Psych EmergenciesEPT MLP Training

Gil,M PA-C

8th leading cause of death for all ages 3rd leading cause of death in adolescents In the past 20 years suicide killed more

people than HIV and AIDS 90% of patients who commit suicide suffer

from a diagnosable mental illness About 40-60% of those who die by suicide

are intoxicated at the time of death 10% of patients who attempt suicide will re

attempt within one year

Stats

Current suicidal ideation Intent/ Plan Hx of Suicide Attempts

◦ Date, circumstances, and method Hx of Mental illness

◦ Intensity of current depressive symptoms◦ Current treatment ◦ Psychotic Symptoms

Auditory command hallucinations, external control, and religious pre occupation

Drug and alcohol use Concurrent medical illness Past or Present hx of Violence/Aggression Recent life stressors Current living situation

History

Make sure patient is fully undressed prior to entering room

Patients belonging should be taken and stored He/She should be checked for any pills, drugs,

weapons, sharp objects ect. Observe patient from doorway or discuss with

nursing interaction, ensure that patient is not threatening

Pt should have sitter at bedside if he/she has active SI complaint or are a danger to themselves

ED Evaluation

Only 13% of surveyed psychiatrists perform a physical exam on their inpatients

Inspect head for trauma or prior neurosurgery◦ Signs of basilar skull fracture

Ocular exam◦ Pinpoint pupils – narcotics, organophosphates or clonidine◦ Dilated pupils – stimulant or anticholinergics, withdrawal from

sedatives, narcotics or post anoxic injury◦ EOMS- impairment seen with Wernicke’s encephalopathy or space

occupying lesions◦ Nystagmus-

Vertical (brain stem lesion), Wernicke’s encephalopathy or congenital Horizontal or rotatory nystagmus suggests drug or more commonly alcohol

toxicity PCP intoxication – blank open eye stair with roving gas, nystagmus and

dilated pupils

Physical Exam

Neck exam- meningeal signs or thyroid enlargement Chest exam – auscultate for PNA, PTX, CHF, COPD,

Heart Murmur – valvular heart disease (endocarditis) Abdominal exam – obstruction, perforation,

hemorrhage, or infection in the abdominal cavity, enlarged liver (jaundice or asterixis)

Inspect skin for rashes, Kaposi sarcoma or petechiae, Track marks

Neuro exam is most frequent deficiency in charts, perform basic neuro exam depending on suspicion of medical diagnosis

Fever in combination with psychiatric complaint is concerning for intracranial infection of systemic illness

Hypoglycemia and hypoxia are common causes of agitation and AMS

Organic Causes

Hypoglycemia may be responsible for up to 10% of altered behavior in ED patients

UDS is unlikely to change managements, patients typically will admit to drug or etoh use if being seen for a psychiatric complaint

Labs including blood chemistries, CBC, UA, toxicology and alcohol have only a 20% sensitivity of detecting a medical disorder

History alone has 95% sensitivity

Diagnostic Testing

CXR – unnecessary in most patients unless hx of cough, tachypnea or low pulse ox, more liberal use in the elderly

CT Head – worrisome headache, focal neuro exam, at risk for chronic subdural (dialysis, anticoagulated, alcoholic, seizures, falls)

LP – Patients with fever, meningismus or immunocompromised

SAD PERSONS ScalePoints

•Sex •Age (<19 or > 45)•Depression or Hopelessness•Previous suicide attempts or psychiatric care•Excessive alcohol or drug use•Rational thinking loss•Separated, divorced or widowed•Organized or serious attempt•No Social Supports•Stated future intentScore 6-8: Full Emergency Psychiatric Eval/TreatmentScore 9 or greater: Immediate Psychiatric Hospitalization

1121121212

Compliance with psychiatric medications Social Support Involvement in a religious group Being a parent Positive coping skills Adequate treatment of chronic pain or

substance abuse Adequate followup

Factors Protective Against Suicide

Patient and Complaint Dependent Attempted Suicide

◦ CBC, BMP◦ Etoh, UDS, APAP, Salicylate level◦ EKG◦ Preg

At a minimum◦ Most will require Istat8, UDS, etoh, preg

Lab Workup

PERS- Consult for voluntary admissions, ED Consults

CSB- Social Worker who will find placement for ECO/TDO patients

ECO- Emergency Custody Order TDO- Temporary Detention Order

◦ Medical- Patients who are deemed not able to refuse treatment or lab work because of medical condition

Abbreviations to Know

4% of the time a medical diagnosis is missed Deficiencies in history and physical examination accounted

for the vast majority of illness Most common are infection, pulmonary, thyroid, diabetic,

hematopoietic, hepatic and CNS disease Hypoglycemia, Hypoxia and Thyroid disease should be

considered in all patients with new onset psychiatric disease Serum Sodium > 160 mEq/L is associated with AMS Serum Sodium < 115 mEq/L produces confusion, coma and

even seizures Hypercalcemia < 14 mg/dl can cause lethargy and mental

status change◦ Malignant neoplasms and hyperparathyroidism account for the vast

majority of hypercalcemia

Not Missing A Medical Dx

Disturbance of consciousness occurring over a short time and affecting attention, with impairment in other cognitive function

May be disoriented to time or place but not to person

Perceptual disturbances including misinterpretations, illusions or hallucinations

Disturbances develop abruptly and fluctuate Drug toxicity or withdrawal accounts for up to 30%

of all cases of delirium UTI is one of the most common causes of delirium in

the elderly

Delirium

Effective loss of reality testing, a disturbance of thought processes and consequently, changes in behavior

Disrupts perception and disorganizes thinking to a degree that interferes with social interactions

Suspect medial etiology in new cases of psychosis, especially if patient in > 40 y.o

Psychosis

Major depression diagnosis requires alterations in mood, psychomotor activity, and cognition

15% of patients with major depression commit suicide

Depression

Persistently elevated, expansive or irritable mood

At least three of the following: inflated self esteem or grandiosity, decreased need for sleep, increased talkativeness, flight of ideas, easy distractibility, increased activity or an excessive quest for pleasure

Mood disturbance is severe enough to markedly interfere with job performance and personal relations

Mania

Complaints of anxiety, nervousness, panic or stress

Sleep disturbance, irritability, difficulty concentration, easy fatigue, restlessness, and muscle tension

If a patient has a panic attack after age 35 and there is no clear cut psychologic precipitant, suspect a medical cause, hyperthyroidism, hypoxia, hypoglycemia, or drug toxicity.

Anxiety

Sensation of bugs crawling under skin- associated with cocaine or speed use

Bugs on the walls – alcohol withdrawal Visual Hallucinations are strongly associated

with a medical pathology Seizure prior to presentation suggests postictal

sate or nonconvulsive status epilepticus Palpitations, tremor and weight loss suggests

hyperthyroidism Headache suggests CNS tumor, meningitis or

chronic subdural hematoma

Key History

Late age (over 40) of onset of a new behavioral symptom No past medical history of psychiatric illness Sudden onset of altered behavior Presence of a toxidrome Visual Hallucinations Known systemic disease with new onset behavior change New Medication Altered behavior temporally related to a convulsive seizure Abnormal vitals Disorientation Clouded consciousness

Findings Suggestive of An Underlying Medical Basis For Psychiatric Symptoms

Very Uncooperative patient ◦ 5 MG IM Haldol + 2 MG IM Ativan + 50 MG IM

Benadryl, one syringe◦ OR 10mg Geodon IM

Somewhat cooperative◦ PO dosing of above Rx

Treatment of Agitation

Acute behavior changes in elderly are at risk for adverse outcomes

Common sequela to infection or other disease

Nearly 20% of elderly patients brought for emergency psychiatric eval may be suffering from a drug reaction◦ Review BEERS Criteria

http://chpw.org/resources/Providers/Beers_Criteria.pdf

Elderly