em 9.1 - the psychiatric patient

Psychosis is a profound disturbance in ___ or ___ to think such that the patient is no longer in touch with reality.

Mood; ability.

Psychosis may occur in what type of psychiatric disorders?

Psychiatric mood disorders.

What mood disorder may occur with psychotic features?

Bipolar I with psychotic features.

Psychosis is often a hallmark of what psychiatric disorder?

Schizophrenia.

Besides psychiatric disease, what major causes can produce psychosis?

Underlying medical disease, overdose, or drug use.

What 7 medical/non-psychiatric causes should be considered in acute agitation?

Hypoglycemia, hypoxia, head injury, delirium, intoxication/withdrawal, CNS infection/meningitis, and hyperthyroidism.

What metabolic abnormality can cause acute agitation?

Hypoglycemia.

What respiratory abnormality can cause acute agitation?

Hypoxia.

What traumatic condition can cause acute agitation?

Head injury.

What altered-mental-status condition can cause acute agitation?

Delirium.

What substance-related causes can cause acute agitation?

Intoxication or withdrawal.

What CNS infectious cause can cause acute agitation?

CNS infection/meningitis.

What endocrine condition can cause acute agitation?

Hyperthyroidism.

How is acute psychosis/agitation primarily diagnosed?

Clinically.

What are the components of the initial evaluation of psychosis?

Interview, quick mental status exam, complete neurologic exam, and head CT if new-onset psychosis.

What history component is part of the evaluation of psychosis?

Interview.

What psychiatric assessment should be performed in psychosis?

Quick mental status exam.

What neurologic evaluation should be performed in psychosis?

Complete neurologic exam.

When should a head CT be obtained in psychosis?

New-onset psychosis.

What labs are included in the psychiatric workup? [11]

CBC, CMP, salicylate, APAP, TSH, UDS, UA, tox screen, blood ETOH, ± POC glucose, and ± CK.

What blood count is included in the psychiatric workup?

CBC.

What chemistry panel is included in the psychiatric workup?

CMP.

What overdose-related salicylate test is included in the psychiatric workup?

Salicylate level.

What acetaminophen test is included in the psychiatric workup?

APAP level.

What thyroid test is included in the psychiatric workup?

TSH.

What urine drug test is included in the psychiatric workup?

UDS.

What routine urine study is included in the psychiatric workup?

UA.

What general toxicology study is included in the psychiatric workup?

Tox screen.

What alcohol test is included in the psychiatric workup?

Blood ETOH.

What bedside glucose test may be included in the psychiatric workup?

± POC glucose.

What muscle-injury/rhabdomyolysis lab may be included in the psychiatric workup?

± CK.

What are the goals of the psychiatric lab workup?

Exclude an underlying medical illness, identify conditions requiring immediate reversal, and rule out conditions that cannot be managed on a psychiatric ward.

Why should underlying medical illness be excluded before psychiatric admission?

The psychiatric symptoms may actually be caused by a medical illness.

What type of condition should psychiatric labs identify immediately?

A condition that should be reversed immediately.

Why must medical problems be identified before transfer to a psychiatric ward?

Some conditions cannot be treated on a psychiatric ward.

What practical reason may psychiatric facilities require labs before admission or transfer?

To satisfy admitting providers.

Is routine laboratory testing of psychiatric patients universally agreed upon?

No; testing of psychiatric patients is debated.

Why are psychiatric labs often still required even though routine testing is debated?

They may be required to get the patient admitted or transferred.

What is the first management approach for an agitated patient when appropriate?

Verbal de-escalation.

What are the major verbal de-escalation strategies for an agitated patient? [12]

Stand near the door, plan an exit route, ask how you can help, offer food/drink, keep hands visible, stand at an angle, introduce yourself and ask what to call them, use short sentences, agree where possible, give choices, set boundaries, and start early.

Where should you stand while verbally de-escalating an agitated patient?

Near the door.

What should you plan before approaching an agitated patient?

Your exit route.

What open-ended question can help de-escalate an agitated patient?

"How can we help you?"

How should you introduce yourself to an agitated patient?

Introduce yourself and ask, "What should I call you?"

What type of sentences should you use with an agitated patient?

Short sentences.

Should you argue with an agitated patient over every incorrect statement?

No; agree with them wherever you reasonably can.

What should you offer during verbal de-escalation to increase cooperation?

Choices.

What should be established early with an agitated patient?

Boundaries.

When should de-escalation begin?

Early.

What medication-related question may help a slightly agitated patient?

"Can I give you anything to make you calmer?"

What may offering an anxiolytic early accomplish in a slightly agitated patient?

Prevent the agitation from progressing.

Should early medication be considered in every agitated patient?

No; only when appropriate.

When should the early-anxiolytic approach NOT be used?

Agitated delirium.

What presentation suggests agitated delirium?

Acute psychosis with sweating and hyperactivity.

What potentially fatal event can agitated delirium progress to?

Cardiac arrest.

What 3 major complications can occur with agitated delirium?

Rhabdomyolysis, hyperkalemia, and hyperthermia.

What muscle-breakdown complication can occur with agitated delirium?

Rhabdomyolysis.

What potassium abnormality can occur with agitated delirium?

Hyperkalemia.

What temperature abnormality can occur with agitated delirium?

Hyperthermia.

What is essential in the treatment of agitated delirium?

Rapid sedation.

Which medication is preferred for rapid sedation of agitated delirium?

Ketamine.

Why is ketamine preferred for agitated delirium?

Rapid onset.

What is the B52 regimen?

50 mg Benadryl IM + 5 mg Haldol IM + 2 mg Ativan IM.

When are benzodiazepines useful in agitated/psychiatric patients?

Anxious patients, including drug intoxication, and patients with alcohol withdrawal.

Which medication class is useful for an anxious patient, including drug intoxication?

Benzodiazepines.

Which medication class is used for alcohol withdrawal?

Benzodiazepines.

When are antipsychotics useful?

Mood or thought disorders causing psychosis, undifferentiated psychiatric patients, and alcohol intoxication.

When are antipsychotics especially useful in psychosis?

When a mood or thought disorder is at the source of the psychosis.

Can antipsychotics be used in an undifferentiated psychiatric patient?

Yes.

Which medication class may be used in alcohol intoxication?

Antipsychotics.

Why may an antihistamine be given with an antipsychotic?

To attenuate extrapyramidal effects and akathisia.

What adverse effects of antipsychotics can antihistamines help attenuate?

Extrapyramidal effects and akathisia.

What are the major rules for using physical restraints?

Use 4-point leather restraints on all four limbs, apply them with a team, document attempts to avoid restraints and the rationale for use, and perform required rechecks/re-documentation.

How should restraints be applied?

By a team.

Is documentation required when restraints are used?

Yes.

What must be documented about attempts before restraints are used?

Attempts at avoiding restraints.

What must be documented about the decision to use restraints?

The rationale for their use.

How often should a restrained patient be rechecked?

At the interval required by institutional protocol.

Is there one universal exact time interval for restraint rechecks?

No; it depends on institutional protocol.

What is usually required again at each restraint recheck?

Documentation.

At what general age does a first psychotic break usually occur?

Young adulthood.

What is the typical age range for a first psychotic break in males?

18-25 years.

What is the typical age range for a first psychotic break in females?

25-35 years.

What two manifestations of a break with reality are emphasized in psychosis?

Delusions and hallucinations.

What is a delusion?

A fixed, false belief that persists despite incontrovertible evidence to the contrary.

What is a hallucination?

A sensory perception in the absence of an external stimulus.

Is a hallucination the same as a mistaken belief about the external environment?

No.

Which type of delusion is plausible?

Ordinary/non-bizarre delusion.

Which type of delusion is implausible?

Bizarre delusion.

What is the difference between a delusion and a hallucination?

A delusion is a fixed false belief; a hallucination is a sensory perception without an external stimulus.

What are the diagnostic steps for new-onset psychosis?

Complete neurologic exam, psychiatric history including past medications and diagnoses, head CT, and psychiatric labs.

What neurologic evaluation should be performed in new-onset psychosis?

Complete neurologic exam.

What should be included in the psychiatric history for new-onset psychosis?

Past medications and past diagnoses.

What imaging should be obtained for new-onset psychosis?

Head CT.

What labs should be obtained for new-onset psychosis?

Psychiatric labs.

What medical/non-primary psychiatric conditions can cause psychosis?

Autoimmune disease, B12 deficiency, drug use, CNS infection, mass lesion, syphilis, endocrine disorders, hepatic encephalopathy, intracranial hemorrhage, withdrawal, and medication side effects.

What autoimmune category can cause psychosis?

Autoimmune disease.

What vitamin deficiency can cause psychosis?

B12 deficiency.

What substance-related cause can produce psychosis?

Drug use.

What CNS infectious cause can produce psychosis?

CNS infection.