psychiatric emergencies
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Psychiatric Emergencies
Wesley Zeger, DOUniversity of Nebraska Medical Center
GSACEP Core Lecture Series
GSACEP © 2005
Objectives
• List typical presentations of psychiatric emergencies
• List 2 aspects of the role of the emergency medicine physician
• Describe an organized approach for the evaluation of the psychiatric patient
• Describe the difference between active and passive restraints
• List 3 psychiatric symptoms that may have underlying medical etiologies
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Objectives
• List 8 risk factors for psychiatric symptoms presenting as underlying medical conditions
• List the components of the psychiatric assessment
• List the components for the SADPERSONS screening exam
• List complications of psychiatric medications and the management
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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…
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Your Patient Returns…
• About 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.
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The ED Population
• At Least 10% of ED Patients present with Psychiatric Emergencies
• Up to 50% of ED Patients have psychiatric illnesses
• Up to 50% of psychiatric patients have an underlying undiagnosed medical condition
• Up to 50% of patients with substance abuse have psychiatric illnesses
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Typical Presentations
• Depressed
• Anxious/Agitated
• Uncooperative
• Suicidal/Homicidal
• Substance abuse
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Role of the Emergency Physician
• Medical Assessment/Stabilization
• Risk Assessment– Delirium/psychosis– Suicide
• Disposition
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Initial Approach - Unstable
• Safety Net (IV, O2, Monitors)• Evaluate ABC’s• Consider Etiologies
– Toxic/Metabolic• Drugs, electrolytes, endocrine, etc…
– Infectious• Sepsis, CNS infections, etc…
– Structural• Subdural, CNS Hemorrhage, etc….
– Not a pure psychiatric etiology
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Initial Approach - Stable
• Assess Potential for Violence
• Assess for Medical Etiology
• Risk Assessment– Psychiatric evaluation
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The Violent Patient
• Typical Associated Diagnoses:– Substance Abuse/Withdrawl– Schizophrenia, paranoid features– Bipolar– Personality Disorders– Depression
• Safety is a top priority• All Psychiatric Patients get Undressed• Search for Weapons/Disarm
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The Violent Patient
• Keep Safe distance– Do not provoke– Keep Exit Readily accessible
• Rapidly Assess Potential for Staff/Patient Harm– Better to underestimate– Concern for Violence >>> Perceived Risk
• Restrain IF Necessary
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Use of Restraints
• Indication: Real perceived risk that Patient Violence will cause harm to Staff or Patient
• Preventive Measure– Not Punitive
• Goal is to Prevent Harm to Staff/Patient based on perceived Risk of Patient Violence
• Degree of Restraint Clinically Dependent
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“Levels” of Restraint
• Passive– Verbal– Non-Verbal– Show of Force
• Active– Chemical– Physical
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Passive Restraints
• Non-Verbal– Quiet Room– Privacy from “chaotic” ED (not isolation!)– Convey patient advocacy
• Verbal– Define clear boundaries of expected behavior
• Show-of-Force– Need Adequate Personal– Hope is to avoid need of further restraint– May worsen situation
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Active Restraints
• Chemical– Explain Necessity of Restraint– Minimize Risk of inadvertent Needlestick– Haloperidol (Haldol) – 5-10 mg IM/IV q 15-20
min– Ziprasidone (Geodon) – 10-20 mg IM– Ativan – 1-2 mg IM/IV q 15-20 min
• Often used in conjunction with Haldol
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Active Restraints
• Phenothiazines– May cause Extrapyramidal side effects
• Dystonia• Akathesia
– Treatment• Benadryl – 50 mg IV• Cogentin – 1-2 mg IV
– Effective in the Elderly at lower doses (1-2mg)– Theoretical lowering of seizure threshold
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Active Restraints
• Physical– Explain Necessity
– Adequate Personal
– If Female is restrained, need female present
– Use 4/5 point leather restraints
– Supine Position
– Restrain for least amount of time necessary
– Nursing Intensive (must frequently assess)
– Requires Good Documentation
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Medical Assessment
• Are these symptoms related to a medical illness?– Delirium– Psychosis– Anxiety
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Delirium
• Acute disturbance in consciousness
• Perceptual disturbances
• Can wax and wane
• Common in patients > 65
• 15-30% mortality in hospitalized elderly patients
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Acute Psychosis
• Disturbances in thought processes
• Disorganized thinking
• Perception disturbances
• Interferes with social interactions
• A medical etiology should always be sought in new onset psychosis, especially if > 40
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Anxiety
• Complains of anxiety, nervousness, stress• May have sleep problems, restlessness, or
concentration problems• If age > 35 without a clear-cut precipitant, a
medical etiology should be pursued– AMI– PE– Drugs– Endocrinopathies
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Medical Evaluation
• Historical Risk Factors
• High-risk exam findings
• Diagnostic studies
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Risk Factors For Medical Etiology
• New onset behavior symptoms and age > 40• Sudden alteration in consciousness• No history of psychiatric disease• Visual hallucination• New medication• Known systemic disease• Abnormal vital signs• Seizure temporally related to behavior change• Alterations in consciousness
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High –Risk Exam Findings
• Vitals:– Hypertension or hypotension– Hyperventilation or hypoventilation– Tachycardia or Bradycardia– Fever– Hypoxia
• Abnormal Neurologic exam• Obvious trauma• Dermatologic findings
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Diagnostics
• If AMS, then need glucose screening
• Routine versus clinically directed testing
• History 94% sensitive for underlying medical condition
• Institutional Protocols
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Risk Assessment
• Determine risk of harm to self or others
• Psychiatric Assessment– Appearance– Orientation– Thought Content– Perceptions– Suicide Risk
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Psychiatric Assessment
• Psychiatric History– Current/Past psychiatric history– Medications
• Social History– Drug Abuse– Social Situation
• Alternative Information Sources– Family/Friends– EMS
• Psychiatric Exam
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Psychiatric Exam
• Appearance– Disheveled, well-groomed, etc.
• Affect– Flat?
• Behavior– Anxious, agitated, violent, etc..
• Orientation– Person, place and time
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Psychiatric Exam
• Mood– Depressed, manic, etc..
• Speech– Pressured, slow, flight of ideas, etc.
• Insight• Thought Content
– Hallucinations, delisions
• Suicidal/Homicidal• Judgement
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Psychiatric Exam
• Mini-Mental Status Exam– Attention– Memory– Orientation– Calculation– Most useful with prior baseline established
• Overall goal is to gain better insight into patient’s current disease status
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Suicide
• Overall, 8th Leading cause of Mortality
• 3rd-leading cause of death in adolescents
• 31,000 deaths per year
• 8-22 ED suicide-related visits for each completed suicide
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Suicide
• Women Attempt more often
• Men 4 times more likely to Succeed
• Highest Rates among White American Males ages 65 and Older
• Firearms most common means of success for both Males and Females (57%)
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Suicidal Patient
• Stabilize• Assess Risk
– Risk Factors (many)– Protective Factors
• Get Psychiatry/Social Services Involved– Avoid Independent decisions
• Know State Laws regarding Involuntary Admission
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Suicide – Risk Factors
• Epidemiologic
• Psychiatric history
• Symptoms– Hopelessness– Impaired concentration– Anxiety/agitation– Panic Attacks
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Suicide – Protective Factors
• Medication Compliance
• Social Support
• Involvement in a religious group
• Being a parent
• Adequate treatment of chronic syndromes
• Positive coping skills
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Suicide – Screening Tools
• Useful in remembering pertinent questions
• Useful in communications with consultant
• Useful in medical documentation
• Not a substitute for clinical judgement
• SADPERSONS
• Modified SADPERSON
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SAD PERSONS
• Sex: male – 1 point• Age: <19, > 45 – 1 pt.• Depression – 2 pts.• Previous attempts – 1 pt.• Excessive drug use – 1 pt• Rational thinking loss – 2 pt
• Separated/Divorced – 1 pt• Organized attempt – 2 pts.• No social support – 1 pt.• Stated future attempt – 2 pts
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Modified SADPERSONS
• Sex - 1
• Age (<19 or > 45) - 1
• Depression - 2
• Previous attempts or psychiatric care - 1
• Excessive drug or alcohol use - 1
• Rational thinking loss - 2
• Separated, divorced, or widowed - 1
• Organized or serious attempt - 2
• No social support - 1
• Stated future intent - 2
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SADPERSONS Scoring
• SADPERSONS– < 2 – DC Home
– 3-6 – consider hospitalization or close outpatient follow-up
– > 6 Admit
• Modified SADPERSONS– 6-8 – Full psychiatric
evaluation/treatment
– > 9 - Admit
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Disposition – Psychiatric Etiology
• From your assessments, if you discharge this patient home:– Is this patient at increased risk (either
intentionally or “unintentionally”) to harm themselves or others?
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NMS
• Complication of anti-psychotic drugs– Occurs within weeks after therapy started– Occurs with increase in dosage
• Symptoms– Fever– Muscle rigidity– AMS– Autonomic Instability
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NMS
• Pathophysiology – unclear
• Complications– Rhabdomyolysis– Renal Failure– Hepatic Failure– Cardiovascular Collapse
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NMS - Treatment
• Key is early identification
• Discontinue Drug
• Hydration
• Supportive Measures
• Severe Cases– Dantrolene 1mg/kg (max 10mg/kg), IV push– Bromocriptine – Used in case reports
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Serotonin Syndrome
• Increasing frequency secondary to relatively new SSRI’s being prescribed– Prozac
– Zoloft
– Paxil
– Luvox
• Can occur with any drug that increases CNS levels of serotonin– MAOI’s, TCA’s
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Serotonin Syndrome
• Occurs when excessive CNS serotonin exists
• Precipitated variety of ways– Increase dosage of drug– Overdose– Interaction with other drugs that enhance
SSRI’s activty• Demerol, codeine, dextramethoraphan, etc…
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Serotonin Syndrome
• Constellation of symptoms– Altered mental status– Behavior changes– Neuromuscular abnormalities/altered muscle
tone (lower extremities > upper extremities)– Autonomic instablilty– Hyperpyrexia– Diarrhea
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Serotonin Syndrome
• Treatment– Key is identification
• Need to differentiate from NMS
– Supportive care (decontaminate prn)– Symptoms typically last 6-24 hours– Cyproheptadine may be useful
• 4mg po, or 0.25 mg/kg po, TID
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To Sum Up…
• Psychiatric patients need thoughtful work-up– Consider medical/trauma etiologies
– Do good psychiatric exam
• Get ancillary services/unit involved early• Admit:
– Patients at risk for self-harm• Suicidal, psychotic
– Patients at risk for harming others• Homicidal, psychotic
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Pitfalls
• Diagnosis: New onset anxiety
• Diagnosis: Conversion disorder
• Not addressing abnormal vital signs
• Inadequate amount of personnel used for physical restraints
• Failure to consider medical etiology
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Red Flags
• Abnormal vital signs• Abnormal physical exam• No Hx of psychiatric disease• Hx or evidence of potential trauma• Hx of substance abuse/use
– Prescribed
– Illicit
• Acute worsening of disease
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