lecture 23: psychiatric emergencies

uncover an organic condition, keep everyone SAFE

what is the goal of an ED psych encounter?

•Life threatening examples: sepsis, delirium, toxidromes (acetaminophen, salicylates, TCAs, neuroleptic malignant syndrome serotonin syndrome), metabolic (DKA, hepatic encephalopathy), and trauma (subdural/epidural hematomas)

examples of organic conditions commonly mistaken for psychiatric disorders:

•Assess or screen for high-risk: suicidal/homicidal, psychotic/violent, risk of elopement

•Place in room with no objects/devices that can be used to harm self or staff

•Undress patient, provide hospital gown, screen for weapons

components of triaging a psych pt

many psych drugs prolong QTc

EKG might be helpful for a psych pt because

medical clearance

-better to say "medically stable" or "completed focused medical assessment"

•an administrative term to aid in disposition, not a clinical term

-does NOT mean pt is free from disease requiring treatment; but can be treated at psych facility

psychiatric hold

•involuntary confinement for safety.

•Gives healthcare providers legal custody of patient. Does not confer treatment against their wishes, except for threat to life or limb (i.e. trauma, overdose, etc.)

•An imminent danger to themselves (suicide/self-harm/poor insight)

•An imminent danger to others (homicidal ideation)

•Gravely disabled.

how can a patient qualify for a psychiatric hold?

•Short-term emergency hospitalization

•Extension to ongoing inpatient hospitalization

•Intensive outpatient treatment

what are the levels to mandatory psychiatric care?

•Appearance

•Orientation

•Affect/mood

•Thought content - delusions/organization/obsessions

•Perception - hallucinations

•Speech

•Insight/Judgement

•Cognition

components of a mental status exam:

-quickly control, ensure safety

-if possible, start with verbal de-escalation--> pharm sedation--> physical restraint

work up for acute agitatiioin

•hypoglycemia, hypoxia, head trauma, delirium, intoxication/withdrawal, hyperthyroid, CNS infection (meningitis)

potential medical etiologies of acute agitation

agitated delirium

several street drugs can cause this type of agitation

•Hyperactive heart, muscle contractions, tachypnea can lead to ---> Hypoxia, hyperthermia, rhabdomyolysis, or cardiac arrest

-respect personal space: at least 2 arms length distance

-do not be provocative, introduce self, be concise

-identify expectations

-listen, set limits

-offer choices

-debrief pt and staff

recommendations for verbal de-escalation

•IM is most common, IV often impractical/impossible initially

most common administration type of pharm 'restraints' for agitated pt

an antipsychotic

if problem with agitated pt is psych or alcohol, pharm de-escalation is

Benzodiazapene

if problem with agitated pt is a sympathomimetic overdose, pharm restrain them with

Diphenhydramine

___________ can reduce side effects of antipsychotics

Patient poses immediate threat to self/others/obstructing evaluation

-don't use willy nilly! admages rapport and potentially harmful

indication for physical restraints

-abnormal vitals

-age <12 or >40 without previous diagnosis

-focal neuro findings, visual hallucinations, psychomotor retardation, recent memory loss, sudden onset, no prior psychiatric illnesses, no family hx, hx of substance abuse

clues that a new onset psychosis could have an organic cause

neuroleptic malignant syndrome

•Symptoms: fever, muscle rigidity, altered mental status, autonomic instability

•Can occur at anytime

treat in ICU with dantrolene (muscle relaxant), bromocriptine

treatment of neuroleptic malignant syndrome

-neuroleptic malignant syndrome

-seizures

-orthostatic hypotension

-extrapyramidal effects

-QT prolongation

antipsychotic adverse reactions

akathisia

motor restlessness due to adverse effect of antipsychotic

propranolol

treatment of akathisia

acute laryngospasm

life threatening dystonia associated with antipsychotic use

benzotropine/diphenhydramine

treat the extrapyramidal effects of antipsychotics with

rural

is suicide rate higher in rural or urban areas

firearms

primary method of suicide

previous attempt

strongest risk factor for suicide

suicide

10th leading cause of death overall

highest among men >70

age and gender with highest rate of suicide

•Form of self-treatment, allows them to dissociate, to relieve negative emotions/thoughts

why do pts use self-harm behaviors?

adolescents and young adults

age demographic with the highest rate of self-harm behaviors

Patient safety screener (PSS-3)

-ED suicide screening tool

•In the past 2 weeks:

•Have they felt depressed

•Have they had suicidal thoughts

•Any history of an attempt?

•Recent (within 6 months)?

•Network of stable, supportive relationships

•Responsibility for young children

•Religious beliefs

•Success in a job/education

•Coping/problem solving skills

•Limited access to lethal means

protective factors against suicide

54%

____% of people who die by suicide had no known mental health conditions

•First, ABCs --> address trauma, toxidrome, medical complications

•May need to be admitted for medical complications/trauma/surgery

first step in assessing a pt with a suicide attempt

•Must no longer be suicidal

•Have somewhere to stay, with trusted relationship

•Access to lethal means removed

•Use a discharge checklist (education, safety plan, medications, activities, follow up)

indications to send a suicidal patient to an intensive outpatient service