Download Psychiatric Emergencies in the Pediatric Emergency Department

Psychiatric Emergencies in the
Pediatric Emergency Department
Michael F. Ziegler, MD
Assistant Professor of Pediatrics and
Emergency Medicine
Emory University/Children’s Healthcare of
Atlanta
Scope of the Problem
US Dept of Health and Human Services
1 in 10 children in USA (4 million) suffers from a
mental illness
Only 20% will receive needed care
• Psychotherapy recommended for < 50% of patients
evaluated for suicide attempt in the ED with even fewer
actually complying with referral
World Health Organization
By 2020 childhood neuropsychiatric disorders
will be 1 of the top 5 causes of morbidity,
mortality and disability among youth worldwide
Scope of the Problem
 Overall ED use increasing, same seen for psychiatric
concerns
 1993 to 1999 (Sills and Bland)
 1.6% of all ED visits in the < 19yo age group were for mental health
 326.8 visits/10,000 people/year were psychiatric
• 13.6% diagnosed as suicide attempt
• 10.8% diagnosed as acute psychosis
• Largest increase seen in nonurgent diagnoses (i.e. same as non-psych
visits)
 Increase felt to be due to decreased availability of mental health
providers (actual numbers vs. access)
 1995 to 1999 (Page)
 59% increase in pediatric psychiatric visits to a children’s hospital
ED
Scope of the Problem
Higher rate of admissions
1 year study by Khan, et al ‘02
227 children with psychiatric illness evaluated
• 32% admitted
 60% to medical floors due to lack of facilities for
mental health
 Longer turn around times to discharge, admission
and transfer to floor when compared to non-psych
19,734 children with non-psychiatric illness evaluated
• 5.5% admitted
Scope of the Problem
Suicide
2 million US adolescents attempt suicide each
year
2000 succeed
Third leading cause of death for age 15-24
years
Fourth leading cause of death for age 10-24
years
19% of US adolescents report serious
consideration of suicide in the past year
Scope of the Problem
 PECARN workgroup
5 site project to define
incidence and character
of psychiatric
emergency visits to
pediatric emergency
departments and to
develop intervention
strategies to address
increasing utilization
“Psych” vs. “Non-psych”
An artificial distinction based on our lack of
knowledge and understanding of
psychiatric illness
Seizures used to be a psychiatric diagnosis
Schizophrenia now understood in a physiologic
model with increased dopamine levels
Many psychiatric problems are exaggerated
responses of normal coping and adaptive
functions in the brain/psyche (i.e. PTSD, Panic
Attacks, Dissociative Disorders)
General Approach
Crisis intervention
Usual coping and adaptive patterns of child and
family disrupted
Risk to patient’s health and wellbeing
Risk to patient’s safety
Risk to others
Assessment, treatment and disposition must
include the child and the family
Ensure physical and emotional safety of child
Provide support and nurturance
Set limits on behavior
The ED environment
 Everything should be done in a non-judgmental and
caring manner
 “Check your own pulse first”
 Patients should be searched
 Removal of weapons or drugs that might be used to hurt self or
others
 Clothing should be removed and confiscated
 Decreases elopement
 Place in a safe and quiet environment
 Decrease stimulation
 Minimize access to dangerous materials
 Chemical or physical restraints as necessary and
appropriate
Evaluation
 Orienting data
 Relevant history
 Acute vs. sub-acute
presentation
 Medical history and
physical examination
 Assess for organic causes
 Mental status of the
patient
 Assess for organic causes
 Define specific problem
 Family evaluation
 Disposition viability
Mental Status Exam
 Orientation
 Appearance
 Memory
 Acute and remote
 Cognition
 concentration
 Behavior
 Relating ability
 Speech
 Pressured?
 Affect
 Thoughts
 Looseness of
associations
 Flight of ideas
 Hallucinations
 Insight and judgment
 Strengths
 Synthesis
Ancillary studies
 Not generally
necessary if history
and physical can
exclude organic
etiology of symptoms,
however, reasonable
considerations
include:
Ancillary studies
 Urine or serum drug
screens
 Assessment of
pregnancy in females
 Chemistries
 CBC
 ABG
 Liver enzymes
 Thyroid studies
 LP
 CT/MRI
 Blood lead level
 Ammonia level
 HIV/RPR
 ESR/ANA
 Cortisol
 EEG
Toxidromes
 Sympathomimetics
Tachycardia/HTN/hyperthermia/euphoria/dilated pupils
 Opioids
Pinpoint pupils/bradypnea/hypotension
 Anticholinergic delirium
“red as a beet, dry as a bone, blind as a bat, and mad
as a hatter”
 Cholinergic excess
SLUDGE
 Extrapyramidal symptoms
Required work-up for “medical clearance”
Grady 13b
CBC, BMP, UDS, Urine Beta for females
Peachford Pediatric Psychiatric Hospital
UDS and Urine Beta for females
Rest depends on your judgment
Pharmacotherapy
 Agitated, violent or psychotic patients
Antihistamines
Benzodiazepines
Neuroleptics
Atypical antipsychotics
 Mood stabilizers primarily for bipolar disorder
Lithium
Depakote-better for childhood bipolar
Tegretol-better for childhood bipolar
Benzodiazepines
Ativan 0.05-0.1mg/kg/dose
Rapid sedation
No active metabolites
Short half-life
Route: PO/IM/IV/PR/SL
Problems
Respiratory depression
Paradoxical reaction
• Worse in developmentally delay or organic brain
syndromes
Neuroleptics
 Antipsychotic effects take 7-10 days, but
sedation immediate
 Haloperidol
Children: 0.025-0.075mg/kg/dose (max 2.5mg)
>12yo: 2-5mg/dose
Route: PO/IM (IV with caution)
Problems
 EPS
• Treat with diphenhydramine or benztropine
 NMS
• Treat with Dantrolene
Droperidol
 Better sedation than Haldol
 “Black box” warning for prolongation of QT
interval leading to Torsades de Pointes
Several new studies disputing this point
No strong evidence to support a causal relationship
between use of Droperidol and fatal arrhythmias
 Dose 0.03-0.07mg/kg/dose (max 2.5mg)
 Problems
Orthostatic hypotension
Serotonin syndrome (esp. seen with LSD)
Atypical antipsychotics
Lower incidence of EPS
Ziprasidone
No dosage info available for children
Associated with prolonged QT
Olanzapine
Route: ODT/IM
0.12-0.29mg/kg/dose
Combo therapy
Diphenhydramine with
Neuroleptics/Atypical antipsychotics
Reduced EPS
Increased sedation
Benzodiazepines with
Neuroleptics/Atypical antipsychotics
Increased sedation
Depression
 Inflexible sad mood
 Anxiety
 Self-deprecation
 Loss of functioning
 Suicidal/homicidal
ideation
Most important aspect
to assess
 Associated with
School problems
Chronic illness
Genetic predisposition
 Developmental
differences
Infancy
Childhood
Adolescence
Suicide
 Most acute aspect of
psychiatric emergencies
 Greatest benefit from
intervention
 Suicidal tendencies are
typically fleeting with
increases after stressors,
but decrease to zero
within several weeks after
the acute event in most
adolescents
Suicide Stats
 Rare before puberty, but not non-existent
 Age perceptions of death
 Attempts more common in females
 Ingestions most common method in attempts
 Completion more common in males
 Firearms most common method in completed attempts
 Neighborhood
 Rural-firearms
 Suburban-carbon monoxide
 Urban-jumping from buildings
 Suicide attempts via ingestion in age 5-14 years 5 times
more common than all forms of meningitis
Completed suicides
 >90% have a psychiatric condition
 Depression and substance abuse
 Psychosis (small percentage, but
high risk)
 Impaired judgment,
hallucinations, delusions of
persecution
 1/3 have made previous attempts
 1/2 have been ill for over 2 years
 Family history of suicide
 History of physical or sexual abuse
 Gay, lesbian or bisexual sexual
orientation
Assessment
ASK!!!
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Frequency of thoughts about suicide
Intensity of these thoughts
Duration of these thoughts
Specificity of plan
Hopelessness
Rapid denial in apparent significance
of attempt worrisome
Remember that lethality of past
attempts is not synonymous with
intention!!!
Treatment
Psychiatric consultation
Never prescribe antidepressant
medications
Encourage family to tell patient they want
him or her to live and that suicide is
forbidden
Tender, but firm with setting boundaries
Disposition
 Inpatient
No studies exist that
show a reduction in risk
of future suicide
attempts or completed
suicides for patients
hospitalized
 Outpatient
Follow up within days
“Sanitized” residence
Contract for safety
 No evidence this
prevents suicide
Psychosis
 Severe disturbance in
patient’s mental
functioning
Cognition
Perception
 World is threatening
Mood
 Ecstatic or despondent
Impulses
Reality testing
Age at onset
 Autism
Onset before 30 months of age
 Other developmental disorders
Onset between 30 months – 12
years
Asperger’s syndrome (intelligent
autism)
 Schizophrenia
Onset in adolescence
 Acute reactive psychosis and
Bipolar disorder
Onset in late childhood or
adolescence
Organic vs. Psychiatric
Features
Organic psychosis
Psychiatric
psychosis
Onset
Acute
Gradual
Pathologic autonomic
signs
May be present
Absent
Vital signs
May be abnormal
Normal
Orientation
Impaired
Intact
Recent memory
Impaired
Intact
Intellectual ability
May be impaired
Intact
Hallucinations
Visual or Tactile
Auditory
Organic causes of psychosis
 CNS lesions
 Structural and functional
 CNS hypoxia
 Metabolic disorders
 Collagen-vascular
disease
 SLE
 PAN
 Infections
 Toxins
Management
Psychiatric consultation
Admission to medical unit if organic cause
suspected
Avoid antipsychotic meds if possible
Use physical restraints if toxin induced
psychosis not suspected
Schizophrenia
 0.5% prevalence in
population
 Males = females
 Possible excess of
Dopamine
 Common features
 Flat or bizarre affect
 Loose associations
 Auditory hallucinations
 Thoughts spoken aloud
 Delusions of external
control
 Concrete thinking
Acute Reactive Psychosis
 Time limited loss of
reality caused by
externally imposed
traumatic events
 Not a permanent
psychiatric disorder
 Prognosis depends
on ability to
reestablish safe and
dependable support
Manic-Depressive or Bipolar Disorder
 0.5% prevalence
 Adult and Childhood
forms
 Childhood form aka “rapid
cycling”
 Strong family history
connection
 Common features
 Insomnia
 Hyperactivity
 Pressured speech
 Emotional lability
 Flight of ldeas
 Inflated self-esteem
 Aggressive and
combative
 Reckless behavior
 Hypersexual
 Buying sprees
Other psychiatric disorders
 PTSD
Reexperiencing, avoidance, hyperarousal
 Dissociative Disorders
Extreme trauma leads to splitting of integrated functions
of identity, memory and consciousness
Includes conversion reactions, fugue states and multiple
personality disorders
 School refusal
Main goal is restoration of normal function
Do not do excessive labs!
Send them back to school!
ADHD
Associated with depression and suicide
attempts
Associated with bipolar disorder
Associated with antisocial personality
disorder
Conduct Disorders
Repetitive, socially unacceptable behavior,
without evidence of medical or other
psychiatric disorder
Males 5 times more likely to develop than
females
High incidence of violence
Usually seen in conjunction with law
enforcement
Diagnosis of exclusion
Conduct Disorders
 Narcissistic
 Manipulative
 No remorse or guilt
 Angry at detection
and punishment
 Persecution complex
 Substance abuse
 Sexual promiscuity
Assessment and Treatment
 Assess for medical or
psychiatric illness
 Firm control and
detailed expectations
with assistance of
security and restraints
when necessary
 Parents should be
directed to assist with
control of behavior in
department
Antisocial Personality Disorder
 Classic triad
Bed wetting
Pyromania
Cruelty to animals
 Common to many
serial killers
Thank you for your time and
attention!
Now, can someone please get me
a change of underwear, a match,
some gasoline and a puppy?