COMPREHENSIVE PSYCHIATRIC EMERGENCY PROGRAM

(CPEP)

2013

EMERGENCY MEDICAL Guidelines/Protocols

MHMRA OF HARRIS COUNTY

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CPEP EMERGENCY MEDICAL PROTOCOL The Psychiatric Emergency Service located at the NeuroPsychiatric Center (NPC) is an emergency mental health facility available to citizens of Harris County for the diagnosis, treatment and referral of individuals experiencing a mental health crisis. The center is open 24/7 and staffed with psychiatrists, mental health nurses and other mental health professionals. The PES is not a hospital and it is not a part of Ben Taub General Hospital though it occupies the Old Ben Taub Emergency Room space and is next door to the current BTGH and Emergency Center. Our primary mission is to provide assessment, treatment and disposition of patients presenting with a behavioral or emotional crisis. Even though we are staffed with psychiatric physicians and nurses, our programs are designed, equipped and staffed to provide mental health care and treatment. We do have some limited capability to handle minor medical problems and conditions so as to prevent patients in mental health crisis the additional stress of having to go and wait in an ER while in a psychiatric crisis. Patients who present with acute, emergent medical problems that we are not equipped to manage or treat will be directed to a medical ER for treatment and stabilization This document outlines the general medical guidelines and parameters for certain common conditions that might present in the PES. It is not meant to be exhaustive of all medical situations that we may encounter in the PES. This document also does not replace the clinical judgment of the physician on duty as to when to accept or refer a patient for further medical evaluation or stabilization. The physician must document the clinical rational for referral or acceptance of a patient with an acute medical condition. The PES staff will assist law enforcement officers in obtaining an ambulance for ER transport and providing supportive care for any involuntary patient presenting with a life threatening condition that is not obvious to the officer prior to bringing the patient to the PES. When a patient is brought in by law enforcement with a condition that is not life threatening but exceeds the capabilities and resources of the PES to further assess, treat and stabilize the officer will be asked to take the patient to the BTGH ER for a medical evaluation.

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Indicators of Serious Medical Conditions The following lists some common indicators of severe medical illness. If any of these indicators are present and apparent with any patient being considered for transport to the NPC the law enforcement officer is advised to take this individual to the nearest medical emergency room rather than bringing them to the NPC.

Known overdose of Tylenol or any product containing acetaminophen within the past 12-24 hours.

Known overdose of any drug or chemical within 12 -24 hours in which the patient has evidence of any of the following:

• Intoxication (including smell or appearance) • Drowsiness • Slurred speech • Inability to walk or stand, staggering • Vomiting • Confusion • Trembling or tremors • Shivering and /or sweating • Seizures • Unstable vital signs

Chest Pain • Pain may be felt in jaw, neck, shoulders, arms, back, or abdomen • Accompanied by shortness of breath, nausea and/or vomiting

Wounds with bleeding that does not stop with a simple dressing

Pain of any nature where patient is unable to stand/walk without assistance.

Inability to arouse the patient by loud voice or moderate “shaking”. Seizures within the last 1 hour, if not being treated for a known seizure disorder.

Cough with any of the following: • Painful breathing • Blood from nose and or mouth

Traumatic injury from a fall with pain involving the head and/or neck, and any change of mental status as result of injury.

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Allergic Reactions-Anaphylaxis Usually accompanied by rash, itching, urticaria, flushing, hypotension, laryngospasm Reaction occurs within 5 minutes of offending agent Laryngospams and hypotension may be life threatening Treatment mainstay Epinephrine 1:1000 solution, 0.3-0.5 mg (0.3 to 0.5 of 1:1000 solution) IM or SC

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Asthma Wheezing, dyspnea, respiratory rate >28/min pulse >110, diaphragm, muscle fatigue and paradoxical diaphragmatic movement may decrease rate. Call 911 Administer supplemental Oxygen to maintain saturation >90% on pulse oximeter. O2 saturation less than 90 and / or medical distress with breathing difficulties send to ER 911 for medical evaluation.

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Chest Pain Symptoms can vary and may be indicative of a number of underlying etiologies ranging from indigestion to life threatening conditions such as MI or dissection of the aorta. Complaints of chest pain that are accompanied by unstable vital signs, shortness of breath, change in color, peripheral edema diaphoresis palpitations known cardiac risk factors severe anxiety call 911 and/or transport to BTGH ER ASAP. Patients with a known history of cardiac disease and /or risk factors such as age, weight, high blood pressure or presence of hyperglycemia require a medical consult from the Baylor Family Medicine consultant or transfer to the BTGH for further evaluation. It is good to remember that females experiencing an acute cardiac arrest may not manifest the typical symptoms of substernal chest pain (heaviness) or pain radiation to jaw or back. African American or Hispanic females above the age of 40 with known cardiovascular risk factors and the above symptoms should be considered for obtaining a baseline EKG. If EKG shows Q-T changes, ST elevation or depression, Q waves, Inverted T waves, Changes from previous EKG’s Consider transfer to BTGHQ waves, Inverted T waves, Changes from previous EKG’s Transfer to BTGH ER

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Delirium It is important for the PES physician to rule out underlying medical conditions in patients who present with altered mental status. Some of these underlying conditions if mild may be treated in the PES. However many times when delirium is suspected a medical work up is indicated in the form of labs and or other diagnostic testing that may fall out of the scope of the PES to evaluate. When a patient presents with altered mental status accompanied with vital sign abnormalities such as fever, increased pulse, labored breathing and blood pressure fluctuations consideration of an underlying medical condition must be considered. Hallucinations other than auditory hallucinations, i.e. visual, tactile, or olfactory can often indicate severe substance abuse withdrawal, or other medical conditions. Patients who present with disorientation and confusion above and beyond that, which can be explained by an affective or psychotic exacerbation of their mental disorder, should be evaluated thoroughly to rule out an underlying medical condition.

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Dementia Severe cognitive impairment remains a serious disposition problem for the PES. If the patient after initial evaluation including an assessment of vital signs does not have acute medical problems or a superimposed psychiatric condition that will respond to treatment, the PES social service staff will provide assistance to the officer in locating the appropriate social service agency to aid and place the individual, but these patients can not be admitted to the PES, as disposition is often a very serious problem. If it is determined that the patient doesn’t need acute psychiatric intervention and has an identified place to return to such as family, nursing home or personal care home and the patient is allowed to return by the facility the officer can be directed to return the patient to the facility.

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Drug Overdose

If there is a history of overdose of potentially dangerous medication or toxic substance within 24-48 hours of admission with the presence of any of the following: Unstable VS Altered LOC Abnormal EKG Lethargy Refer patient to Medical ER for clearance.

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Hypertension

BP > or = to 180/120 should be referred for medical clearance. Stage 1 Hypertension 140-159/90-99 start thiazide diurectic such as HCTZ 25-50 mg q AM and monitor BP q shift or reinstate prior treatment if known and effective. Stage 2 Hypertension 160-179/100-119–reinstate prior treatment regimen if known and effective or start HCTZ 25-50 mg q AM along with ACEI such as lisinopril 10-20 mg q AM with q shift monitoring of BP. If chest pain, abnormal EKG or other unstable vital signs with any stage 1 or stage 2 elevation of BP consult with the Baylor Family medicine consultant to discuss other options or need for transfer of patient to a medical ER.

• Severely elevated blood pressure is defined as elevated blood pressure (>180 mmHg systolic or >110 mm Hg diastolic) without risk factors for end organ damage.

• Hypertensive urgency is defined as severely elevated blood pressure (> 180 mmHg systolic or > 110 mmHg diastolic) in the presence of risk factors for progressive end-organ damage.

• Hypertensive emergency is defined as severely elevated blood pressure (>180 mmHg systolic or >110 mmHg) with signs and symptoms of end-organ damage.

Medication Dosage Onset/Duration of Action

Precautions

Captopril 25 mg PO or 25 mg sublingual; repeat as needed

Oral:15-30 min/6-8 hours SL: 10-20 min/2-6 hr

Hypotension, renal failure, renal artery stenosis

Clonidine 0.1 – 0.2 mg PO, repeat hourly as required to a total dosage or .6 mg

30-60 min/ 8-16 hr

Hypotension, drowsiness, dry mouth

Labetalol 200-400 mg PO; repeat every 2-3 hours

1-2 hr/2-12 hr Bronchoconstriction, Heart block, orthostatic hypotension

Amlodipine 2.5 mg – 5 mg 1-2 hr/12-18 hr Tachycardia, hypotension

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JNC VII classificationClassification Systolic Diastolic

Normal blood pressure < 120 mmHg < 80 mmHg

Pre-hypertension 120 -139 mmHg 80 – 89 mmHg

Stage I hypertension 140 – 159 mmHg 90 -99 mmHg

Stage II hypertension 160 or greater 100 or greater

Classification Systolic Diastolic

Normal blood pressure < 120 mmHg < 80 mmHg

Pre-hypertension 120 -139 mmHg 80 – 89 mmHg

Stage I hypertension 140 – 159 mmHg 90 -99 mmHg

Stage II hypertension 160 or greater 100 or greater

Hypertensive EmergencyBlood Pressure Fundoscopic Findings Neurologic Status

>220/140 Hemorrhages, exudatesPapilledema

Headache, confusion, somnolence, stupor,Visual loss, seizures, focal neurologic deficits, coma

Blood pressure Cardiac Findings Renal Symptoms

>220/140 Cardiac enlargement, prominent apical pulsation, congestive heart failure

Oliguria, proteinuria, azotemia

Blood pressure Gastrointestinal Symptoms

>220/140 Nausea and vomiting

Blood Pressure Fundoscopic Findings Neurologic Status

>220/140 Hemorrhages, exudatesPapilledema

Headache, confusion, somnolence, stupor,Visual loss, seizures, focal neurologic deficits, coma

Blood pressure Cardiac Findings Renal Symptoms

>220/140 Cardiac enlargement, prominent apical pulsation, congestive heart failure

Oliguria, proteinuria, azotemia

Blood pressure Gastrointestinal Symptoms

>220/140 Nausea and vomiting

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Hyperglycemia In the PES our goal is not to determine or establish the patient’s optimal insulin regimen, but to stabilize the patient for hospital transfer or f/u with their primary care physician. The following protocol may be optimal for the cooperative patient in good medical condition and without other risk factors. The physician should not rely solely upon the protocol below but must exercise clinical judgment taking into account the history and overall physical status for each patient. Obtain finger stick glucose upon admission, if 400 or more refer for medical clearance, and or consult Baylor Family Medicine for consultation. (note glucometer only measures up to 400). If signs of Keto Acidosis altered: Mental Status, nausea, vomiting, abdominal pain, ketotic breath, dehydration. If possible confirm with Keto-Stick. Refer for medical clearance or transfer to ER for treatment. If glucose < 400 Measure blood glucose stat and do FS QID before meals and before bed. If glucose <180 and insulin dosage is known continue treatment with adjustment in dosage. If glucose 180 or above give long acting insulin Lantus 10 U. Order electrolytes and Order sliding scale regimen as below:

1. If Blood Glucose <180 No Insulin 2. If Blood Glucose 180- 220 Give 4u Regular SQ 3. If Blood Glucose 220- 260 Give 6u Regular SQ 4. If Blood Glucose 260- 320 Give 8u Regular SQ 5. If Blood Glucose 320- 400 Give 10u Regular SQ 6. If Blood Glucose >400 Give 10u Regular SQ and Notify MD

(MD to determine if patient needs to be sent for medical clearance and or consult with Baylor Family Medicine consultant)

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Hypoglycemia

1. Establish Diagnosis: • Glucose<50 mg/dl • Sweating, anxiety, tremors, tachycardia and palpitations • Seizures, fatigue, syncope, headache, behavior changes and

visual disturbance. 2. If alert, give juice and sandwich 3. If drowsy , give glucose gel or IV glucose 4. If unconscious , call 911, and administer IV glucose or glucagon 1 mg

IM 5. Call Baylor consultant to discuss work-up of hypoglycemia as

outpatient 6. After treatment repeat Accucheck Q 4 hours X3

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Alcohol Withdrawal Follow (CIWA)

Initiate following orders

1. Detox. Precautions. Observe patient for withdrawal and instruct

patient to report symptoms to staff

2. If patient reports or appears to be having withdrawal symptoms do

CIWA. And notify MD. Repeat as needed.

3. If CIWA is 5 or greater initiate CIWA protocol Q2h while awake.

Initiate CIWA Q2h and follow procedure below:

• For CIWA >9 and <20 give (Check One) □ Librium, 50mg, PO □ Phenobarbital, 60mg, PO

□ Clonazepam, 1mg, PO □ Lorazepam, 1mg, PO

• For CIWA >19 give (Check One) □ Librium, 100mg, PO □Phenobarbital, 60mg, PO

□ Clonazepam, 2mg, PO □Lorazepam, 2mg, PO

4. If CIWA goes to 3 or below change CIWA to Q4h.

5. If CIWA goes to 10 or greater change CIWA to Q2h until it goes to 3

or less, then go to Q4h.

If CIWA is 2 or less for 3 consecutive times discontinue CIWA.

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Benzodiazepine Withdrawal The likelihood and severity of benzodiazepine withdrawal is dependent upon dose and length of exposure to the drug. The clinical concern is the development of seizures following abrupt cessation of this class of drugs. Sound clinical judgment as to the need for intervention while and or referral while in a CPEP program is necessary on the part of the physician. Signs of benzodiazepine withdrawal include:

• Anxiety • Agitation • Tremor • Tachycardia • Nausea/vomiting • Blood pressure lability • Delirium • Hallucinations

Patients with blood pressure lability, delirium or hallucinations due to verifiable history of benzodiazepine dependence should be referred to a medical ER for clearance. The major strategy for treating benzodiazepine withdrawal is to substitute a long acting benzodiazepine agent such as chlordiazepoxid (Librium) at an equivalent dosage for 5 days and taper by 25% every 5 days until discontinued. The following table from UTMB/Texas Tech managed Care Network Pharmacy and Therapeutics Committee provides some broad guidelines to help the physician to make this determination.

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Opiate Withdrawal (Follow OWA)

Initiate following orders

1. Observe for opiate withdrawal and instruct patient to report

symptoms.

2. If patient reports or appears to have withdrawal symptoms do OWS

(opiate withdrawal scale) and notify doctor

3. If score is 4 or greater, implement the following.

• Clonidine, 0.1mg, QID on first day.

• Clonidine, 0.1mg, TID on second day.

• Clonidine, 0.1mg BID on third day.

• Clonidine, 0.1mg, AM the discontinue on fourth day.

4. OWS Scale now and Q4h while awake and on awakening if after 4

hours.

5. After Scale use this Clonidine schedule to be given in addition to

routine Clonidine:

• Clonidine, 0.1mg, for OWS >3

• Clonidine, 0.2mg, for OWS>7

6. Hold Clonidine, prn, 0.2mg, P.O. if SBP<107mm.

7. Hold all Clonidine including routine if SBP<86.

8. Caution patient about possible fainting and falling (orthostatic

hypotention) and to get down promptly (sit or lie down) if they feel

faint.

9. For specific symptoms use:

• Immodium, 2mg, P.O., prn after loose stool

• Bentyl, 20 mg, P.O., q6h, prn abdominal cramps

• Naproxyn, 500mg, P.O., BID routine for aches and malaise

• Mylanta, 30cc, P.O., prn indigestion

• Chlorpromazine, 25mg, P.O., q4h, prn nausea

• Acetominophen, 650mg, P.O., prn bone pain