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

• Stable vs Unstable

• Violent vs non-Violent

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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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Psychiatric Toxicolgy

• Neuroleptic Malignant Syndrome (NMS)

• Serotonin Syndrome

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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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