Download INTRODUCTION TO EMERGENCY PSYCHIATRY

INTRODUCTION TO EMERGENCY
PSYCHIATRY
Kheradmand Ali MD
Assistant Professor of Psychiatry
Shahid Beheshti Medical University
Definition
A psychiatric emergency is a
disturbance in thoughts, feelings, or
actions that requires immediate
treatment.
(Kaplan and Sadock, 1996)
Properties
• Can happen at any time either outside or
during a treatment episode.
• Can happen anywhere
– Not confined to the Emergency Room
– May happen on other services or involve other
disciplines.
The Patient in the Emergency Setting
Central Principles
• Assessment of Acuity
• Assessment of Risk
– Risk to self
– Risk to others
• Disposition to address risk factors
• Documentation.
Acuity
• Acuity is often “in the eye of the beholder”
• Acute conditions or symptoms may exist
within the context of chronic illnesses.
• Often acuity needs to be assessed within the
context of available support mechanisms.
– May also be resolved with appropriate support
mechanisms.
Risk
• Should be viewed as existing along a
continuum.
– There is no black or white
• Risk varies with time.
• Prediction of likely behavior may be made
utilizing risk assessment
Disposition
• Application of problem solving strategies.
• Should address identified areas of acuity and
risk.
• Should encompass the “least restrictive
care”doctrine.
– Care should be provided in the least restrictive
setting possible while still providing protection for
the patient.
Documentation
• Purpose
– To summarize the assessment and care of the emergency
patient
– To provide a roadmap which can be continued by follow up
care providers.
• Should follow a logical progression of thought
(problem solving strategy) and logical conclusions
based on assessment.
• Should not include conclusions that can not be
substantiated. (ie. Diagnoses, etc.)
The Care provider in the
Emergency Setting
Risks
• Violence in the emergency setting
– Generally more risk than in non-emergent
settings.
• Secondary gain issues
• Legal exposure
Protection in the emergency
setting
• Knowledge of historical risk factors etc. prior to
seeing the patient.
– Careful review of the record is time well spent.
•
•
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Be alert to risks of impending violence.
Careful attention to therapeutic alliance issues.
Attention to safety of physical surroundings.
Include others if needed ( ex. Police, etc.)
– Confidentiality ends where there is risk of injury
Protection in the emergency
Setting
• Be aware of secondary gain issues
– May help in prediction of behavior including
violence.
• Document, document, document
– Does not refer to volume of documentation but
rather quality of documentation.
Summary
• Psychiatric emergencies can occur anywhere at any time.
• Important issues include protection of the patient as well as
of the practitioner and staff.
• Central principles guiding assessment and treatment in the
emergency setting include assessment of risk and acuity,
plan and disposition, and appropriate documentation.
• Central principles guiding protection of practitioners in the
emergency setting include appropriate knowledge,
remaining alert, including others, and documentation.
The Role of the ED Psychiatrist
• First and foremost, a consultant.
• An expert, presumably, in the evaluation and
treatment of mental illness.
• As such, the ED psychiatrist is expected to provide
assistance with intractable or complex psychiatric
patients. This often means spearheading
interventions in the ED itself.
• Often, the psychiatrist is also expected to provide
input on whether a pt needs to be hospitalized or
not, and whether the unwilling pt meets criteria for
involuntary admission.
In Preparation for the Meeting
• First, one must gather information from the ED
resident, as would any other consultant.
• Request preliminary lab tests or other diagnostic
studies.
– Urine toxicology, always. Other tests are ordered
depending on the particulars of the case.
• Ensure that the patient is searched and gowned, and
that her belongings are sequestered, if these things
haven’t been already done.
• Review documentation, past and present, if
available.
A Run-Through of Common
Presentations
• Depression
– With or without suicidality
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•
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Adjustment reactions
Mania
Psychosis
Intoxication
Withdrawal
A Run-Through (Cont.)
• Medical issues with psychiatric manifestations,
including delirium
• Anxiety
• Dementia
• Aggression
– With or without homicidality
• These problems are by no means mutually exclusive;
several issues may present at once.
• Generally, there is one thread uniting these different
presentations – the failure of outpatient or social
resources to contain the problem.
A Primer on Particular Problems
• Suicide
– Etymology. Latin origins: (sui) self- (cide) death. Ergo, selfinjurious behavior sans death-wish is not a suicide
attempt.
– Eighth leading cause of death in men. (Higher than
homicide.)
– Third leading cause of death in adolescents (15 to 24 yo).
– 55% of successful suicides employ a firearm.
– Men succeed more often than women, but women
attempt more frequently than men.
• Very Difficult to Predict
Developing A Sense for Suicidality
• There are certain, unequivocal risk-factors
– Demographic: male sex; Caucasian; social isolation; in or
past middle age (most significantly > 65); occupation (past
or present) that involves risk-taking; cultural or religious
beliefs that favor suicide in certain situations (e.g., harikiri
in Japan); local epidemics (The Sorrows of Young Werther;
Kurt Cobain’s aggrieved idolators).
– Historical: previous suicide attempts; history of psychiatric
illness (particularly depression), impulsivity, or drug/EtOH
abuse; family history of suicide; history of abuse (sexual,
physical, or emotional), recent loss, or trauma;
characterological vulnerabilities (particularly cluster B).
Developing A Sense (Cont.)
• Risk factors for suicide (cont.)
– Immediate: anxiety; impulsivity; aggression; intoxication;
EtOH/drug dependence; agitation; hopelessness;
depression; psychosis; ideation, with plan (pt’s perception
of its lethality important to clarify); physical or chronic
illness; easy access to lethal methods; little access to
health care; low rescue potential.
• Collateral information can be very helpful at all
times, but especially here – where the consequences
of an incomplete story and a reticent patient can be
disastrous.
General Management of Suicidality
• Clarify Diagnosis
• Assess Risk
– Active vs. Passive. Plan or no plan. Perceived lethality.
• Ascertain need for inpt or outpt management
– Voluntary vs. involuntary admission. Is pt at immediate
risk?
– If pt at elevated, albeit long-term risk, any outpatient plan
should involve imminent, reliable follow up.
– The more people willing to be involved in the outpatient
plan the better – namely, family, friends, coworkers,
physicians.
A Primer on Psychosis
• Defined loosely as a disturbance in thought
process and content, often associated with an
impaired ability to relate to others and to
intersubjective experience (e.g., reality).
• Hallucinations, delusions, disorganized thoughts,
and anomalous experiences may be evident.
• The etiologies of acute psychosis include:
–
–
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Affective disorders (MDD, BAD)
Delirium
Dementia
Primary psychotic disorder
Intoxication or withdrawal
Developing A Hunch for
Homicidality
• Risk Factors:
– History of violence; aggression
– Impulsivity; intoxication
– Sincere plan
• Common etiologies include:
– Psychosis (command AHs); affective disorders; personality
vulnerabilities; substance intoxication or withdrawal
Management of Homicidality
• Elucidate Diagnosis
• Clarify threat to other(s)
– General vs. specific
• If threat is deemed serious
– Notify police
– Make efforts to warn individual(s) (Tarasoff ruling)
– Admit pt until threat subsides
• Don’t hesitate to admit involuntarily even if precise
psychiatric diagnosis remains elusive in the ED
Back to the Hot One
• ED evaluations should be just as comprehensive as
they would be anywhere else, though the exam
should be focused to address the particular question.
• You find the patient banging away at the walls of his
seclusion room. He is clearly agitated.
• Near the door to his room, a young woman is crying
– his girlfriend. You speak with her at length in order
to flesh out the history.
• You then proceed to enter the seclusion room.
Assessing Agitation
• An agitated patient shouldn’t be restrained or medicated immediately.
First, the psychiatrist should determine the pt’s “risk of escalation.”
• An agitated pt can be placed in one of four stages of agitation, depending
on the likelihood of de-escalation.
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Stage 1: the agitation is mollified by verbal cues, without limits or boundaries being invoked.
Stage 2: the agitation is contained verbally through limit-setting, but it persists nonetheless.
Stage 3: the agitation subsides during transient physical restraint.
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Stage 4: the agitation requires pharmacotherapy. It is otherwise intractable.
Often stages 3 and 4 are conflated.
• It takes experience to identify which pt can be safely approached, and
how, and when. It is best to err on the side of caution: always have an exit
strategy, and ensure that others can quickly come to your assistance, in
case that’s required.
• NEVER PLAY HERO(INE) AND TAKE THINGS INTO YOUR OWN HANDS!
Involuntary Admission
• Pt at immediate risk for hurting self or
others due to mental illness or mental
retardation.
• Pt is mentally ill (or mentally retarded)
and unable to care for self as to acutely
endanger his or her life.
The Emergency Armamentarium
• If agitated, but not psychotic:
– Benzos (lorazepam) generally suffice
– Beware of paradoxical disinhibition; this often occurs in the elderly
• If psychotic:
– Antipsychotics generally suffice
– Augment with benzos for further control
• If medical etiology apparent:
– Use antipsychotics for behavioral control, at the same time that underlying
medical illness is addressed
• If substance withdrawal (sedative/EtOH):
– Benzos first-line treatment
• PO administration is preferred if pt amenable
A Run-Down of Meds
• Benzos (potentiate GABA)
– Lorazepam (fast-acting): 1-2 mg PO/IM
– Chlordiazepoxide (long-acting; preferred in EtOH withdrawal): 5-10 mg PO/IM
– Adjust dose based on age, hepatic issues, body size, medical conditions, etc.
Avoid in delirious patients, as benzos tend to exacerbate.
• Antipsychotics
– Typicals: Haloperidol, fluphenazine. D2 antagonism. More likely to cause EPS,
TD. Older. Haloperidol: 2-10 mg PO/IM.
– Atypicals: Risperidone, ziprasidone, aripiprazole, quetiapine, olanzapine.
5HT2A antagonism, D2 antagonism. Z. and A. associated with 5HT1A agonism.
Less propensity for causing EPS, TD, or akathisia, but more likely to cause
metabolic issues: obesity, DM. Risperidone: 1-4 mg PO.
– Adjust dose based on age, body size, previous response to tx, medical issues,
etc. Monitor for EPS, TD, conduction issues, metabolic problems.
The Low-Down on Drugs
• Intoxication
– EtOH, or other sedatives (benzos)
– Psychedelics, including MJ, LSD, psilocybin
– Opiates
– Amphetamines
– Cocaine
– Phencyclidine
– Others: inhalants, butyl nitrate, MDMA, steroids, anti-cholinergics
• Intoxication with any of these could lead to affective dysregulation and
psychosis.
• Pharmacotherapy generally not required for acute management, but
agitation and psychosis may be treated with benzos and/or antipsychotics
– especially for phencyclidine intoxication.
• Elucidate extent of use, route of intake, and impairments resulting from
use.
The Low-Down (Cont.)
• Withdrawal
– Generally not medically serious, unless the pt is withdrawing from
EtOH or benzos, in which case seizures may develop. Treat EtOH and
benzo withdrawal with benzos.
– Withdrawal from other drugs can feel terrible, no doubt about it – but
not life-impairing. Cocaine withdrawal, however, is associated with
intense dysphoria, sometimes AHs, and occasional active SI.
– A suicidal pt withdrawing from cocaine (or other drug) may require
acute psychiatric hospitalization.
Other Sundry Psychiatric
Emergencies
• NMS (Neuroleptic Malignant Syndrome)
– A medical, as well as a psychiatric emergency
– Associated with anti-psychotics and with any dopamine blocking medication
– Associated with muscle rigidity, autonomic dysfunction, fever, and altered
mental status
• Serologic markers include elevated CK, demonstrating rhabdomyolysis; metabolic
acidosis; and leukocytosis
– Treat by stopping offending agent, maintaining hydration, and encouraging
adequate cooling. Dopamine agonists or ECT may play a role
– Especially in patients with longstanding psychosis, NMS may be confused with
catatonia, which is not associated with autonomic dysfunction nor fever. This
can be a fatal oversight, so always keep NMS in mind
Other Emergencies (Cont.)
• Lithium Toxicity
– Associated with nausea, vomiting, diarrhea, weakness, fatigue,
lethargy, confusion, seizure, and potentially coma
– Toxicity not entirely correlated with serum lithium level; toxicity may
develop at different levels for different people
– Obtain BMP, serum lithium level, and EKG
– Encourage hydration; consider hemodialysis in extreme cases
PSYCHIATRIC
EMERGENCY
• Conditions need immediate interventions &any
Delay increase risk for patients and others
• One of the most Pitfall in Psychiatric
Emergency is NEGLECT &IGNORE of
ORGANIC CAUSALITY in Emotional
Disorders
PSYCHIATRIC
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EMERGENCY
SUICIDE & HOMICIDE
AGGRESSION & VIOLENCE
CATATONIA
NMS (Neuroleptic Malignant Syndrome)
PSYCHIATRIC
EMERGENCY
• Prevalence:
%20 of referrals; Suicidal
%10 of referrals; Aggressive or Violency Behavior
%40 of ALL Referrals need Hospitalization
• Male= Female
• Single> Married
• Often Night Time
PSYCHIATRIC
EMERGENCY
• Clinical Evaluation:
FIRST : Emergency Interventions
THEN: Diagnosis & Treatment of Major Disease
SUICIDE
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Suicidal Thought
Suicidal Threat
Suicidal Attempt: F >M
Committed Suicide: M>F
SUICIDE
• Psychiatric Disorder:
MDD, Dysthymia, BMD
Schizophrenia,Schizophreniform,Brief Psychotic
Disorder
PTSD,OCD,GAD
Personality Disorders
SUICIDE
• Medical Problems:
CNS Disease (Epilepsy, MS, AIDS, Dementia,
Hantington)
Endocrine (Cushing Disease, Anorexia Nervosa,
Kleinfelter)
GI (Peptic Ulcer, Cirrhosis)
Immobility , Disfigurement , Persistent Chronic
Pain
SUICIDE
ETIOLOGY
• Biologic
Serotonergic Hypofunction, Platlet MAO decrease
,Genetic
• Psychologic
Hoplessness, Depression, Impulsivity, Aggressivity
• Social
Family Discord ,Divorce, Single, Lack of Support
SUICIDE
HIGH RISK SUICIDE:
• Male
• >45 Yrs old
• Single & Divorce
• Unemployment
• Unstable Family & Interpersonal Relationship
• Severe Depression, Psychosis, Personality
Disorder, Substance Use (Alcohol)
SUICIDE
HIGH RISK SUICIDE
• Hopelessness
• Prolonged & Severe Suicidal Thought
• HX of Several Attempts, with Plan, Low
Rescue, Use of Fatal Methods
AGGRESSION
& VIOLENCE
AGGRESSION
• Goal directed Behavior (verbal or nonverbal)
for Hurt
VIOLENCE
• Severe & Sudden Goal directed Behavior to
Destruction of property OR Hurt OR Kill
others
AGGRESSION & VIOLENCE
• BMD
• Schizophrenia, Schizophreniform, Brief
Psychotic Disorder
• MDD
• Personality Disorders
AGGRESSION & VIOLENCE
RISK EVALUATION:
• Demographic Characteristics:Male ,15-24 Yrs,
Low SES &Social Support
• Evaluation of Thought, Attempt, Plan for
Violence, Weapons Availability
• Past HX of: Violence, Antisocial Behaviors
,Impulse Control Disorder (Substance,….)
• HX of Major Stressor: Loss, Family Discord…
AGGRESSION & VIOLENCE
Impending Violence:
• Verbal or Physical Threatening
• Progressive Restlessness
• Weapons Carrier
• Substance or Alcohol Abuser
• Excited Catatonia
• Paranoid (Psychosis)
• Personality Disorder
NOROLEPTIC MALIGNANT SYNDROM(NMS)
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Fatal Complication due to Antipsychotics
Abrupt Discontinuation Levodopa in Parkinsonism
Anytime in Treatment Course
Prevalence:%/02- 2.4
Mortality Rate:%10-20
Male>Female
Young>Geriatrics
NOROLEPTIC MALIGNANT SYNDROM(NMS)
Major Symptoms:
• Muscle Rigidity
• Increase in Body Temperature
AND 2 Symptoms of:
Diaphoresis/ Tremor/ Dysphagia/ Mutism/
Urinary Incontinency/Tachycardia/Alteration
in Consciousness level/Leucocytosis/HTN/
Muscle Injury (CPK)
NEUOROLEPTIC MALIGNANT SYNDROM(NMS)
Treatment (Conservative)
• FIRST: Discontinuation of AP
• Decrease Body Temperature
• Monitoring of Vital Signs, Hydratation,
Electrolyte, I/O
• Muscle Relaxant (Bromocriptine,Amantadine,
Dantrolene)
FOR 5-10 DAYS
NEUOROLEPTIC MALIGNANT SYNDROM(NMS)
Prevention
• Use of AP in Appropriate Indications
• Use of AP in Minimum Effective Dose
• Use of AP with Cholinergic Properties