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Behavioral & Behavioral & Psychiatric Psychiatric Problems Problems Scott Marquis, MD Scott Marquis, MD

Behavioral & Psychiatric Problems

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Behavioral & Psychiatric Problems. Scott Marquis, MD. What is a behavioral emergency?. An unanticipated behavioral episode Behavior that is threatening to patient or others Requires immediate intervention by emergency responders. Abnormal Behavior. No clear definition, but is maladaptive - PowerPoint PPT Presentation

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Page 1: Behavioral & Psychiatric Problems

Behavioral & Behavioral & Psychiatric Psychiatric ProblemsProblems

Scott Marquis, MDScott Marquis, MD

Page 2: Behavioral & Psychiatric Problems

What is a behavioral What is a behavioral emergency?emergency?

An unanticipated behavioral An unanticipated behavioral episodeepisode

Behavior that is threatening to Behavior that is threatening to patient or otherspatient or others

Requires immediate intervention Requires immediate intervention by emergency respondersby emergency responders

Page 3: Behavioral & Psychiatric Problems

Abnormal BehaviorAbnormal Behavior No clear definition, but is No clear definition, but is

maladaptivemaladaptive Deviates from societies norms and Deviates from societies norms and

expectationsexpectations Interferes with individual well-Interferes with individual well-

being and ability to functionbeing and ability to function Harmful to self or othersHarmful to self or others

Page 4: Behavioral & Psychiatric Problems

Behavioral ChangeBehavioral Change NeverNever assume a patient has a assume a patient has a

psychiatric illness until all possible psychiatric illness until all possible physical causes have been ruled physical causes have been ruled outout

Page 5: Behavioral & Psychiatric Problems

‘‘Clues’Clues’Underlying Physical IllnessUnderlying Physical Illness

Sudden onsetSudden onset Visual, but not auditory, hallucinationsVisual, but not auditory, hallucinations Memory loss or impairmentMemory loss or impairment Altered pupil size, asymmetry, or Altered pupil size, asymmetry, or

impaired reactivityimpaired reactivity Excessive salivation or incontinenceExcessive salivation or incontinence Unusual breath odorsUnusual breath odors

Page 6: Behavioral & Psychiatric Problems

Behavioral ChangeBehavioral ChangePossible CausesPossible Causes

Low blood sugarLow blood sugar HypoxiaHypoxia Inadequate cerebral blood flowInadequate cerebral blood flow Head traumaHead trauma Drugs, alcoholDrugs, alcohol Excessive heat or coldExcessive heat or cold CNS infectionsCNS infections

Page 7: Behavioral & Psychiatric Problems

Behavioral Change Behavioral Change PathophysiologyPathophysiology

Biological or organicBiological or organic PsychosocialPsychosocial Socio-culturalSocio-cultural

Page 8: Behavioral & Psychiatric Problems

Organic CausesOrganic Causes DiseaseDisease

Metabolic disorders, infection, Metabolic disorders, infection, endocrine disorders, neoplastic endocrine disorders, neoplastic disease, cardiovascular disease, or disease, cardiovascular disease, or degenerative diseasedegenerative disease

Physical injuryPhysical injury Head traumaHead trauma

Page 9: Behavioral & Psychiatric Problems

More Organic CausesMore Organic Causes ToxinsToxins

Drug abuse, medication reactions, Drug abuse, medication reactions, carbon monoxidecarbon monoxide

Disturbance in cognitive Disturbance in cognitive functioningfunctioning Delirium, dementiaDelirium, dementia

Page 10: Behavioral & Psychiatric Problems

Psychiatric DisordersPsychiatric Disorders

Page 11: Behavioral & Psychiatric Problems

EpidemiologyEpidemiology Mental health problems affect as Mental health problems affect as

much as 20% of general populationmuch as 20% of general population More than all other health problems More than all other health problems

combined!combined! An estimated 1 in 7 persons will An estimated 1 in 7 persons will

need treatment for an emotional need treatment for an emotional disturbance at some time in their disturbance at some time in their liveslives

Page 12: Behavioral & Psychiatric Problems

Anxiety DisordersAnxiety Disorders Most common psychiatric problem Most common psychiatric problem

encountered in outpatients encountered in outpatients Painful uneasiness, a reaction to Painful uneasiness, a reaction to

difficult situations or past/present difficult situations or past/present life stressorslife stressors

Interferes with effective functioningInterferes with effective functioning Agitation or restlessness quite often Agitation or restlessness quite often

confused as something elseconfused as something else

Page 13: Behavioral & Psychiatric Problems

Anxiety DisordersAnxiety Disorders Anxiety, generalizedAnxiety, generalized Panic disordersPanic disorders PhobiasPhobias Obsessive-compulsive disorderObsessive-compulsive disorder Post-traumatic syndromesPost-traumatic syndromes

Page 14: Behavioral & Psychiatric Problems

Mood DisordersMood Disorders Patient mood ranges from Patient mood ranges from

extremely low to euphoric behaviorextremely low to euphoric behavior May often be more subtle, a loss of May often be more subtle, a loss of

interest or enjoyment in any of interest or enjoyment in any of his/her normal pleasureshis/her normal pleasures

Physical complaints are commonPhysical complaints are common

Page 15: Behavioral & Psychiatric Problems

DepressionDepression Hopelessness, worthlessness, Hopelessness, worthlessness,

sleep or eating disturbances, sleep or eating disturbances, unable to concentrate, slowed unable to concentrate, slowed reaction timereaction time

AlwaysAlways ask about suicide! ask about suicide! A factor in 50% of suicidesA factor in 50% of suicides

Page 16: Behavioral & Psychiatric Problems

Bipolar DisorderBipolar Disorder Manic-depressive cyclesManic-depressive cycles Manic – euphoric, grandiose, Manic – euphoric, grandiose,

pressured, may claim to have pressured, may claim to have special powersspecial powers

Depressed – sad, hopeless, Depressed – sad, hopeless, suicidal, “crash” after maniasuicidal, “crash” after mania

May be delusional in either phaseMay be delusional in either phase

Page 17: Behavioral & Psychiatric Problems

Psychotic DisordersPsychotic Disorders ““A break from reality”A break from reality” Not always a psychiatric cause; Not always a psychiatric cause;

consider alcohol, drugs, and consider alcohol, drugs, and medication reactionsmedication reactions

One percent of general population One percent of general population will be diagnosed with will be diagnosed with schizophreniaschizophrenia

Page 18: Behavioral & Psychiatric Problems

SchizophreniaSchizophrenia Debilitating distortions of speech Debilitating distortions of speech

and thoughtand thought Bizarre hallucinations, delusions, Bizarre hallucinations, delusions,

or behavioror behavior Social withdrawalSocial withdrawal Lack of emotional expressiveness, Lack of emotional expressiveness,

“flat”“flat”

Page 19: Behavioral & Psychiatric Problems

SchizophreniaSchizophrenia ParanoidParanoid CatatonicCatatonic DisorganizedDisorganized UndifferentiatedUndifferentiated

Page 20: Behavioral & Psychiatric Problems

Substance-Related Substance-Related DisordersDisorders

IntoxicationIntoxication DependenceDependence WithdrawalWithdrawal

A close friend of psychiatric illnessA close friend of psychiatric illness Particularly tight links to Particularly tight links to

depression and suicidal behavior!depression and suicidal behavior!

Page 21: Behavioral & Psychiatric Problems

Violent PatientsViolent Patients

Page 22: Behavioral & Psychiatric Problems

SuicideSuicide NeverNever dismiss any suicidal threat, no dismiss any suicidal threat, no

matter how well you know the patientmatter how well you know the patient

Suicide rate in your prehospital Suicide rate in your prehospital population is 10 times that of the population is 10 times that of the general population!general population!

Women attempt suicide more oftenWomen attempt suicide more often Men Men succeedsucceed more often more often

Page 23: Behavioral & Psychiatric Problems

Who is at greatest risk?Who is at greatest risk? White men over 40White men over 40 Living alone, divorced, or widowedLiving alone, divorced, or widowed Substance abuse problemsSubstance abuse problems Severe depressionSevere depression Past suicide attemptsPast suicide attempts Highly lethal planHighly lethal plan

Page 24: Behavioral & Psychiatric Problems

SuicideSuicide Asking about a specific suicide Asking about a specific suicide

plan will plan will notnot make suicide more make suicide more likely!likely!

Having a detailed plan does put Having a detailed plan does put your patient at higher riskyour patient at higher risk

Page 25: Behavioral & Psychiatric Problems

Suicide Suicide Additional Risk FactorsAdditional Risk Factors

Means are available, low likelihood of Means are available, low likelihood of rescuerescue

Poor physical health; chronic disease Poor physical health; chronic disease or pain syndromeor pain syndrome

Recent loss of a loved one, anniversaryRecent loss of a loved one, anniversary Sudden life changes; unemployment, Sudden life changes; unemployment,

bankruptcy, imprisonmentbankruptcy, imprisonment Family history of suicide, especially a Family history of suicide, especially a

parentparent

Page 26: Behavioral & Psychiatric Problems

Managing Behavioral Managing Behavioral EmergenciesEmergencies

Page 27: Behavioral & Psychiatric Problems

Guiding PrinciplesGuiding Principles Respect the dignity of the patientRespect the dignity of the patient Assure your own as well as the Assure your own as well as the

patient’s and others safetypatient’s and others safety Diagnose and treat organic causes Diagnose and treat organic causes

of behavioral disordersof behavioral disorders Work with law enforcement to Work with law enforcement to

improve patient care outcomesimprove patient care outcomes

Page 28: Behavioral & Psychiatric Problems

Scene Size-UpScene Size-Up Pay careful attention to dispatch Pay careful attention to dispatch

information for indications of information for indications of potential violencepotential violence

Never enter potentially violent Never enter potentially violent situations without police supportsituations without police support

If personal safety is uncertain, If personal safety is uncertain, stand by for policestand by for police

Page 29: Behavioral & Psychiatric Problems

Scene Size-UpScene Size-Up In suicide cases, be alert for In suicide cases, be alert for

hazardshazards Automobile running in closed garageAutomobile running in closed garage Gas stove pilot light blown outGas stove pilot light blown out Electrical devices in waterElectrical devices in water Toxins on or around the patientToxins on or around the patient

Page 30: Behavioral & Psychiatric Problems

Scene Size-UpScene Size-Up Quickly locate the patientQuickly locate the patient Stay between patient and doorStay between patient and door Scan quickly for any dangerous Scan quickly for any dangerous

articlesarticles If patient has a weapon, ask him/her If patient has a weapon, ask him/her

to put it downto put it down If he/she won’t, back out and wait for If he/she won’t, back out and wait for

the policethe police

Page 31: Behavioral & Psychiatric Problems

Scene Size-UpScene Size-Up Look for…Look for…

Signs of possible underlying medical Signs of possible underlying medical problemsproblems

Methods or means of committing Methods or means of committing suicidesuicide

Multiple patientsMultiple patients

Page 32: Behavioral & Psychiatric Problems

General ApproachGeneral Approach Do not argue or shout Do not argue or shout Remove disturbing persons or Remove disturbing persons or

objectsobjects Provide emotional supportProvide emotional support Explain all procedures carefully to Explain all procedures carefully to

anxious or confused patientsanxious or confused patients

Page 33: Behavioral & Psychiatric Problems

Initial AssessmentInitial Assessment Rapid assessment of ABC’sRapid assessment of ABC’s Identify and treat potentially life-Identify and treat potentially life-

threatening illness and injuriesthreatening illness and injuries Observe patient’s outward Observe patient’s outward

behavior and body languagebehavior and body language

Page 34: Behavioral & Psychiatric Problems

Interview ApproachInterview Approach Communicate in a calm and non-Communicate in a calm and non-

threatening, nonjudgmental waythreatening, nonjudgmental way Identify yourself and offer the Identify yourself and offer the

patient assistancepatient assistance Seek the patient’s cooperationSeek the patient’s cooperation Encourage patient to talk; show Encourage patient to talk; show

you are listeningyou are listening

Page 35: Behavioral & Psychiatric Problems

Interview ApproachInterview Approach Be supportive and limit Be supportive and limit

interruptionsinterruptions Respect patient’s space, limit Respect patient’s space, limit

touching unless given permissiontouching unless given permission Be direct and always tell the truthBe direct and always tell the truth Involve trusted family, friendsInvolve trusted family, friends

Page 36: Behavioral & Psychiatric Problems

Focused HistoryFocused History Ask for and acknowledge patient’s Ask for and acknowledge patient’s

complaintscomplaints Determine onset of behavioral eventDetermine onset of behavioral event Ask about precipitating factors; Ask about precipitating factors;

remove patient from these, if possibleremove patient from these, if possible Existing life situationExisting life situation Previous psychiatric as well as Previous psychiatric as well as

medical historymedical history

Page 37: Behavioral & Psychiatric Problems

Focused HistoryFocused History Mental status, affect, and behaviorMental status, affect, and behavior Current medications and alcohol or Current medications and alcohol or

illicit drug useillicit drug use Evaluate potential for suicide!Evaluate potential for suicide!

Page 38: Behavioral & Psychiatric Problems

AssessmentAssessmentSuicidal PatientsSuicidal Patients

Do not trust “rapid recoveries”Do not trust “rapid recoveries” Do something tangible for the Do something tangible for the

patientpatient Do not try to deny that a suicide Do not try to deny that a suicide

attempt occurredattempt occurred NeverNever challenge a patient to go challenge a patient to go

ahead, do itahead, do it

Page 39: Behavioral & Psychiatric Problems

AssessmentAssessmentViolent PatientsViolent Patients

Find out if patient has threatened or Find out if patient has threatened or has history of violence, aggression, has history of violence, aggression, combativenesscombativeness

Assess body language for clues to Assess body language for clues to potential violencepotential violence

Listen for clues to violence in Listen for clues to violence in patient’s speechpatient’s speech

Monitor movements, physical activityMonitor movements, physical activity Be firm, clearBe firm, clear

Page 40: Behavioral & Psychiatric Problems

Physical ExamPhysical Exam Vital signs and general appearanceVital signs and general appearance Skin examSkin exam Mental statusMental status Evidence for medical problem, Evidence for medical problem,

recent trauma, or an overdoserecent trauma, or an overdose Threat to self or othersThreat to self or others Patient able to provide for needsPatient able to provide for needs

Page 41: Behavioral & Psychiatric Problems

Management PrinciplesManagement Principles Treat life-threatening medical Treat life-threatening medical

problems or traumatic injury first problems or traumatic injury first and foremostand foremost

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

Page 42: Behavioral & Psychiatric Problems

Management PrinciplesManagement Principles Maintain scene safety; control any Maintain scene safety; control any

violent situationsviolent situations NeverNever leave the patient alone leave the patient alone Transport patient against his/her Transport patient against his/her

will, if indicatedwill, if indicated Restrain the patient only as last Restrain the patient only as last

resortresort

Page 43: Behavioral & Psychiatric Problems

Restraining PatientsRestraining Patients A patient may be restrained if you A patient may be restrained if you

have good reason to believe have good reason to believe he/she is a danger to:he/she is a danger to: YouYou Himself/herselfHimself/herself OthersOthers

Page 44: Behavioral & Psychiatric Problems

Restraining PatientsRestraining Patients Have sufficient manpowerHave sufficient manpower Have a plan; know who will do whatHave a plan; know who will do what Use only as much force as needed; Use only as much force as needed;

don’t be punitivedon’t be punitive When the time comes, act quickly; When the time comes, act quickly;

take the patient by surprisetake the patient by surprise Use at least four rescuers, one for Use at least four rescuers, one for

each extremityeach extremity

Page 45: Behavioral & Psychiatric Problems

Restraining PatientsRestraining Patients Use humane restraints (soft Use humane restraints (soft

leather, cloth) on limbsleather, cloth) on limbs Secure patient to stretcher with Secure patient to stretcher with

straps at chest, waist, thighsstraps at chest, waist, thighs If patient spits, cover his/her face If patient spits, cover his/her face

with surgical maskwith surgical mask Once restraints are applied, never Once restraints are applied, never

remove them!remove them!

Page 46: Behavioral & Psychiatric Problems

Chemical RestraintsChemical Restraints When physical restraints alone are When physical restraints alone are

not enoughnot enough Establish on-line medical controlEstablish on-line medical control Haloperidol (Haldol), 5-10 mg IV or IMHaloperidol (Haldol), 5-10 mg IV or IM Lorazepam (Ativan), 1-2 mg IV or IMLorazepam (Ativan), 1-2 mg IV or IM Diphenhydramine (Benadryl), 25-50 Diphenhydramine (Benadryl), 25-50

mg IV or IM or hydroxyzine, 50-100 mg IV or IM or hydroxyzine, 50-100 mg IMmg IM

Page 47: Behavioral & Psychiatric Problems

Chemical RestraintsChemical Restraints Haldol and movement disorders do Haldol and movement disorders do

not mix wellnot mix well Worsens extrapyramidal effectsWorsens extrapyramidal effects Minimal anticholinergic and Minimal anticholinergic and

cardiovascular effectscardiovascular effects Ativan ideal for agitation due to Ativan ideal for agitation due to

withdrawalwithdrawal Beware of additive CNS depressant effectBeware of additive CNS depressant effect

Page 48: Behavioral & Psychiatric Problems

Chemical RestraintsChemical Restraints Antihistamines Antihistamines

Hydroxyzine useful in drug abusers, Hydroxyzine useful in drug abusers, little habituationlittle habituation

Benadryl can worsen asthma Benadryl can worsen asthma symptoms and lower seizure symptoms and lower seizure thresholds at higher dosesthresholds at higher doses

Page 49: Behavioral & Psychiatric Problems

Behavioral EmergenciesBehavioral EmergenciesPearlsPearls

Look carefully for physical causes Look carefully for physical causes to explain behavioral emergenciesto explain behavioral emergencies

Pay special attention to your own Pay special attention to your own and others safetyand others safety

Ask about suicide or past violent Ask about suicide or past violent behaviorbehavior

Treat patients fairly and with as Treat patients fairly and with as much dignity as possiblemuch dignity as possible