Behavioral Emergencies PARAMEDIC PROGRAM Summer 08.

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Transcript of Behavioral Emergencies PARAMEDIC PROGRAM Summer 08.

  • Behavioral Emergencies


    Summer 08

  • Strange But TrueA 28-year old male was brought into the ER after an attempted suicide. The man had swallowed several nitroglycerin pills and a fifth of vodka. When asked about the bruises about his head and chest, he said that they were from him ramming himself into the wall in an attempt to make the nitroglycerin explode.

  • Whats this all about?Is it normal or abnormal?Prevalence?Pathophysiology of behavioral and psychiatric disordersFactors that alter behavior or emotional statusMedical legal considerationsOvert behaviors associated with behavioral and psychiatric disorders

  • Verbal techniques useful in mgmt of the emotionally disturbed pt.Appropriate safety measuresWhen should family, etc be removed from premises?Techniques for physical assessmentWhen are you expected to transport a patient against his/her will?To restrain or not?

  • TermsAffectAngerAnxietyConfusionDepressionFearMental statusOpen-ended questionsPosturePost-traumatic stress syndromePsychogenic amnesiaSchizophrenia BereavementBiological/organicBipolar disorderCatatoniaDeliriumDelusionsDementia Flat affectManicMultiple personality disorderPhobiaPositional asphyxia

  • Behavioral and Psychiatric EmergenciesNot clear cutThey require a complete history, exam, and careful/skilled approachMost of what you do will depend on your people skillsBehavioral emergencyBehavior is so unusual, bizarre, threatening or dangerous possibly life-threatening to self or others

  • What is normal, anyway???Determined byCulture Ethnic groupsSocioeconomic classPersonal interpretation, opinionDoes itInterfere with core life functions?Pose a threat to the life or well-being of the patient or others?Significantly deviate from societys expectations?

    Normal ? Behavior that is readily acceptable in a society!

  • Pathophysiology~ 20% of population has some type of mental health problem1 in 7 will require treatmentAnxietyDepressionEating disordersMild personality disordersBehavioral and psychiatric disorders incapacitate more people than all other health problems combined!

  • True/not true?All mental patients are unstable and dangerous Their conditions are incurable

  • Biological causesAlcoholDrugs (including OTC, Rx)InfectionTumors

  • Potential Organic CausesFrontal atrophy from Alzheimers diseaseBrain neoplasm

  • Psychosocial Personality styleDynamics of unresolved conflictCrisis management methodsEnvironmentTraumatic childhood incidents

  • Sociocultural SituationalRelationshipsSupport systemsSocial isolationRape/assaultWitnessing acts of violenceLoss of a jobOngoing prejudice or discrimination

  • Assessment of behavioral patientsThe same as for all other patientsScene size-up look for hazardsInitial assessment watch posture & body languageFocused history Physical examinationYou begin your care at the same time good interpersonal skills!

  • More about the H & EListen open-ended questionsPay attentionSpend timeBe assuredDo not threatenLet there be silencePlace yourself at their levelKeep a safe & proper distanceAppear comfortableDont judgeNever lie

  • Mental status examinationGeneral appearanceBehavioral observations verbal and non-verbalOrientation MemorySensorium is pt. focused, paying attention?Perceptual processes thought patterns ordered?Mood and affectIntelligenceThought processesInsightJudgmentPsychomotor

  • Form a general impression

  • Dementia25 50% over 85 y/o have dementia Alzheimers most commonMini-strokesAffected person sometimes recognizes first signsKeys?Lost while driving, etcCommon tasksDifficulty with wordsTime between first symptoms & death 7 10 years

  • DementiaGradual impairment of memory and cognitive functionsForgetfulnessFailure to recognize objects or stimuliOrientationExcellent recall of past historyMay not remember current eventsAffectNormal or flat, depending on stage of conditionAphasiaImpaired communicationApraxiaImpaired motor activitiesAgnosiaFailure to recognize objectsDisturbance in executive functioningImpaired ability to plan, organize or sequence

  • DementiaCauses:Alzheimers diseaseAIDSParkinsons diseaseVascular diseaseHead traumaSubstance abuse

  • Dementia and DeliriumDelirium may occur in dementia patientsDelirium PresentationRapid onset (hours or days)Inattention, disorientation, memory impairment and visual hallucinationsCauses of delirium are usually reversibleRule out acute medical problems, medication changes

  • Treatment SupportiveMedsAriceptCognex

  • SchizophreniaGross distortions of realityPreoccupation with inner fantasiesWithdrawal from social interactionDisorganization of thoughts, perceptions, and emotionsBehavior linked with medication noncomplianceChronic substance abuse in teenage years linked to development of the disease

  • Schizophrenia SymptomsDisorganized behavior/dressFlat affectDisorganized speechIncoherent or frequently veers off trackDelusionsHallucinationsOften auditory; sometimes visualMotor MovementsMay act upon hallucinations

  • Profiles of Schizophrenic BehaviorDelusional:A man who wraps his house in tin foil to divert the rays from FBI satellites.Paranoid:The man introduces himself as Jesus Christ and tells you that the city council is out to crucify him.

  • Profiles of Schizophrenic BehaviorDisorganized (interview with a physician):S____t on you all who rip into my internals! The grudgerometer will take care of you all! I am the Queen, see my magic, I shall turn you all into sidgelings forever!

  • Profiles of Schizophrenic BehaviorUndifferentiated:Magical thinkingCreates new words or cryptic languageCannot reason abstractly

  • Diagnosis of SchizophreniaTwo or more symptoms must each be present for a significant portion of each month over the course of 6 months. Sx must cause a social or occupational dysfunction Most schizophrenics are diagnosed in early adulthood

  • Approach To A SchizophrenicBe supportiveBe nonjudgmentalDont reinforce the patients hallucinations but know that he considers them realSpeak openly and honestlyBe encouraging and realisticBe alert for aggressive behaviorRestrain patient if necessary

  • Anxiety DisordersPanic AttacksAcute, unprovoked episodesLast approximately 1 hourSymptoms: Cardiac chest pain, nauseaDyspnea or a sense of feeling smotheredFear of going crazyParesthesia, dizzinessTrembling, shaking

  • Mood Disorders: ManiaSudden onset with rapid progression of symptoms (days)Presentation:Progressive inflation of self-esteemDistracted, racing thoughtsDelusions may occurVery talkative with rapid speechExcessive involvement in high pleasure/high risk activities

  • Management for anxiety disorderSimple, supportiveBe empatheticAssess medical complaints & tx prnConsider sedativeValiumVersedAtivanBenadryl

  • Bipolar disorderOne or more manic episodes with or without depression, lasting at least one weekNot commonEpisodes often begin suddenly and escalate rapidlyDisorder usually develops in adolescence or early adulthood

  • The Stages of ManiaMildOn top of the worldEgocentricDecreased need for sleepSevere elationRapid speechIllogical associationsDelusions of grandeurExcessive involvement in pleasurable activities with high potential for consequences

  • Mood Disorders: DepressionSituational vs. persistentLack of interest in daily activitiesAltered mood impairs daily functioningMay be present with other disorders Bipolar diseaseSubstance abuse

  • Presentation of DepressionBizarre behavior usually not seen in depressionInability to see beyond the persons immediate situationLethargy, slow thought process and speechStooped posturePoor appearance

  • General Management ConsiderationsBehavioral crisis development and management are viewed as a spectrumPatients do not suddenly develop anger or passivityUse the scene dynamics wisely to effect patient cooperationNever leave depressed or suicidal patient alone

  • Management (cont.)Assess situationProtect self and othersSummon law enforcement if necessaryIf no evidence of immediate danger, then one EMT responsible for assessing, treating and communicating with patientTransport with consent (when possible) without sirens

  • The Spectrum

  • When is it time for patient restraint?

  • RestraintsUse only when necessary Patient is a danger to themselves or othersLook for all possible causes for the behaviorRestraints must allow for adequate monitoring of vital signsRestraints applied by law enforcement must allow sufficient slack

  • RestraintsPatient must be able to straighten the abdomen and chest and take full breathsThe officer must accompany the patient in the ambulanceApproved equipment for prehospital personnelPadded leatherSoft restraints (posey, velcro, seatbelts)

  • Unapproved Methods Of Restraint For Prehospital PersonnelHard plastic ties or device that requires a key to removeBackboard, scoop, or flat used to sandwich the patient Hog - tied (hands and feet behind the patient)Methods or material that could cause neurovascular compromise Evaluate and document the condition of the restrained extremity (neurovascular check) every 15 minutes.

  • Documentation of Restraint ApplicationReason the restraints were needed Which agency applied the restraints Information and data regarding the monitoring of circulation to the restrained extremityInformation and data regarding the monitoring of respiratory status while restrained

  • Somatoform disordersSomatization disorderPt is preoccupied with physical symptomsConversion disorderLoss of function (blindness, paralysis)HypochondriasisExaggerated interpretation of physical symptoms

  • Neurotransmitters and Behavior

  • Neurotransmitters: NorepiPromotes awakening and enhances dreamsElevates moodCNS locations: cortex, medulla, hypothalamus, limbic system, cerebellumNorEpi locations outside the CNSMania and delusions with overstimulationDepression with low levels

  • Neurotransmitters: DopamineStimulates emotional responses Controls subconscious skeletal movementCNS locations: cerebral cortex, hypothalamus and limbic systemSchizophrenia and schizoid symptoms from amphetamines

  • Neurotransmitters: SerotoninControls sleep, sensory perception, mood controlThermal regulationCNS locations: hypothalamus, limbic system and cerebellumHallucinations with LSD and overstimulationDepression and anxiety with low levels

  • Neurotransmitters: GABAGamma aminobutyric acidDepresses mood and emotionCNS locations: everywhere!Enhanced by benzodiazepinesAnxiety from low levels of GABA

  • Neurotransmitters and Drug Therapy

  • Top prescribed Rx for 2004 & 2007#6, 13 Zoloft (SSRI)#9, 98 Zyprexa (Antipsychotic)#13, 15 Effexor XR (SSRI)#18, 85 Risperdal (Antipsychotic)#19, 31 Seroquel (Antipsychotic)#23, 16 Ambien#47, 19 Welbutrin (SSRI)#53, 86 Ablify (Antipsychotic)#58, 1 Paxil (SSRI)#69, 34 Adderall (Amphetamine)

  • Additional Top Rx - 2003AlprazolamLorazepamClonazepamProzacAmitryptilineTrazadoneDiazepamTemazepamRemeron (Serotonin stimulant)Concerta (amphetamine)

  • Drug Therapies: AntipsychoticsPhenothiazines and their derivativesMellaril, Navane, risperidone, thorazine, stelazine, ProlixinDopamine blockadeWill produce a flatter affectSuppress hallucinations and delusionsSide effects: hypotension, dystonic reactions

  • Drug Therapies: LithiumMetallic compoundSlows the elevated use of serotonin, norepi and dopamine in the synapseSlows sodium transport into the cell and reduces nerve transmissionEffective for chronic control of maniaIn mania, sodium transport occurs 200% more than normal!

  • Drug Therapies: TCA, MAOIBoth work to keep norepinephrine in the synapse longerElevates activity and mood in depressionAnticholinergic effectsOverdoseInitially, massive amounts of norepi released Lack of reabsorption drops functional norepi levels dramaticallySystemic effects!

  • Drug Therapies: SSRIKeeps serotonin in the synapseProzac, Paxil, ZoloftOverdose symptoms typically limited

  • Serotonin SyndromeMedications that work in similar areas as SSRIsTCAs and MAOIsTramadol (narcotic)Meprobamate (Sedative-hypnotic)PromethazineIntense potentiation of SSRI effects

  • Medical Causes Of Behavioral Crises

  • Clues Suggestive Of A Potential Medical Cause Of The BehaviorAbnormal vital signsDepressed level of consciousnessObtundedEvidence of drug or toxin ingestionVery sudden onset of symptomsFocal neurological signsNo previous psychiatric historyPresence of specific physical symptoms

  • A 24 year-old female was seen for manic-type symptoms. She had irritability, rapid speech and distracted conversation. These symptoms had progressed over a 1-week period. She had no history of mental illness or drug intoxication. Lab tests revealed a markedly high T4 level and she was diagnosed with thyrotoxicosis.

  • A 28 year-old female with a history of bipolar disorder was experiencing significant withdrawal and depression. She was apathetic with a flat affect and did not seem to interact with things around her. An hour after admission, she was lethargic, nonresponsive and hypotensive. Lab tests revealed lithium toxicity.

  • A 20 year-old was talking incoherently, picking at her clothes and staring into space. After she was admitted to the hospital, her level of consciousness rapidly deteriorated, becoming disoriented and less responsive. She had no history of psychiatric disease or drug use. Her only history was that of herpes zoster. After an EEG and lumbar puncture, she was diagnosed with encephalopathy.

  • Suicide 9th leading cause of death overall3rd leading cause of death in 15-24 age groupWomen attempt suicide more often, but men are more often successful

  • Assessing Potentially Suicidal PatientsPerform appropriate H & EProvide appropriate psychological careDocument observations, especially any detailed plans

  • Risk factors for suicidePrevious attemptsDepressionAge (15-24, & >40)Alcohol or drug abuseDivorced or widowedGiving away personal belongingsLiving alone/increased isolationPsychosis with depressionMajor separation traumaMajor physical stresses

  • Risk factors, cont.Loss of independenceLack of goals & plans for futureSuicide of same-sexed parentExpression of a plan for suicidePossession of mechanism for suicide (gun, rope, pills)

  • Age-related conditionsGeriatricsYou may mistake depression for dementiaAssess their ability to communicateProvide reassuranceCompensate for vision, hearing lossTreat with respectAvoid administering medication if possibleTake your timeAllow family & friends to be with patient

  • Pediatrics Avoid separating young child from parentMake all explanations brief and simple; repeat oftenBe calm, speak slowlyIdentify yourselfBe truthfulEncourage child to help with his careDont discourage child from crying, showing emotionAllow child to keep favorite blanket or toy

  • Peds, cont.Dont leave child alone, even for short periodIf you must be separated from child, introduce care giver who will take over

  • Management of Sudden Death SituationsResuscitate patient unless obviously deadKeep family informed Be truthful Avoid trite phrases Do not offer false hope Empathize/sympathize Allow emotional response Maintain professionalism

  • Management of terminally illDo not isolate the familyAllow feelings to be expressedProvide for patients physical comfortAllow for patients dignity in dying processResuscitate according to local protocol regardless of a living will

  • GriefMany different reactionsCultural differencesDenialAngerBargainingDepressionAcceptance

  • How you doin?Helplessness/GuiltAnger/FrustrationAvoidanceNightmaresGallows humorPhysiological response

  • Can you cope?RestExerciseHumorHobbiesHave a life outside of EMSTalk!Others?