Download Behavioural Emergencies

Differentiating Medical from Psychiatric Disease
Dr Peter Jordan
Registrar Teaching
Northern Hospital 2013
Case 1
 0220 27 YO Female – Known to CATT
 Increasing agitation 12/24. HR 122 RR 30 BP 130/70.
Cannot accurately record temp (combative)
 Assessment – Non cooperative – Responding to
hallucinations
 DDx?
Evidence
 Limited largely to surveys/ consensus guidelines
 Increasing number of prospective trials
 Approx 25% populations suffer from some form of
mental illness
 3% ED presentations acute behavioural disturbance
 1% Self harm
Elderly
 If>70 40% have altered mental state
 Elderly patients admitted to the hospital with delirium -
mortality 15%-30%
 30% of patients older than 64 presenting to ED = clinically
depressed - 75% missed by ED doctors
 Drug toxicity or withdrawal accounts for up to
30% of all cases of delirium
Meldon S, Emerman C, Schubert D. Recognition of depression in geriatric ED
patients by emergency physicians. Ann Emerg Med 1997;30:442-447.
Drug/ alcohol
 Approx 10% alcohol dependence at some point
 5% Drug dependency (life time)
 Drug dependent - 50% have comorbid psych illness
Medical Causes
 Approx 4% missed
 Frequency:
 Infectious
 Pulmonary
 Thyroid
 Diabetic
 Hematopoietic
 Hepatic
 CNS disease
Findings suggestive of a medical cause
• Late age (over 40) of onset
• No past history of psychiatric illness
• Sudden onset of altered behavior
• Presence of a toxidrome
• Visual hallucinations
• Known systemic disease with new-onset behaviour change
• New medication
• temporal relattionship to a convulsive seizure
• Abnormal vital signs
• Disorientation
• Clouded consciousness
Etiology
 Meningitis/ sepsis
 Electrolyte abnormality (Na/ Ca)
 Hypoxia
 Endocrine
 Hypoglycaemia (hyper)
 Thyroid
 hypopararathytoid (Ca > 1.4)
 Hypocortisolaemia
Definitions:
Delirium - Delirium is a disturbance of consciousness
that occurs over a short time and primarily affects
attention, with subsequent impairment of other
cognitive functions
Memory impairment usually involves recent memory
Develops abruptly and often fluctuates over the course
of the day
Clinical Features:
Onset
Delirium: Sudden
Dementia: Insidious
Psychosis: Sudden
Consciousness
Delirium: Reduced
Dementia: Clear
Psychosis: Clear
Attention
Delirium: Globally disordered
Dementia: Normal except in
severe cases
Psychosis: May be disordered
Cognition
Delirium: Globally disordered
Dementia: Globally impaired
Psychosis: Selectively impaired
Hallucinations
Delirium: Usually visual
Dementia: Often absent
Psychosis: Predominantly auditory
Delusions
Delirium: Fleeting, poorly
systematized
Dementia: Often absent
Psychosis: Sustained, systematized
Orientation
Delirium: Usually impaired, at least
for some time
Dementia: Often impaired
Psychosis: May be impaired
Psychomotor activity
Delirium: Increased, reduced,
or shifting
Dementia: Often normal
Psychosis: Varies—hypo- to hyperactive
Speech
Delirium: Often incoherent, slow
or rapid
Dementia: Perseveration, difficulty
finding words
Psychosis: Normal, slow, or rapid
Involuntary movements
Delirium: Often asterixis or coarse
tremor
Dementia: Often absent
Psychosis: Usually absent
24-hour course
Delirium: Fluctuating, varies at
night
Dementia: Stable
Psychosis: Stable
Physical illness or drug toxicity
Delirium: One or both present
Dementia: Often absent, especially
in
Alzheimer’s type
Psychosis: Usually absent
Anxiety
“Anxiety is the space between the ‘now’ and the ‘then.’”—
Richard Abell
If a patient has a panic attack after age 35, and there is no
clear-cut psychological precipitant,suspect a medical
cause; hyperthyroidism, hypoxia, hypoglycemia, or
drug toxicity
Emergency Department
Evaluation
Four screening criteria for identifying patients with
medical illness:
 disorientation
 abnormal vital signs
 clouded consciousness
 age over 40 with no previous psychiatric history
Dubin WR, Weiss KJ, Zeccardi JA. Organic brain syndrome. The
psychiatric impostor. JAMA 1983;249:60-62.
Priorities
 Safety - ?search
 Chemical +/- physical restraint
 Supportive Care
 Food/ drink
 Minimise stimuli
 Orientating stimuli = friends
 Reassurance
Clinical Assessment
 Sit/ Listen
 Non threatening distance/ demeanour
Sensitivity for Detecting Medical Cause:
History – 94%
Exam – 51%
Vital signs – 17%
Path – 20%
Olshaker JS, Browne B, Jerrard DA, et al. Medical clearance and screening of
psychiatric patients in the emergency department. Acad Emerg Med 1997;4:124128
History
“If you talk to God, you are praying; if God talks to you,
you have schizophrenia.”—Thomas Szasz

The presence or absence of a past psychiatric history is
one of the most important determinants of psychiatric vs.
medical illness.
 Most alert adult patients with new psychiatric
symptoms who present to the ED have an organic etiology.
 In one prospective study of 100 consecutive, alert, 16- to
65 year old patients with new psychiatric symptoms
evaluated in the ED, 63% had an organic etiology.
Henneman PL, Mendoza R, Lewis RJ. Prospective evaluation of emergency
department medical clearance. Ann Emerg Med 1994;24(4):672-677.
Cost-Effective Strategies For Patients With
Altered Mental Status
1. Reserve laboratory tests for those patients with no prior
psychiatric history, abnormal vital signs, or other
suspicious findings on history or physical examination.
Caveat: bedside blood sugar elderly
2. Limit toxicologic screens to those cases where
findings will change management (= almost never)
Caveat: suicidal patient and paracetamol/ aspirin
3. Reserve CTs for those patients with a focal neurologic
findings or altered behaviour of undetermined etiology.
Caveat: high-risk patients—warfarin, coagulopathy, elderly,
immunosuppressed
Drug And Alcohol Testing
The most economical and expedient means of detecting
drugs and alcohol is to ask the patient or, in the case of
alcohol, smell the patient’s breath
Self-reporting = 92% sensitive and 91% specific for
identifying a positive drug screen
Self-reporting = 96% sensitive and 87% specific in
identifying a positive ethanol level
Neuroleptic Malignant Syndrome
Affects about 1% of patients treated with neuroleptics.
Most commonly occurs within the first 3-9 days but
can occur after chronic use.
High mortality rate 12%-20% - usually secondary to renal
failure or aspiration pneumonia
Clinical Dx: hyperthermia (from 37.5˚C up to 42˚C),
autonomic instability, encephalopathy, skeletal muscle
rigidity, autonomic instability
Management
 Cease drug
 Aggressive hydration
 Fluid monitoring
 Cooling blankets (antipyretic agents not effective)
 BDZs, Dantrolene
 ICU
Serotonin Syndrome
Encephalopathy, ataxia, nausea, vomiting
Marked autonomic instability
Neuromuscular signs/ symptoms - myoclonus, rigidity,
tremor.
Hyperreflexia, especially lower extremity
Diaphoresis and mild elevations in temperature
(approx 50%)
Treatment = supportive +/- BDZs
Summary
The term “medical clearance” is a misnomer; “medical
assessment” is more appropriate
Beware –
 New behavioural symptom after age 40
 Sudden onset of psychosis or delirium
 The presence of a toxidrome
 Visual hallucinations
 Disorientation
 Altered level of consciousness
 Symptoms that began after starting a new medication
 Abnormal vital signs