Psychiatric Emergencies

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Psychiatric Emergencies

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  • Psychiatric EmergenciesWesley Zeger, DOUniversity of Nebraska Medical CenterGSACEP Core Lecture Series

    GSACEP 2005

  • ObjectivesList typical presentations of psychiatric emergenciesList 2 aspects of the role of the emergency medicine physicianDescribe an organized approach for the evaluation of the psychiatric patientDescribe the difference between active and passive restraintsList 3 psychiatric symptoms that may have underlying medical etiologies

    GSACEP 2005

  • ObjectivesList 8 risk factors for psychiatric symptoms presenting as underlying medical conditionsList the components of the psychiatric assessmentList the components for the SADPERSONS screening examList complications of psychiatric medications and the management

    GSACEP 2005

  • A Psychiatric Emergency?36 y/o female presents with a CC of abdominal pain. She has stable vital signs and is placed in a room after a urine and urine HCG are sent off. You began your interview with her when a critically ill patient presents. After stabilizing that patient you return and you patient has left

    GSACEP 2005

  • Your Patient ReturnsAbout 2 hours later, at the end of your shift, EMS calls and is bringing in a patient with a self-inflicted gunshot wound to the abdomen. She arrives without vital signs. After a short resuscitation, the patient you had a brief encounter with earlier is now pronounced dead.

    GSACEP 2005

  • The ED PopulationAt Least 10% of ED Patients present with Psychiatric EmergenciesUp to 50% of ED Patients have psychiatric illnessesUp to 50% of psychiatric patients have an underlying undiagnosed medical conditionUp to 50% of patients with substance abuse have psychiatric illnesses

    GSACEP 2005

  • Typical PresentationsDepressedAnxious/AgitatedUncooperativeSuicidal/HomicidalSubstance abuse

    GSACEP 2005

  • Role of the Emergency PhysicianMedical Assessment/StabilizationRisk AssessmentDelirium/psychosisSuicideDisposition

    GSACEP 2005

  • Initial ApproachStable vs UnstableViolent vs non-Violent

    GSACEP 2005

  • Initial Approach - UnstableSafety Net (IV, O2, Monitors)Evaluate ABCsConsider EtiologiesToxic/MetabolicDrugs, electrolytes, endocrine, etcInfectiousSepsis, CNS infections, etcStructuralSubdural, CNS Hemorrhage, etc.Not a pure psychiatric etiology

    GSACEP 2005

  • Initial Approach - Stable Assess Potential for ViolenceAssess for Medical EtiologyRisk AssessmentPsychiatric evaluation

    GSACEP 2005

  • The Violent PatientTypical Associated Diagnoses:Substance Abuse/WithdrawlSchizophrenia, paranoid featuresBipolarPersonality DisordersDepressionSafety is a top priorityAll Psychiatric Patients get UndressedSearch for Weapons/Disarm

    GSACEP 2005

  • The Violent PatientKeep Safe distanceDo not provokeKeep Exit Readily accessibleRapidly Assess Potential for Staff/Patient HarmBetter to underestimateConcern for Violence >>> Perceived RiskRestrain IF Necessary

    GSACEP 2005

  • Use of RestraintsIndication: Real perceived risk that Patient Violence will cause harm to Staff or PatientPreventive MeasureNot PunitiveGoal is to Prevent Harm to Staff/Patient based on perceived Risk of Patient ViolenceDegree of Restraint Clinically Dependent

    GSACEP 2005

  • Levels of RestraintPassiveVerbalNon-VerbalShow of ForceActiveChemicalPhysical

    GSACEP 2005

  • Passive RestraintsNon-VerbalQuiet RoomPrivacy from chaotic ED (not isolation!)Convey patient advocacyVerbalDefine clear boundaries of expected behaviorShow-of-ForceNeed Adequate PersonalHope is to avoid need of further restraintMay worsen situation

    GSACEP 2005

  • Active RestraintsChemicalExplain Necessity of RestraintMinimize Risk of inadvertent NeedlestickHaloperidol (Haldol) 5-10 mg IM/IV q 15-20 minZiprasidone (Geodon) 10-20 mg IMAtivan 1-2 mg IM/IV q 15-20 minOften used in conjunction with Haldol

    GSACEP 2005

  • Active RestraintsPhenothiazinesMay cause Extrapyramidal side effectsDystoniaAkathesiaTreatmentBenadryl 50 mg IVCogentin 1-2 mg IVEffective in the Elderly at lower doses (1-2mg)Theoretical lowering of seizure threshold

    GSACEP 2005

  • Active RestraintsPhysicalExplain NecessityAdequate PersonalIf Female is restrained, need female presentUse 4/5 point leather restraintsSupine PositionRestrain for least amount of time necessaryNursing Intensive (must frequently assess)Requires Good Documentation

    GSACEP 2005

  • Medical AssessmentAre these symptoms related to a medical illness?DeliriumPsychosisAnxiety

    GSACEP 2005

  • DeliriumAcute disturbance in consciousnessPerceptual disturbancesCan wax and waneCommon in patients > 6515-30% mortality in hospitalized elderly patients

    GSACEP 2005

  • Acute PsychosisDisturbances in thought processesDisorganized thinkingPerception disturbancesInterferes with social interactionsA medical etiology should always be sought in new onset psychosis, especially if > 40

    GSACEP 2005

  • AnxietyComplains of anxiety, nervousness, stressMay have sleep problems, restlessness, or concentration problemsIf age > 35 without a clear-cut precipitant, a medical etiology should be pursuedAMIPEDrugsEndocrinopathies

    GSACEP 2005

  • Medical EvaluationHistorical Risk FactorsHigh-risk exam findingsDiagnostic studies

    GSACEP 2005

  • Risk Factors For Medical EtiologyNew onset behavior symptoms and age > 40Sudden alteration in consciousnessNo history of psychiatric diseaseVisual hallucinationNew medicationKnown systemic diseaseAbnormal vital signsSeizure temporally related to behavior changeAlterations in consciousness

    GSACEP 2005

  • High Risk Exam FindingsVitals:Hypertension or hypotensionHyperventilation or hypoventilationTachycardia or BradycardiaFeverHypoxiaAbnormal Neurologic examObvious traumaDermatologic findings

    GSACEP 2005

  • DiagnosticsIf AMS, then need glucose screeningRoutine versus clinically directed testingHistory 94% sensitive for underlying medical conditionInstitutional Protocols

    GSACEP 2005

  • Risk AssessmentDetermine risk of harm to self or othersPsychiatric AssessmentAppearanceOrientationThought ContentPerceptionsSuicide Risk

    GSACEP 2005

  • Psychiatric AssessmentPsychiatric HistoryCurrent/Past psychiatric historyMedicationsSocial HistoryDrug AbuseSocial SituationAlternative Information SourcesFamily/FriendsEMSPsychiatric Exam

    GSACEP 2005

  • Psychiatric ExamAppearanceDisheveled, well-groomed, etc.AffectFlat?BehaviorAnxious, agitated, violent, etc..OrientationPerson, place and time

    GSACEP 2005

  • Psychiatric ExamMoodDepressed, manic, etc..SpeechPressured, slow, flight of ideas, etc.InsightThought ContentHallucinations, delisionsSuicidal/HomicidalJudgement

    GSACEP 2005

  • Psychiatric ExamMini-Mental Status ExamAttentionMemoryOrientationCalculationMost useful with prior baseline establishedOverall goal is to gain better insight into patients current disease status

    GSACEP 2005

  • SuicideOverall, 8th Leading cause of Mortality3rd-leading cause of death in adolescents31,000 deaths per year8-22 ED suicide-related visits for each completed suicide

    GSACEP 2005

  • SuicideWomen Attempt more oftenMen 4 times more likely to SucceedHighest Rates among White American Males ages 65 and OlderFirearms most common means of success for both Males and Females (57%)

    GSACEP 2005

  • Suicidal PatientStabilizeAssess RiskRisk Factors (many)Protective FactorsGet Psychiatry/Social Services InvolvedAvoid Independent decisionsKnow State Laws regarding Involuntary Admission

    GSACEP 2005

  • Suicide Risk FactorsEpidemiologicPsychiatric historySymptomsHopelessnessImpaired concentrationAnxiety/agitationPanic Attacks

    GSACEP 2005

  • Suicide Protective FactorsMedication ComplianceSocial SupportInvolvement in a religious groupBeing a parentAdequate treatment of chronic syndromesPositive coping skills

    GSACEP 2005

  • Suicide Screening ToolsUseful in remembering pertinent questionsUseful in communications with consultantUseful in medical documentationNot a substitute for clinical judgementSADPERSONSModified SADPERSON

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  • SAD PERSONSSex: male 1 pointAge: 45 1 pt.Depression 2 pts.Previous attempts 1 pt.Excessive drug use 1 ptRational thinking loss 2 ptSeparated/Divorced 1 ptOrganized attempt 2 pts.No social support 1 pt.Stated future attempt 2 pts

    GSACEP 2005

  • Modified SADPERSONSSex - 1Age ( 45) - 1Depression - 2Previous attempts or psychiatric care - 1Excessive drug or alcohol use - 1Rational thinking loss - 2Separated, divorced, or widowed - 1Organized or serious attempt - 2No social support - 1Stated future intent - 2

    GSACEP 2005

  • SADPERSONS ScoringSADPERSONS< 2 DC Home3-6 consider hospitalization or close outpatient follow-up> 6 AdmitModified SADPERSONS6-8 Full psychiatric evaluation/treatment> 9 - Admit

    GSACEP 2005

  • Disposition Psychiatric EtiologyFrom your assessments, if you discharge this patient home:Is this patient at increased risk (either intentionally or unintentionally) to harm themselves or others?

    GSACEP 2005

  • Psychiatric ToxicolgyNeuroleptic Malignant Syndrome (NMS)Serotonin Syndrome

    GSACEP 2005

  • NMSComplication of anti-psychotic drugsOccurs within weeks after therapy startedOccurs with increase in dosageSymptomsFeverMuscle rigidityAMSAutonomic Instability

    GSACEP 2005

  • NMSPathophysiology unclearComplicationsRhabdomyolysisRenal FailureHepatic