Psychiatric Emergencies (Behave)

What races have the highest rates of suicide in the US

American Indian / Alaska Native (#1)

White (#2)

Native Hawaiian / Pacific Islander (#3)

What is the gender difference in suicide

Women are more likely to attempt

Men are more likely to die

Most Common Methods of Suicide in US Adults

Firearm (#1)

Suffociation (Most for children)

Poisoning

What age ranges are most common in suicide

85+ (#1)

75-84 (#2)

35-44 (#3)

Deliberate self-harm/ Parasuicide/ Self-injurious behavior (SIB)

Willful self-inflicting of painful, destructive, or injurious acts without intent to die.

Types of Suicidal ideation

Passive

Active

Passive Suicidal ideation

Wish to be dead

Active Suicidal ideation

Thought of serving as the agent of one’s own death

Suicide attempt

Self-injurious behavior with a nonfatal outcome accompanied by explicit or implicit evidence that the person intended to die

Aborted suicide attempt

Potentially self-injurious behavior with explicit or implicitly evidence that the person intended to die but stopped the attempt before physical damage

Suicide

Self-inflicted death with explicit or implicit evidence that the person intended to die.

Risk Factors for Suicide

History of suicide attempt (#1)

Psychiatric disorders

Substance use

Medications

Age, sex, race

Marital status

Occupation

Military service

Adverse childhood experiences

Family history

Medical illness

What medications have been linked to suicidial behavior

Antidepressants

Glucocorticoids

Anticonvulsants

Tramadol (Ultram)

Varenicline (Chantix)

Isotretinoin (Accutane)

Montelukast (Singulair)

What anticonvuslants are linked to sucidiality

Gabapentin

Lamotrigine

Oxcarbazepine

Tiagabien

what professions are considered high risk for suicide

First responders (police, fire, EMS)

Military

Doctors/dentists

What are protective factors for suicide

Social support and family connectedness

Pregnancy and parenthood

Religiosity and participating in religious activities

What are myths about suicide

Asking about suicide will put the thought into their head

If someone is suicidal, they will do it no matter what you do.

If someone is going to do it, they are not going to tell you

If you stop someone from killing themselves, they will just find another way.

Columbia Suicide Severity Rating Scale (CSSRS)

An assessment tool that can be universally used to evaluate a patient for suicidal ideation and behavior

Nine Item (PHQ-9)

A depression scale that can indicate sucidiality

Beck Hopelessness Scale

20-item true/false questionnaire that correlates more closely with current suicide attempt than depression severity

What are the elements of suicide evaluation

Ideation

Plan

Intent

What questions are asked in the ideation part of evaluation for suicide?

Presence of suicidal thoughts?

Changes to any chronic suicidal thoughts?

Lost interest in living?

Better off dead?

What questions are asked in the plan part of evaluation for suicide?

Has a plan been formulated or implemented, including a specific method, place, and time?

Are the means of committing suicide available or readily accessible?

What is the lethality of the plan?

What is the likelihood of rescue?

What questions are asked in the intent part of evaluation for suicide?

Have any preparations/ acts of furtherance been made or how close has the patient come to completing the plan?

What is the strength of the intent to carry out suicidal thoughts and plans, including the ability to control impulsivity?

What should be assessed along side suicidality eval

Assess for hopelessness and their view of the future

Assess for acceptance of suicide

Assess for alcohol and substance abuse history, including a history of binge drinking

Observe whether the patient is disconnected or disengaged during the clinical interview, or shows a lack of rapport

assess for protective factors, support systems, and anything that you can pick up on in the patient’s wording that may be a reason for them to live,

What are the main aspects of management for suicidiality

Reduce immediate risk

Manage underlying factors

Monitoring and follow-up

How do we reduce immediate risk for suicide

Consider immediate hospitalization

contact the patient's mental health provider

Have a staff member sit with the patient while arrangements for further care are made

Clear the room of objects that could potentially be used to inflict harm

belongings also may need to be searched

patient demands to leave, security staff or local police may need to be called

need to be transported to the appropriate facility via ambulance

How should be immediatly hospitalized for suicidiality

Patients who have attempted suicide

Patients at imminent risk for self-harm

What are resources for managment for suicide

Inpatient admission

Partial Program

Psychiatry/Psychologist

Crisis hotline (988)

Pennsylvania 201

Voluntary Commitment

What is the duration of the 201

Patient can leave on their own (72-hour notice)

What is the age of consent for 201

14 y/o

Pennsylvania 302

Involuntary Commitment for up to 120 hours

What is needed to file a 302

petitioner, mental health administrator/delegate, and examining physician

OR

2 physicians

If given a 302, what can the patient no longer do

own, possess, or purchase a firearm

Pennsylvania Act 65

Adolescents age 14 up until 18, Parents/guardians of minors <18 can consent to outpatient or inpatient treatment without the consent of the other

What is the immediate risk reduction for elevated risk suicidiality but not imminent harm

Involve family members or people close to the patient

Ask about the availability of firearms and make them temporarily inaccessible to the patient

Increase the frequency of clinical contact with the patient

Aggressively treat psychiatric disorders

Contract for Safety

what medications for psychiatric conditions should be avoid in a suicidial patien

TCAs and MAOIs

Contract for Safety

Patients can promise clinicians that they will try not to harm themselves when they are suicidal.

What can be a precipitating event for suicide

Death of loved one

Loss of job

Divorce

School / Social Failure

Sexual Identity Crisis

Trauma

When is the risk of suicidiality high after hospitalization

high in the first week after discharge

particularly if patients perceive that they have lost a therapeutic support system

survivors of suicide are at high risk for

MDD,

PTSD,

Prolonged Grief Disorder,

suicidality

National Alliance on Mental Illness (NAMI)

Survivors of suicide support groups

Neuroleptic Malignant Syndrome

Life threatening condition Associated with a class of medications that block dopamine transmission

Presentation of Neuroleptic Malignant Syndrome

develop over days

Fever

Rigidity

Mental status change

Autonomic instability

What medications are linked to neuroleptic malignant syndrom

High Potentcy Typical Antipsychotics (#1)

• Haloperidol (Haldol)

• Fluephenazine (Prolixin)

Low Potency Typical

• Chlorpromazine (THorazine)

Atypical

• Clozapine (Clozaril)

• Rispierdone (Risperdal)

• Olanzapine (Zyprexa)

antiemetics

• Metoclopramide (Reglan)

  • Promethazine (Phrergen)

When does Neuroleptic Malignant Syndrome tend to occur

Usually occurs in the first 2 weeks of treatment

Most occur within 30 days

Risk Factors for Neuroleptic Malignant Syndrome

Prior episode

High potency antipsychotics

Exhaustion

Dehydration

Iron deficiency

Agitation

Rapid dose escalation/ higher total dose

Lithium

What is most common first symptom of Neuroleptic Malignant Syndrome

Mental Status Change

How can Mental Status Change present with Neuroleptic Malignant Syndrome

agitated delirium with confusion

patient appearing alert but dazed and unresponsive

What type of rigidity is seen in neuroleptic malignant syndrome

lead pipe rigidity

lead pipe rigidity

stable resistance through all ranges of movement

cogwheel phenomenon

Rigidity with superimposed tremor may lead to a ratcheting quality

How does muscle rigidity in neuroleptic present

Lead Pipe Rigidity

Cogwheel Phenomenon

Unresponive to anti-Parkinson’s

Dysarthria

Dysphagia

Rhabdomyolysis

Akinesis

Trismus

What satisfies the fever requirement for neuroleptic malignant

Temp > 100.4 orally on 2 occasions measured orally

How does the autonomic instaiblity present for neuroleptic malignant

Tachycardia

Labile or high blood pressure

Tachypnea

Dysrhythmias

Diaphoresis

Urinary incontinence

What lab most correlates to the severity of neuroleptic malignant syndrome

Serum CK

What are the lab results for Neuroleptic Malignant Syndrome

Elevated serum CK

Leukocytosis

Mild LDH elevation

Mild LFT elevation

hypocalcemia,

hypomagnesemia,

hypo/hypernatremia,

hyperkalemia,

metabolic acidosis

Myoglobinuric acute renal failure (Rhabdo)

low serum iron

Treatment for Neuroleptic Malignant Syndrome

STOP THE AGENT

Admit to ICU

Maintain cardiorespiratory stability

Maintain euvolemia

Lower fever

Lower blood pressure if markedly elevated

Heparin or low molecular weight heparin for prevention of deep venous thrombosis

Use benzodiazepines to control agitation and/or muscle rigidity, if necessary

Dantrolene

Bromocriptine

Amantadine

ECT

How do we lower fever in neuroleptic malignant

Cooling blankets

More aggressive physical measures may be required: ice water gastric lavage and ice packs in the axilla

Dantrolene

Direct-acting skeletal muscle relaxant

MOA for Dantrolene in NMS

Reduction of heat production as well as rigidity

Risk of Using Dantrolene

hepatotoxicity

respiratory depression

What is the duration for medications for treatment of NMS

10 days after symptoms resolve with slow taper after

Bromocriptine

Dopamine agonist

MOA of Bromocriptine for NMS

restores lost dopaminergic tone

SE of Bromocriptine

Hypotension

Vomiting

Amantadine

Dopaminergic and anticholinergic effects

Indication for Amantadine

alternative to bromocriptine for NMS

Indication for ECT for NMS

pharmaceutical resistance after 1 week,

those with residual catatonia,

those in whom lethal catatonia is suspected as an alternative or co-occurring disorder

SE of ECT

: cardiac arrhythmias,

status epilepticus,

temporary memory impairment

What are poor neuro prognostic factors for NMS

severe hypoxia

grossly elevated temperatures for a long duration.

How do we restart neuroleptics following treatment of NMS

Wait at least two weeks before resuming therapy, longer if any clinical residua exist

Use lower rather than higher potency agents

Start with low doses and titrate upward slowly

Avoid combining lithium

Avoid dehydration

Carefully monitor for symptoms of NMS

Serotonin Syndrome

Potentially life-threatening condition associated with increased serotonergic activity in the central nervous system

What are the cases that serotonin syndrome is typically seen

Therapeutic medication use

Inadvertent interactions between drugs

Intentional self-poisoning

S/p cardiac arrest in patients treated with therapeutic hypothermia

What is the most common medication associated with serotonin syndrome

SSRIs

What is the most likely medications to cause serotonin syndrome

SNRIs

TCAs

What effect does serotonin have in the body

Modulates attention, behavior, sleep-wake cycle, and thermoregulation

promotes platelet aggregation

Regulates gastrointestinal motility

vasoconstriction

What receptors are stimulated in serotonin syndrome

5-HT1A

5-HT2A

What medications can cause serotonin syndrome

SSRI

SNRI

TCA

MAOIs

Lithium

LSD

MDMA

Cocaine

Amphetamines

Oxycodone

Meperidine (Demerol)

Tramadol (Ultram)

Ondansetron (Zofran)

Chlorpheniramine

Presentation of Serotonin Syndrome

Headache,

Altered mental status

• agitation,

• confusion

Autonomic Instability

• Hyperthermia,

• Shivering

• tachycardic,

• diaphoretic

• Dilated pupils

• Hyperactive Bowel Sounds (N/V/D)

• HTN

Neuromuscular hyperactivity

• Clonus

• Hyperreflexia

• Tremor

• Increased muscle tone

Death

Hunter Criteria

The diagnostic criteria for Serotonin Syndrome

• Must have taken a serotonergic agent

• One of the following

  • Spontaneous clonus

  • Inducible clonus PLUS agitation or diaphoresis

  • Ocular clonus PLUS agitation or diaphoresis

  • Tremor PLUS hyperreflexia

  • Hypertonia PLUS temperature above 38ºC PLUS ocular clonus or inducible clonus

What is considered “presence of serotoninergic agent” for Hunter Criteria

Overdose

Drug-drug interaction of 2 serotonergic agents

Initiation or increased dose of a serotonergic agent or an agent that decreases the metabolism of a serotonergic agent

When does Serotonin Syndrome typically preesent

majority present within 24 hours of a change in dose or initiation of a drug

Most within 6 hours

Complications of Serotonin Syndrome

DIC

Rhabdomyolysis/ myoglobinuria

Metabolic acidosis

Renal failure

Acute respiratory distress syndrome

What labs are ordered for Serotonin Syndrome

CBC

CMO

CPK

TSH

Coag

UA

Blood Culture

LP / CSF Study

Head CT

CXR

EKG

What is the disposition for Serotonin Syndrome

Mild symptoms for 4-6 hours + Normal Mental + Normal Vitals + No DTR or Clonus → Discharge to home with close follow-up

Moderate Symptoms → Admit for observation on cardiac montior

Severe → ICU

Treatment for Serotonin syndrome

Discontinue all serotonergic agents

IV Fluids

O2 > 94%

For tachycardia and HTN → short acting BBs or CCBs

For hypotension → Pressors (Avoid dopamine)

Sedate with benzos (Lorazepam or Diazepam)

For hyperthermia → Muscle Relaxer

Cyproheptadine

Cyproheptadine

Histamine-1 receptor antagonist with nonspecific 5-HT1A and 5-HT2A antagonistic properties

Indication for Cyproheptadine

benzodiazepines / supportive care fail control agitation / vital signs of Serotonin syndrome

SE of Cyproheptadine

Sedation

Where is the most common place for providers to be vicitim of violence

ED

What are the most common dx in combative patients?

Drug or ETOH intoxicaiton/withdrawal

What should be obtained in all agitated patients at minimum

Rapid glucose

Pulse Ox

Complete Vitals

FIND Me

A mnemonic for the causes of agitation

• Functional [ie, psychiatric]

• Infectious

• Neurologic

• Drugs

• Metabolic

• Endocrine

What are safety interventions for agitated patients

Metal detectors, Security, Monitors, Limiting access

safe distance to the door

stand between the patient and the door

Keep your arms to your sides and hands our of your pockets

Potentially have another staff member or security with you

Objects removed from room / patient

What are some signs of impending violence

Provocative behavior

Angry demeanor

Loud, aggressive speech

Tense posturing (eg, gripping arm rails tightly, clenching fists)

Frequently changing body position, pacing

Aggressive acts

What is the initial managment for agitation

Attempt verbal de-escalation techniques

Set boundaries / expectations

Indications for Restriants for Agitation

Imminent harm to others

Imminent harm to the patient

Significant disruption of important treatment or damage to the environment

Continuation of an effective, ongoing behavior treatment program

Types of Restraints

Seclusion

Physical

Chemical