situations, confused patients, or those in severe pain. Levels 3 through 5 are based on anticipated resource needs. In this study, 83.5% of all behavioral health visits were triaged as ESI level 2.

To assess triage accuracy, the authors compared each child’s assigned ESI level against what actually happened during their visit.

Overtriage

Overtriage means a child was assigned a higher acuity score than their clinical course supported. For a child assigned ESI level 2, overtriage was defined as meeting ALL of the following [1]:

Stable vital signs within 2 hours of arrival (heart rate and respiratory rate not high risk for age, SpO2 ≥93% or not recorded)
Pain score <7 (or not recorded)
GCS of 15 (or not recorded)
No emergency medications during the visit

In other words, the triage nurse predicted high acuity, but the visit didn’t bear that out.

Undertriage

Undertriage means the opposite: a child was assigned a lower acuity score than their clinical course warranted. For example, a child triaged as ESI level 4 (expected to need 1 resource) who ended up being admitted, needing emergency medications, or using multiple resources. The triage nurse underestimated how sick the child was or how much care they would need.

Undertriage Disproportionately Affects Minority Children and Spanish-Speaking Families

The most concerning equity finding was in undertriage.

After adjusting for clinical and visit characteristics, undertriage was significantly more likely for Hispanic children (AOR 1.46), non-Hispanic Black children (AOR 1.28), and children whose families preferred Spanish (AOR 1.31), all compared to non-Hispanic White and English-speaking patients [1]. The authors point to implicit clinician bias, systemic racism, and underutilization of professional interpreters as likely contributors.

The safety implications are real. Children whose acuity is underestimated may face longer waits, miss time-sensitive interventions, or leave the ED without being seen despite elevated risk.

Overtriage Was Common

More than half of all visits (57%) were overtriaged [1]. These children received a higher acuity triage score than their clinical course supported.

The strongest predictor was age. Children aged 5-9 had over 4-fold higher adjusted odds of overtriage compared to those aged 10-14 (AOR 4.43), possibly because younger children have a limited ability to communicate their symptoms and needs.

To a lesser degree, non-Hispanic Black children also had higher adjusted odds of overtriage compared to non-Hispanic White children (AOR 1.17). The authors cite research on adultification, the tendency to perceive Black youth as older or more threatening than they are, as a potential contributor. This means Black children in this study were more likely to be both undertriaged and overtriaged compared to White children. The errors are not unidirectional. They likely reflect different biases operating at different points in care.

Take Home Points

The ESI has limited ability to differentiate pediatric behavioral health presentations. In this study, 83.5% of behavioral health visits were triaged as ESI level 2.
UNDERTRIAGE was more likely for Hispanic children (AOR 1.46), non-Hispanic Black children (AOR 1.28), and Spanish-speaking families (AOR 1.31), raising concerns about missed acuity in these groups.
OVERTRIAGE occurred in 57% of visits, driven most strongly by younger age (AOR 4.43 for ages 5 to 9) and to a lesser degree by non-Hispanic Black race (AOR 1.17).

References

Hoffmann JA, Foster AA, Rojas CR, et al. Overtriage and undertriage of children presenting to the emergency department for behavioral health. JAMA Netw Open. 2026;9(3):e263042. Full text
McHugh M, Tanabe P, McClelland M, Khare RK. More patients are triaged using the Emergency Severity Index than any other triage acuity system in the United States. Acad Emerg Med. 2012;19(1):106-109. doi:10.1111/j.1553-2712.2011.01240.x

By Michelle Lin, MD|2026-03-28T19:43:20-07:00Mar 28, 2026|Pediatrics, Psychiatry|

SAEM Clinical Images Series: When Needles Go Beyond Sewing and Acupuncture

needles

A 64-year-old male with a history of bipolar 1 disorder, PTSD, anxiety, depression, obsessive-compulsive disorder, GERD, and HTN presented to the ED with the chief complaint of foreign body and self-injury. He reported years of sticking sewing needles into his right arm, most recently yesterday. He explained that inserting needles makes him feel better with mild associated pain. He endorsed suicidal ideas, elaborating that he did not want to stop injuring himself. He also reported depression and wished that he was not alive. He stated that he had told his therapist that he didn’t want to present to the ED today and added that he wanted to leave the ED and did not want to be seen by the psych team. He denied homicidal ideation.

Additional Images

Physical Exam

Extremities: When palpating the right forearm, multiple linear hard objects are felt in the subcutaneous tissue. The patient can flex/extend the wrist, supinate and pronate, and flex/extend the elbow without issue. No erythema or fluctuance. No obvious insertion site noted.

Laboratory Data

None

Case Question: Identify the abnormality on the 2-view forearm x-ray.

Numerous linear metallic foreign bodies are present throughout the right forearm; several new foreign bodies are noted. Bony exam is significantly limited due to the presence of numerous (greater than 50) linear metallic densities throughout the forearm. Mild to moderate degenerative changes of the wrist and elbow are noted.

Case Discussion

Take-Home Points

Removal of metallic foreign bodies is an individualized risk vs benefit decision based on the following: signs of infection, suspected level of contamination, type of metal, cooperativeness of the patient, location nearby vital structures, cosmetic deformity, and pain. When the risk of removal outweighs the benefits or if the patient does not desire removal, foreign body removal is not always needed.
Regarding prophylaxis, antibiotics need not be routinely administered if the wound is clean. Tetanus vaccination status should be reviewed, and the vaccine (Tdap) and/or potentially tetanus immune globulin should be administered if indicated.

References

Rupert J, Honeycutt JD, Odom MR. Foreign Bodies in the Skin: Evaluation and Management. Am Fam Physician. 2020 Jun 15;101(12):740-747. PMID: 32538598.
Lane JC, Mabvuure NT, Hindocha S, Khan W. Current concepts of prophylactic antibiotics in trauma: a review. Open Orthop J. 2012;6:511-7. doi: 10.2174/1874325001206010511. Epub 2012 Nov 30. PMID: 23248721; PMCID: PMC3522105.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By Winston Wu, MD|2024-10-15T10:59:39-07:00Oct 25, 2024|Psychiatry, Radiology, SAEM Clinical Images|

Welcome to the AIR Psychosocial Module! After carefully reviewing all relevant posts in the past 12 months from the top 50 sites of the Digital Impact Factor [1], the ALiEM AIR Team is proud to present the highest quality online content related to related to psychosocial emergencies in the Emergency Department. 3 blog posts met our standard of online excellence and were approved for residency training by the AIR Series Board. More specifically, we identified 1 AIR and 2 Honorable Mentions. We recommend programs give 1 hours of III credit for this module.

AIR Stamp of Approval and Honorable Mentions

In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR stamp of approval is awarded only to posts scoring above a strict scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.

Take the AIR Psychosocial Module at ALiEMU

Interested in taking the AIR quiz for fun or asynchronous (Individualized Interactive Instruction) credit? Please go to the above link. You will need to create a free, 1-time login account.

Highlighted Quality Posts: Psychosocial

Site	Article	Author	Date	Label
Rebel EM	Low Dose vs Standard Dose Take-Home Buprenorphine From the ED	Tara Persaud Holmes, MD, MBA	5 June 2023	AIR
Don’t Forget the Bubbles	Medical Emergencies in Eating Disorders	Owen Hibberd, Kat Priddis	29 Sep 2023	HM
RCEM Learning	Acute Dystonia	Esther Wilson	12 Aug 2023	HM

(AIR = Approved Instructional Resource; HM = Honorable Mention)

If you have any questions or comments on the AIR series, or this AIR module, please contact us!

Lin M, Phipps M, Chan TM, et al. Digital Impact Factor: A Quality Index for Educational Blogs and Podcasts in Emergency Medicine and Critical Care. Ann Emerg Med. 2023;82(1):55-65. doi:10.1016/j.annemergmed.2023.02.011, PMID 36967275

By Chris Belcher, MD|2024-04-30T10:28:32-07:00May 8, 2024|Approved Instructional Resources (AIR series), Psychiatry|

Background

Acute agitation in the emergency department is a common issue that frequently requires the use of chemical sedation to preserve safety for patients and healthcare workers. A commonly employed treatment regimen is the combination of haloperidol 5 mg + lorazepam 2 mg + diphenhydramine 50 mg (B-52). Diphenhydramine is included in this treatment regimen primarily to prevent extrapyramidal symptoms [1,2]. However, the incidence of extrapyramidal symptoms (EPS) with haloperidol is quite low when treating agitation in the emergency department (ED) [3,4]. Therefore, the excessive and prolonged sedation from adding prophylactic diphenhydramine may outweigh the intended benefit and should be reserved for treatment of EPS if symptoms occur.

Evidence

Jeffers et al. conducted a multicenter, retrospective, cohort study which compared the efficacy and safety of haloperidol, lorazepam, and diphenhydramine (B-52) (n=200) vs. haloperidol and lorazepam (52) (n=200) in treating patients >18 years old with acute agitation in the ED [5]. Their primary outcome was the administration of additional agitation medication(s) within 2 hours.

Outcomes	52 (n=200)	B52 (n=200)	p-Value
Administration of additional sedative within 2 h, n (%)	40 (20)	28 (14)	0.11
Median ED LOS (hours)	13.8	17	0.03
Use of restraints, n (%)	53 (26.5)	86 (43)	0.001
Hypotension, n (%)	7 (3.5)	32 (16)	<0.001
Administration of anticholinergic within 2 days, n (%)	15 (7.5%)	6 (3%)	0.04
Itching/allergies, n (%)	1 (0.5)	1 (0.5)	1.00
Home benztropine, n (%)	2 (1)	4 (2)	0.41
Insomnia, n (%)	4 (2)	0 (0)	0.06
Unknown, n (%)	8 (4)	1 (0.5)	0.02

Overall, the B-52 combination resulted in more oxygen desaturation, hypotension, physical restraint use, and longer length of stay. However, the conclusions from this study may be limited as it was a relatively small study and it used surrogate markers to assess clinical endpoints.

Further discussion regarding the onset and duration of IM medications for acute agitation may be found in this blog post.

Bottom Line

The risk of extrapyramidal symptoms following haloperidol for agitation in the ED is relatively low
Diphenhydramine may not be necessary when using haloperidol + lorazepam to treat agitation in the ED
ED length of stay is increased with the addition of diphenhydramine to haloperidol + lorazepam

Want to learn more about EM Pharmacology?

Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site.

References

Mokhtari A, Yip O, Alain J, Berthelot S. Prophylactic administration of diphenhydramine to reduce neuroleptic side effects in the acute care setting: a systematic review and meta-analysis. J Emerg Med. 2021 Feb;60(2):165–74. doi: 10.1016/j.jemermed.2020.09.031. PMID: 33131965.
Vinson DR, Drotts DL. Diphenhydramine for the prevention of akathisia induced by prochlorperazine: a randomized, controlled trial. Ann Emerg Med. 2001 Feb;37(2):125–31. doi: 10.1067/mem.2001.113032. PMID: 11174228.
Klein LR, Driver BE, Miner JR, Martel ML, Hessel M, Collins JD, et al. Intramuscular midazolam, olanzapine, ziprasidone, or haloperidol for treating acute agitation in the emergency department. Ann Emerg Med. 2018 Oct;72(4):374–85. doi: 10.1016/j.annemergmed.2018.04.027. PMID: 29885904.
Schneider A, Mullinax S, Hall N, Acheson A, Oliveto AH, Wilson MP. Intramuscular medication for treatment of agitation in the emergency department: A systematic review of controlled trials. Am J Emerg Med. 2021 Aug;46:193–9. doi: 10.1016/j.ajem.2020.07.013. PMID: 33071100.
Jeffers T, Darling B, Edwards C, Vadiei N. Efficacy of combination haloperidol, lorazepam, and diphenhydramine vs. Combination haloperidol and lorazepam in the treatment of acute agitation: a multicenter retrospective cohort study. J Emerg Med. 2022 Mar 11;S0736-4679(22)00057-9. doi: 10.1016/j.jemermed.2022.01.009. PMID: 35287982.

By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2022-04-09T10:15:43-07:00Apr 16, 2022|EM Pharmacy Pearls, Psychiatry, Tox & Medications|

Human Trafficking in the ED – What you need to know

Human trafficking is a devastating crime, where a human being’s labor is exploited through force, fraud, or coercion, for someone else’s profit (1). For survivors, connecting to support in the community can be incredibly difficult, and may come at the expense of their personal safety (1, 2).

The emergency department (ED) is a rare exception, with some studies estimating that over 60% of trafficked persons will present at some point during their exploitation to the ED (3). Unfortunately, less than 5% of emergency physicians report feeling confident in their ability to identify a trafficked person, citing confusion around patient characteristics and their role as a provider (4).

By learning more about human trafficking, ED providers can better prepare themselves to identify and provide appropriate support to those who experience human trafficking.

What can I do to be ready in the ED?

Understand what human trafficking is and its consequences
Recognize personal bias
Become familiar with how to identify, assess, document, and refer cases of human trafficking
Know your options for survivor advocacy

Click to view full-size image.

Just the Facts – Human Trafficking

What is Human Trafficking?

Human trafficking always involves 3 components –an act, a means, and a purpose.

The “act” refers to the role a trafficker is playing in exploiting the person
The “means” refers to the use of force, fraud, or coercion to exploit a person
The “purpose” is what type of labor they are exploited for (1)

Often human trafficking will overlap with other crimes such as assault, domestic violence, rape, and child abuse (5). Of note, anyone under the age of 18 engaged in commercial sex is considered to be sex trafficked regardless of whether a means is present, as they cannot provide consent.

How many people are affected?

Human trafficking is widespread, but is often undetected, making true estimates of size difficult.

For example, human trafficking prevalence estimates may fail to account for survivors who do not recognize they are being exploited or are afraid to disclose (6, 7).

Who is trafficked?

While no identity is spared, there are certain populations that are at greater risk. These may include:

People of color
Children in welfare and juvenile justice systems
Runaway and homeless youth
Children working in agriculture
Indigenous patients
Migrant laborers
Foreign national domestic workers
Patients with limited English
Patients with disabilities
Members of the LGBTQ community
Patients with limited education
Patients who use substances (6,8)

Why are they targeted?

The only thing all trafficked persons have in common is their vulnerability (1). Trafficking determinants can be conceptualized as “push” and “pull” factors. Push factors lead people to away from their current situation to trafficking (e.g., abuse, poverty, family conflict). Pull factors, drive an individual to something new that increases the risk of trafficking (e.g., income, housing, access to substances) (9, 10).

Who are the traffickers?

In the same way that anyone can be trafficked, anyone can be a trafficker.

Traffickers may be well known in the community, recruiting victims from places of employment or education (1). They may be a family member. They may also lure at-risk individuals by acting as a romantic partner, or by providing emotional affirmation, financial assistance, and material goods (1).

How do traffickers coerce survivors?

A number of tactics can be employed by traffickers, each tailored to the individual survivor but can include any combination of the following (1).

Physical violence
Sexual violence
Emotional violence
Withholding basic needs (food, water, shelter)
Intimidation
Coercion and threats
Economic coercion
Social isolation

Specific situations to be wary of:

Runaway or homeless youth – greater incidence of “survival sex,” where sexual acts are exchanged for basic necessities (1, 11)
Recent immigrants – withholding documentation/ fear of deportation are used as powerful coercion tactic (1, 5, 6)

What are some of the health consequences of Human Trafficking (6)?

Physical abuse (traumatic injury, chronic pain)
Sexual abuse (sexually transmitted infections, pregnancy)
Emotional abuse (post-traumatic stress disorder, suicide ideation)
Poor living conditions (malnutrition, dehydration, exposure injuries)
Substance use, overdose
Death

10 Common Misconceptions of Human Trafficking

Click to view full-size images

Guide for Emergency Department Providers

What are the primary goals of an ED visit with a potentially trafficked patient?

Address the acute presenting illness or injury
Establish the ED as a haven from trauma or exploitation
Offer additional resources, if appropriate and available

The goal of the visit is NOT to elicit a disclosure.

Your role as a provider is not to investigate or confirm the presence of trafficking, but to respect the autonomy of the patient in front of you, meet their healthcare needs, and empower them to seek additional support on their terms.

What steps should I take during my encounter?

Capitalize on the same “trauma-informed” principles used to care for survivors of intimate partner violence and child maltreatment.
Encounter tips (1, 6, 12)
- Separate the potential victim from accompanying persons
If difficult, ask the patient to move to another room for an x-ray or routine test.
- Use a trained interpreter when required
- Foster trust and establish rapport
- Use education about rights and resources as an empowerment tool (12)
Providing nonjudgmental education around violence and safety can normalize the sharing of information and open discussion (12)
- Be patient
- Always get consent before proceeding with any next steps (physical exam, diagnostic tests, and involvement of other providers)

Click for full-size images

Red flags For Human Trafficking (1, 13)

Patient Indicators	Companion Indicators
Delayed presentation	Refuses to leave
Discrepancy between history and clinical presentation	Insists on translating or speaking for the patient
Scripted/memorized history	Controlling, interrupting
Hypervigilance, fearful	Has patient’s documents in their possession
Cannot produce identification	Employer demanding access to medical information
Work-related injury with unsafe conditions
Fearful attachment to a cell phone (often used for communication and tracking)

Red flags for pediatric patients (1, 14)

Accompanied by unrelated, non-guardian adults
Material possessions you reasonably doubt they would be able to afford
Truancy or running away
Multiple sexual “partners”

What are the next steps after my assessment?

Any next steps should always be determined by the patient

Referrals (social work, case manager or discharge specialist, local advocacy services) (6, 15)
Human Trafficking Hotline
- USA – National Human Trafficking Hotline at 1-888-373-7888
- Canada – Canadian Human Trafficking Hotline at 1-833-900-1010

Consider offering admission if unsafe to discharge
Clear and accurate documentation (may be relevant to future legal proceedings)
Consider notifying security if appropriate (6)

Unless local criteria for mandatory reporting are met, Police should only be contacted at the explicit instruction of the patient (6, 16).

Interested in advocacy?

Consider implementing an ED and institutional protocol for human trafficking. A complete protocol guide is available through HEAL Trafficking.

References

Alpert EJ, Ahn R, Albright E et al. Human Trafficking: Guidebook on Identification, Assessment, and Response in a Healthcare Setting. Boston, MA: MGH Human Trafficking Initiative, Division of Global Health and Human Rights, Department of Emergency Medicine.
Human Trafficking. Public Safety Canada, Government of Canada. 2019.
Lederer L, Wetzel C. The Health Consequences of Sex Trafficking and Their Implications for Identifying Victims in Healthcare Facilities. Ann Heal Law. 2013;23(1):61–91.
Viergever RF, West H, Borland R, Zimmerman C. Health care providers and human trafficking: What do they know, what do they need to know? Findings from the Middle East, the Caribbean, and Central America. Front Public Heal. 2015;3:1–9. PMID: 25688343
Canada’s Human Trafficking Laws. British Columbia Public Health Agency. 2014.
Shandro J, Chisolm-Straker M, Duber HC, Findlay SL, Munoz J, Schmitz G, et al. Human Trafficking: A Guide to Identification and Approach for the Emergency Physician. Ann Emerg Med. 2016;68(4):501-508.e1. PMID: 27130802
Global Report on Trafficking in Persons [Internet]. New York; 2014. Available from: https://www.unodc.org/res/cld/bibliography/global-report-on-trafficking-in-persons_html/GLOTIP_2014_full_report.pdf
2021 Trafficking in Persons Report – United States Department of State [Internet]. U.S. Department of State; 2021. Available from: https://www.state.gov/reports/2021-trafficking-in-persons-report/
Macias Konstantopoulos W, Ahn R, Alpert EJ, Cafferty E, McGahan A, Williams TP, et al. An international comparative public health analysis of sex trafficking of women and girls in eight cities: Achieving a more effective health sector response. J Urban Health. 2013. PMID: 24151086
Calhoun C. Push and pull factors. Oxford Dictionary. Soc Sci Oxford Univ Press. 2002;
Walls NE, Bell S. Correlates of engaging in survival sex among homeless youth and young adults. J Sex Res. 2011. PMID: 20799134
PEARR Tool Trauma-Informed Approach to Victim Assistance in Health Care Settings. Dignity Health, in partnership with HEAL Trafficking and Pacific Survivor Center. 2019.
Identifying Victims of Human Trafficking: What to look for in a healthcare setting. National Human Trafficking Resource Center. The Polaris Project.
Tracy EE, Konstantopoulos WMI. Human trafficking: A call for heightened awareness and advocacy by obstetrician-gynecologists. Obstet Gynecol. 2012. PMID: 22525917
Meshkovska B, Siegel M, Stutterheim SE, Bos AER. Female sex trafficking: Conceptual issues, current debates, and future directions. J Sex Res. 2015. PMID: 25897567
Zimmerman C BR. Caring for Trafficked Persons: Guidance for Health Providers. Health Providers. Geneva, Switzerland: International Organization for Migration. 2009.

By Hanni Stoklosa, MD, MPH|2026-06-16T16:17:55-07:00Jan 29, 2022|Emergency Medicine, Expert Peer Review (Non-Clinical), Psychiatry|

Does the Combination of Parenteral Olanzapine with Benzodiazepines for Agitation in the ED Increase the Risk of Adverse Events?

A previous EM Pharm Pearl focused on the adverse events associated with the use of IV olanzapine for agitation. This pearl addresses concerns around using parenteral (IV or IM) olanzapine with parenteral benzodiazepines.

Background

Olanzapine has two FDA boxed warnings, one for increased mortality when used long-term in older adults with dementia-related psychosis and another pertaining to adverse effects of extended release IM olanzapine. However, there exists a potential risk of excess sedation and respiratory depression when IM/IV olanzapine is administered with parenteral benzodiazepines for agitation. The European Medicines Agency recommends separating the administration of IM/IV olanzapine and parenteral benzodiazepines by at least 60 minutes. The FDA does not have a specific recommendation regarding separation of the 2 medications, but cautions against co-administration citing a lack of data. Currently, IM olanzapine is the only second generation antipsychotic with a precaution listed in its FDA prescribing information. This advisory is the result of 160 post-marketing adverse events, including 29 fatalities, associated with IM olanzapine [1].

Literature

When the above cases submitted to the FDA are thoroughly investigated, the problem appears to be related to polypharmacy rather than an olanzapine/benzodiazepines alone [2, 3]. This FOAMcast podcast provides an excellent summary of the data (Table 1). Additionally, the timing of fatalities after the last dose of olanzapine is prolonged in many cases (Table 2) and many of the causes of death are unattributable to olanzapine [1]. Several ED studies have used IV/IM olanzapine in combination with parenteral benzodiazepines to treat agitated patients without an increased signal of airway compromise [4-6].

Table 1: Summary of Fatalities Associated with Olanzapine (n=29)
Olanzapine Alone	Olanzapine + Benzodiazepines	Olanzapine + Benzodiazepines + Other Medications
3/29	1/29	25/29

Table 1: Summary of Fatalities Associated with Olanzapine (n=29)

Olanzapine Alone

Olanzapine

+ Benzodiazepines

Olanzapine

+ Benzodiazepines

+ Other Medications

3/29

1/29

25/29

_{Adapted from FOAMcast podcast: Olanzapine + Benzodiazepines – What is the FDA warning about? [1]}

Table 2: Timing of Fatalities Following Last Olanzapine Dose (n=29)
≤ 1 hour	1-12 hours	12-24 hours	> 24 hours	Unknown
3/29	4/29	8/29	11/29	3/29

_{Marder [1]}

Bottom Line

Separating IV/IM olanzapine from parenteral benzodiazepines by 60 minutes is likely a safe practice, if co-administration of these medications is necessary or desired to treat agitated patients. Patients with ethanol on board are at a higher risk of adverse events [7, 8]. Monitoring should be commensurate with the patient situation and medication(s) chosen.

Want to learn more about EM Pharmacology?

Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site.

References

Marder SR, Sorsaburu S, Dunayevich E, et al. Case reports of postmarketing adverse event experiences with olanzapine intramuscular treatment in patients with agitation. J Clin Psychiatry. 2010;71(4):433-441. doi: 10.4088/JCP.08m04411gry. PMID: 20156413.
Williams AM. Coadministration of intramuscular olanzapine and benzodiazepines in agitated patients with mental illness. Ment Health Clin. 2018;8(5):208-213. doi: 10.9740/mhc.2018.09.208. PMID: 30206503.
Khorassani F, Saad M. Intravenous olanzapine for the management of agitation: review of the literature. Ann Pharmacother. 2019;53(8):853-859. doi: 10.1177/1060028019831634. PMID: 30758221.
Chan EW, Taylor DM, Knott JC, Phillips GA, Castle DJ, Kong DCM. Intravenous droperidol or olanzapine as an adjunct to midazolam for the acutely agitated patient: a multicenter, randomized, double-blind, placebo-controlled clinical trial. Ann Emerg Med. 2013;61(1):72-81. doi: 10.1016/j.annemergmed.2012.07.118. PMID: 22981685.
Cole JB, Moore JC, Dolan BJ, et al. A prospective observational study of patients receiving intravenous and intramuscular olanzapine in the emergency department. Ann Emerg Med. 2017;69(3):327-336.e2. 10.1016/j.annemergmed.2016.08.008. PMID: 27823873.
Martel ML, Klein LR, Rivard RL, Cole JB. A large retrospective cohort of patients receiving intravenous olanzapine in the emergency department. Acad Emerg Med. 2016;23(1):29-35. doi: 10.1111/acem.12842. PMID: 26720055.
Wilson MP, MacDonald K, Vilke GM, Feifel D. Potential complications of combining intramuscular olanzapine with benzodiazepines in emergency department patients. J Emerg Med. 2012;43(5):889-896.
doi: 10.1016/j.jemermed.2010.04.012. PMID: 20542400
Wilson MP, MacDonald K, Vilke GM, Feifel D. A comparison of the safety of olanzapine and haloperidol in combination with benzodiazepines in emergency department patients with acute agitation. J Emerg Med. 2012;43(5):790-797. doi: 10.1016/j.jemermed.2011.01.024. PMID: 21601409.

By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2021-08-19T14:19:38-07:00Mar 13, 2021|EM Pharmacy Pearls, Psychiatry|

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