Date post: | 13-Apr-2017 |
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Psych EmergenciesEPT MLP Training
Gil,M PA-C
8th leading cause of death for all ages 3rd leading cause of death in adolescents In the past 20 years suicide killed more
people than HIV and AIDS 90% of patients who commit suicide suffer
from a diagnosable mental illness About 40-60% of those who die by suicide
are intoxicated at the time of death 10% of patients who attempt suicide will re
attempt within one year
Stats
Current suicidal ideation Intent/ Plan Hx of Suicide Attempts
◦ Date, circumstances, and method Hx of Mental illness
◦ Intensity of current depressive symptoms◦ Current treatment ◦ Psychotic Symptoms
Auditory command hallucinations, external control, and religious pre occupation
Drug and alcohol use Concurrent medical illness Past or Present hx of Violence/Aggression Recent life stressors Current living situation
History
Make sure patient is fully undressed prior to entering room
Patients belonging should be taken and stored He/She should be checked for any pills, drugs,
weapons, sharp objects ect. Observe patient from doorway or discuss with
nursing interaction, ensure that patient is not threatening
Pt should have sitter at bedside if he/she has active SI complaint or are a danger to themselves
ED Evaluation
Only 13% of surveyed psychiatrists perform a physical exam on their inpatients
Inspect head for trauma or prior neurosurgery◦ Signs of basilar skull fracture
Ocular exam◦ Pinpoint pupils – narcotics, organophosphates or clonidine◦ Dilated pupils – stimulant or anticholinergics, withdrawal from
sedatives, narcotics or post anoxic injury◦ EOMS- impairment seen with Wernicke’s encephalopathy or space
occupying lesions◦ Nystagmus-
Vertical (brain stem lesion), Wernicke’s encephalopathy or congenital Horizontal or rotatory nystagmus suggests drug or more commonly alcohol
toxicity PCP intoxication – blank open eye stair with roving gas, nystagmus and
dilated pupils
Physical Exam
Neck exam- meningeal signs or thyroid enlargement Chest exam – auscultate for PNA, PTX, CHF, COPD,
Heart Murmur – valvular heart disease (endocarditis) Abdominal exam – obstruction, perforation,
hemorrhage, or infection in the abdominal cavity, enlarged liver (jaundice or asterixis)
Inspect skin for rashes, Kaposi sarcoma or petechiae, Track marks
Neuro exam is most frequent deficiency in charts, perform basic neuro exam depending on suspicion of medical diagnosis
Fever in combination with psychiatric complaint is concerning for intracranial infection of systemic illness
Hypoglycemia and hypoxia are common causes of agitation and AMS
Organic Causes
Hypoglycemia may be responsible for up to 10% of altered behavior in ED patients
UDS is unlikely to change managements, patients typically will admit to drug or etoh use if being seen for a psychiatric complaint
Labs including blood chemistries, CBC, UA, toxicology and alcohol have only a 20% sensitivity of detecting a medical disorder
History alone has 95% sensitivity
Diagnostic Testing
CXR – unnecessary in most patients unless hx of cough, tachypnea or low pulse ox, more liberal use in the elderly
CT Head – worrisome headache, focal neuro exam, at risk for chronic subdural (dialysis, anticoagulated, alcoholic, seizures, falls)
LP – Patients with fever, meningismus or immunocompromised
SAD PERSONS ScalePoints
•Sex •Age (<19 or > 45)•Depression or Hopelessness•Previous suicide attempts or psychiatric care•Excessive alcohol or drug use•Rational thinking loss•Separated, divorced or widowed•Organized or serious attempt•No Social Supports•Stated future intentScore 6-8: Full Emergency Psychiatric Eval/TreatmentScore 9 or greater: Immediate Psychiatric Hospitalization
1121121212
Compliance with psychiatric medications Social Support Involvement in a religious group Being a parent Positive coping skills Adequate treatment of chronic pain or
substance abuse Adequate followup
Factors Protective Against Suicide
Patient and Complaint Dependent Attempted Suicide
◦ CBC, BMP◦ Etoh, UDS, APAP, Salicylate level◦ EKG◦ Preg
At a minimum◦ Most will require Istat8, UDS, etoh, preg
Lab Workup
PERS- Consult for voluntary admissions, ED Consults
CSB- Social Worker who will find placement for ECO/TDO patients
ECO- Emergency Custody Order TDO- Temporary Detention Order
◦ Medical- Patients who are deemed not able to refuse treatment or lab work because of medical condition
Abbreviations to Know
4% of the time a medical diagnosis is missed Deficiencies in history and physical examination accounted
for the vast majority of illness Most common are infection, pulmonary, thyroid, diabetic,
hematopoietic, hepatic and CNS disease Hypoglycemia, Hypoxia and Thyroid disease should be
considered in all patients with new onset psychiatric disease Serum Sodium > 160 mEq/L is associated with AMS Serum Sodium < 115 mEq/L produces confusion, coma and
even seizures Hypercalcemia < 14 mg/dl can cause lethargy and mental
status change◦ Malignant neoplasms and hyperparathyroidism account for the vast
majority of hypercalcemia
Not Missing A Medical Dx
Disturbance of consciousness occurring over a short time and affecting attention, with impairment in other cognitive function
May be disoriented to time or place but not to person
Perceptual disturbances including misinterpretations, illusions or hallucinations
Disturbances develop abruptly and fluctuate Drug toxicity or withdrawal accounts for up to 30%
of all cases of delirium UTI is one of the most common causes of delirium in
the elderly
Delirium
Effective loss of reality testing, a disturbance of thought processes and consequently, changes in behavior
Disrupts perception and disorganizes thinking to a degree that interferes with social interactions
Suspect medial etiology in new cases of psychosis, especially if patient in > 40 y.o
Psychosis
Major depression diagnosis requires alterations in mood, psychomotor activity, and cognition
15% of patients with major depression commit suicide
Depression
Persistently elevated, expansive or irritable mood
At least three of the following: inflated self esteem or grandiosity, decreased need for sleep, increased talkativeness, flight of ideas, easy distractibility, increased activity or an excessive quest for pleasure
Mood disturbance is severe enough to markedly interfere with job performance and personal relations
Mania
Complaints of anxiety, nervousness, panic or stress
Sleep disturbance, irritability, difficulty concentration, easy fatigue, restlessness, and muscle tension
If a patient has a panic attack after age 35 and there is no clear cut psychologic precipitant, suspect a medical cause, hyperthyroidism, hypoxia, hypoglycemia, or drug toxicity.
Anxiety
Sensation of bugs crawling under skin- associated with cocaine or speed use
Bugs on the walls – alcohol withdrawal Visual Hallucinations are strongly associated
with a medical pathology Seizure prior to presentation suggests postictal
sate or nonconvulsive status epilepticus Palpitations, tremor and weight loss suggests
hyperthyroidism Headache suggests CNS tumor, meningitis or
chronic subdural hematoma
Key History
Late age (over 40) of onset of a new behavioral symptom No past medical history of psychiatric illness Sudden onset of altered behavior Presence of a toxidrome Visual Hallucinations Known systemic disease with new onset behavior change New Medication Altered behavior temporally related to a convulsive seizure Abnormal vitals Disorientation Clouded consciousness
Findings Suggestive of An Underlying Medical Basis For Psychiatric Symptoms
Very Uncooperative patient ◦ 5 MG IM Haldol + 2 MG IM Ativan + 50 MG IM
Benadryl, one syringe◦ OR 10mg Geodon IM
Somewhat cooperative◦ PO dosing of above Rx
Treatment of Agitation
Acute behavior changes in elderly are at risk for adverse outcomes
Common sequela to infection or other disease
Nearly 20% of elderly patients brought for emergency psychiatric eval may be suffering from a drug reaction◦ Review BEERS Criteria
http://chpw.org/resources/Providers/Beers_Criteria.pdf
Elderly