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Behavioral & Psychiatric Problems Scott Marquis, MD

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  • Behavioral & Psychiatric ProblemsScott Marquis, MD

  • What is a behavioral emergency?An unanticipated behavioral episodeBehavior that is threatening to patient or othersRequires immediate intervention by emergency responders

  • Abnormal BehaviorNo clear definition, but is maladaptiveDeviates from societies norms and expectationsInterferes with individual well-being and ability to functionHarmful to self or others

  • Behavioral ChangeNever assume a patient has a psychiatric illness until all possible physical causes have been ruled out

  • CluesUnderlying Physical IllnessSudden onsetVisual, but not auditory, hallucinationsMemory loss or impairmentAltered pupil size, asymmetry, or impaired reactivityExcessive salivation or incontinenceUnusual breath odors

  • Behavioral ChangePossible CausesLow blood sugarHypoxiaInadequate cerebral blood flowHead traumaDrugs, alcoholExcessive heat or coldCNS infections

  • Behavioral Change PathophysiologyBiological or organicPsychosocialSocio-cultural

  • Organic CausesDiseaseMetabolic disorders, infection, endocrine disorders, neoplastic disease, cardiovascular disease, or degenerative diseasePhysical injuryHead trauma

  • More Organic CausesToxinsDrug abuse, medication reactions, carbon monoxideDisturbance in cognitive functioningDelirium, dementia

  • Psychiatric Disorders

  • EpidemiologyMental health problems affect as much as 20% of general populationMore than all other health problems combined!An estimated 1 in 7 persons will need treatment for an emotional disturbance at some time in their lives

  • Anxiety DisordersMost common psychiatric problem encountered in outpatients Painful uneasiness, a reaction to difficult situations or past/present life stressorsInterferes with effective functioningAgitation or restlessness quite often confused as something else

  • Anxiety DisordersAnxiety, generalizedPanic disordersPhobiasObsessive-compulsive disorderPost-traumatic syndromes

  • Mood DisordersPatient mood ranges from extremely low to euphoric behaviorMay often be more subtle, a loss of interest or enjoyment in any of his/her normal pleasuresPhysical complaints are common

  • DepressionHopelessness, worthlessness, sleep or eating disturbances, unable to concentrate, slowed reaction timeAlways ask about suicide!A factor in 50% of suicides

  • Bipolar DisorderManic-depressive cyclesManic euphoric, grandiose, pressured, may claim to have special powersDepressed sad, hopeless, suicidal, crash after maniaMay be delusional in either phase

  • Psychotic DisordersA break from realityNot always a psychiatric cause; consider alcohol, drugs, and medication reactionsOne percent of general population will be diagnosed with schizophrenia

  • SchizophreniaDebilitating distortions of speech and thoughtBizarre hallucinations, delusions, or behaviorSocial withdrawalLack of emotional expressiveness, flat

  • SchizophreniaParanoidCatatonicDisorganizedUndifferentiated

  • Substance-Related DisordersIntoxicationDependenceWithdrawal

    A close friend of psychiatric illnessParticularly tight links to depression and suicidal behavior!

  • Violent Patients

  • SuicideNever dismiss any suicidal threat, no matter how well you know the patient

    Suicide rate in your prehospital population is 10 times that of the general population!Women attempt suicide more oftenMen succeed more often

  • Who is at greatest risk?White men over 40Living alone, divorced, or widowedSubstance abuse problemsSevere depressionPast suicide attemptsHighly lethal plan

  • SuicideAsking about a specific suicide plan will not make suicide more likely!

    Having a detailed plan does put your patient at higher risk

  • Suicide Additional Risk FactorsMeans are available, low likelihood of rescuePoor physical health; chronic disease or pain syndromeRecent loss of a loved one, anniversarySudden life changes; unemployment, bankruptcy, imprisonmentFamily history of suicide, especially a parent

  • Managing Behavioral Emergencies

  • Guiding PrinciplesRespect the dignity of the patientAssure your own as well as the patients and others safetyDiagnose and treat organic causes of behavioral disordersWork with law enforcement to improve patient care outcomes

  • Scene Size-UpPay careful attention to dispatch information for indications of potential violenceNever enter potentially violent situations without police supportIf personal safety is uncertain, stand by for police

  • Scene Size-UpIn suicide cases, be alert for hazardsAutomobile running in closed garageGas stove pilot light blown outElectrical devices in waterToxins on or around the patient

  • Scene Size-UpQuickly locate the patientStay between patient and doorScan quickly for any dangerous articlesIf patient has a weapon, ask him/her to put it downIf he/she wont, back out and wait for the police

  • Scene Size-UpLook forSigns of possible underlying medical problemsMethods or means of committing suicideMultiple patients

  • General ApproachDo not argue or shout Remove disturbing persons or objectsProvide emotional supportExplain all procedures carefully to anxious or confused patients

  • Initial AssessmentRapid assessment of ABCsIdentify and treat potentially life-threatening illness and injuriesObserve patients outward behavior and body language

  • Interview ApproachCommunicate in a calm and non-threatening, nonjudgmental wayIdentify yourself and offer the patient assistanceSeek the patients cooperationEncourage patient to talk; show you are listening

  • Interview ApproachBe supportive and limit interruptionsRespect patients space, limit touching unless given permissionBe direct and always tell the truthInvolve trusted family, friends

  • Focused HistoryAsk for and acknowledge patients complaintsDetermine onset of behavioral eventAsk about precipitating factors; remove patient from these, if possibleExisting life situationPrevious psychiatric as well as medical history

  • Focused HistoryMental status, affect, and behaviorCurrent medications and alcohol or illicit drug useEvaluate potential for suicide!

  • AssessmentSuicidal PatientsDo not trust rapid recoveriesDo something tangible for the patientDo not try to deny that a suicide attempt occurredNever challenge a patient to go ahead, do it

  • AssessmentViolent PatientsFind out if patient has threatened or has history of violence, aggression, combativenessAssess body language for clues to potential violenceListen for clues to violence in patients speechMonitor movements, physical activityBe firm, clear

  • Physical ExamVital signs and general appearanceSkin examMental statusEvidence for medical problem, recent trauma, or an overdoseThreat to self or othersPatient able to provide for needs

  • Management PrinciplesTreat life-threatening medical problems or traumatic injury first and foremost

    Hypoxic? Hypoperfused? Temperature extreme? Hypoglycemic? Overdose? Trauma? Infection?

  • Management PrinciplesMaintain scene safety; control any violent situationsNever leave the patient aloneTransport patient against his/her will, if indicatedRestrain the patient only as last resort

  • Restraining PatientsA patient may be restrained if you have good reason to believe he/she is a danger to:YouHimself/herselfOthers

  • Restraining PatientsHave sufficient manpowerHave a plan; know who will do whatUse only as much force as needed; dont be punitiveWhen the time comes, act quickly; take the patient by surpriseUse at least four rescuers, one for each extremity

  • Restraining PatientsUse humane restraints (soft leather, cloth) on limbsSecure patient to stretcher with straps at chest, waist, thighsIf patient spits, cover his/her face with surgical maskOnce restraints are applied, never remove them!

  • Chemical RestraintsWhen physical restraints alone are not enoughEstablish on-line medical controlHaloperidol (Haldol), 5-10 mg IV or IMLorazepam (Ativan), 1-2 mg IV or IMDiphenhydramine (Benadryl), 25-50 mg IV or IM or hydroxyzine, 50-100 mg IM

  • Chemical RestraintsHaldol and movement disorders do not mix wellWorsens extrapyramidal effectsMinimal anticholinergic and cardiovascular effectsAtivan ideal for agitation due to withdrawalBeware of additive CNS depressant effect

  • Chemical RestraintsAntihistamines Hydroxyzine useful in drug abusers, little habituationBenadryl can worsen asthma symptoms and lower seizure thresholds at higher doses

  • Behavioral EmergenciesPearlsLook carefully for physical causes to explain behavioral emergenciesPay special attention to your own and others safetyAsk about suicide or past violent behaviorTreat patients fairly and with as much dignity as possible

    Biological diseases, toxins, heredityPsychosocial childhood trauma, parental deprivation, dysfunctional family structureSocio-cultural environmental violence (rape, assault, war), death of a loved one, economic/employment problems, prejudice/discrimination, cultural norms/expectationsSkin exam toxidromes?Mental status intellectual functioning,thought content, language, mood, appearance, psychomotor activityHypoglycemia, hypoxia, naloxone/flumazenil

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