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Psychosis, Substance Abuse
Self-Directed Learning Assessment
Nikki Waller, MD
• Discuss recognition, initial stabilization,
and department management of
– Acute psychosis
– Substance abuse
– Suicide/homicide
• Abnormal thought patterns, with intact
• Usually due to mental disorders, but can
be from acute drug intoxication or chronic
• Most important are schizophrenia, mania,
and depression in the setting of the ED
• Delusions and hallucinations
• Most common of the psychoses
• Mood is usually unaffected and flat
• May present quiet and withdrawn or
violent, paranoid and suspicious
• Neuroleptics are the mainstay of
treatment chronically and acutely
• Often present because they have stopped
taking meds
• Often associated with bipolar disorder
• Elevated mood and energy
• Acute mania: fast and pressured speech,
agitation, grandiose delusions, and insomnia
Can be violent
sedating neuroleptics are often needed
Lithium for chronic use, but not in the acute
• Rare to present with psychotic features
• Usually not violent or agitated
• Should be a plan in the
ED to deal with violent or
abusive patients
Obtain as much info as
possible from patient,
family, paramedics etc.
Try to obtain history prior
to restraints or sedatives
May not be able to obtain
any reliable history
May need to interview
with security present if
patient is violent/agitated
• Workup should be guided
by h and p.
If known psychiatric
disorders may require
basic labs, drug levels,
tox/etoh screens, lytes
If new or worsened
presentation, would need
exclusion of organic
causes (uti, drug
ingestion, head injury
• Ensure patient and
healthcare worker
safety first.
Glucose, o2, thiamine,
narcan, and possibly
flumazenil first for
acutely delusional
patient may improve
• Restraint options:
– Seclusion (must be
– Physical restraints (if
necessary, but also
must be watched)
– Drugs: droperidol,
haldol, ativan, geodon
– Start with small doses
and watch for sedative
• Consult psych, frequent documentation of
status if restrained.
• Involuntary commitment if necessary
• Must rule out drug/etoh intoxication or
other reversible cause before they are
“cleared from a medical standpoint” to be
considered only psych.
Depression and Suicide
• Depression
– most common
psychiatric disorder (23%)
– Persistent dysphoric
mood or loss of
interest in activities for
at least 2 weeks
• Suicide
– 2nd leading cause of
death among
teens/young adults
– Women attempt more
– Men more likely
Clinical Features
• Guilt and hopelessness
• Thoughts of death or
• Need Pmhx, psychiatric
Change in
Insomnia/excessive sleep
Difficulty concentrating
Can be situational
Can be medical causes
problems, meds hx
Risk assessment is KEY:
Ask about homicide,
suicide, specific plan, and
what their access is to
those plans.
Take away medication,
weapons etc in the
Suicide Risks
• High risk
Living alone
Physically ill
h/o substance abuse
Prior attempts
• Low risk
No clear/active plan
Gesturing behavior
Strong social support
and follow up
• Rate of suicide in the US is about 1%
(31,000 deaths/yr)
• Drug overdose most common form of
Suicide Attempts
• Get as much history as possible from all sources
• Immediate ABC’s if patient is unstable
• Remove any items patient may have on them that could be a threat (lighter, pills, knife etc)
• For overdose: get time of ingestion, quantity, strength of substance, what substance(s), any
other available substances that are unaccounted for, how much was initially available, when
was patient last seen and normal
• Patient needs a sitter
• Work up as appropriate, but should include cbc, chem 10, urine tox, pregnancy, etoh screen
(gets all alcohols), acetaminophen and salicylate level
• CXR to look for pill fragments
• EKG to document normal QRS, no arrhythmias or prolonged QT
• If “found in the garage with car on”, consider Carbon monoxide levels
• Anything else that may be deemed necessary based on injuries etc.
• Should be carefully documented and determined
with help their mental health provider
Contract for safety
Document careful follow up plan
Adequate social support
Admit those with:
• Active plan
• Cannot contract
• High risk factors
• Acute psychosis
• High risk attempt (gunshot, hanging, significant ingestion
with lethal substance (tricyclics etc)
• Danger to themselves or others (manic, wreckless, severe
suicide risk)
Substance Abuse
• Huge problem in the country, and problem
for EM
• Commonly see “want to stop drinking, or
stop using drugs”,
• But patient may present as an “found
altered and unknown toxin suspected”
“Wants detox”
• For UNC the information you need to
know is:
• Substances used, and on average how much and
for how long
• Last use
• History of withdrawal (DT’s etc)
• Other current medical problems that would need
attention (i.e cocaine use, but now having chest
• Psychiatric history including suicidality
• Are they currently in withdrawal, or getting ready
to go into withdrawal
• Can I clear them from a medical standpoint?
• Once you have cleared them, you can
either call freedom house (UNC specific),
or if they are full, then psych can help
dispo (once they are clear from a medical
• May need admission for r/o mi (if active cp
and cocaine), or if history of withdrawal
seizures from etoh etc.
Acute Presentation of Substance
• ABC’s: check for gag, determine gcs,
?need for immediate intubation
• History (as with suicide attempts)
• Vitals and neurologic status, expecially
pupil size, diaphoresis, heart rate
• Look for toxidrome pattern
Approach to patient
• Toxidromes: common patterns of findings with
specific ingestions (more in the tox lecture)
Coma Cocktail:
• Thiamine (100mg iv): alcoholics are predisposed to thiamine
deficiency and may have wernicke-korsakoff’s.
• Dextrose (1amp d50): for any pt with altered mental status,
check glucose
• Narcan (0.01mg/kg iv): give to suspected narcotic toxidrome,
or severe altered mental status
• Flumazenil: benzo antagonist, but MANY contraindications
and we don’t normally give in the acute setting.
Differential Diagnosis
• Organophosphate poisoning
• Pontine hemorrhage
• Clonidine overdose
Work up
Basic and tox labs
Drug levels (depakote, lithium) if appropriate
Possible head ct/neck ct if trauma is suspected
or if not a clear “tox” history
Urine tox/pregnancy
Cardiac labs if cocaine and chest pain, or if you
cannot determine chest pain
Opiates/Narcotics (heroin/fentanyl)
• Death from respiratory depression
• Sx: depressed mental status
• PE:
– Lethargy
– Pinpoint pupils
– Decreased respiratory drive
• Evaluation: ***responds to Narcan (can give every
2-3 minutes, little bit at the time until max of 10 mg
or mental status returns
Admit: persistently altered, or drugs with long half
life (methadone)
• Death from: mi, arrhythmias, cva, hyperthermia,
renal failure
All sympathomimetics
Sx: euphoric, anxious, agitated, paranoid, “chest
Neuro findings:
– Seizure
– Focal findings (weakness)
– “wash-out”- decreased ms, lethargy, drowsiness with
chronic use, or after prolonged binging
Cardiopulmonary Findings
• Dysrhythymias, hypo or hypertension,
signs of MI
• Asthma or reactive airway disease
• Hyperthermia (> 105.0)
• Can get pneumomediastinum from
Air in soft tissues
And around the
Can also sometimes
See air around the heart
Border (not in this one)
Differential Diagnosis
• CNS infection
• Pheochromocytoma
• Thyroid storm
• Vasculitis
• hypoglycemia
Workup and treatment
• Abc’s, full labs and cxr, ekg, head ct (if needed)
• Benzos (ativan etc) for agitation, chest pain
• If evidence of MI: give nitrates, heparin, ptca if needed
• Treat hypothermia
• If asymptomatic and no end organ damage, then can d/c, but
otherwise admit as appropriate
Hallucinogens (LSD, MDA, PCP,
• Exact mech. Of action unknown, but thought to
interact with serotonin and dopamine
mechanisms in the CNS.
• Death: from activities associated with concurrent
use (driving etc)
• Sx:
– Euphoria, hallucinations
– Bad trip: paranoia, anxiety, unusual thought process
– Most have “sense of self” except with PCP
Signs of Hallucinogens
• Hyperthermia (associated with some)
• Anticholinergic effects
– Dry mouth
– Dialated pupils
– Tachycardia
– Flushing
– delirum
Differential Diagnosis
• Acute psychosis
• Conversion disorder
• Encephalitis
• Neurosyphillis
• Dementia
• Often don’t show up on utox
• Standard labs, check CK if suspect
possible rhabdomyolisis
• Reassurance and Benzos for agitation prn
• d/c if asymptomatic at 4-6 hours
Toxic alcohols
• Will discuss in tox lecture