Download The Evaluation and Treatment of the Acutely Agitated

The Evaluation and Treatment of
the Emergency Psychiatric Patient
W. Scott Griffies, M.D.
LSUNO Department of Psychiatry
An ER Behavioral
Healthcare Infrastructure
• ER physician assessment includes mental status
exam.
• Crisis Assessment S.W., P.N.P., or P.R. include
complete psychosocial assessment.
• Psychiatric Consultant rounds bi-daily.
(possible telepsychiatry)
• Social Service (S.W.) Discharge
Plan/Resources.
CIU/BHETU
• Stabilization Units
• In Conjunction with ER
• 5-30% have medical illness
Disposition Evaluation
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Nature and duration of Illness
Relationship to baseline
Adequacy of self-care
Level of social supports
Risk of homicide/suicide
Differential Diagnosis
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Delirium
Psychotic Disorders
Mood Disorders
Developmentally Disabled – have above
diagnoses, but, since they are often
nonverbal, diagnoses will be primarily
based on behavioral observations and
descriptions.
Medical Delirium
• Acute Onset
• Fluctuating, Altered Sensorium
• Abnormal MMSE
Life-Threatening - WWHHIMP
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Drug withdrawal
Wernicke encephalopathy
Cerebral hypoxemia
Hypoglycemia
Hypertensive encephalopathy
Intracranial bleeding
Meningitis/encephalitis
Poisoning
An Option for Outpatient Psychosocial
Planning of Substance Dependence
• Call AA/NA and have sponsor visit patient
in ER
• Prescribe daily or bidaily NA/AA Group
meetings for first 2 weeks post discharge.
• Follow-up with addiction disorder clinic.
• Register for Rehab Program.
Psychotic Disorders
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Clear sensorium
Delusions
Hallucinations
Disorganized speech and behavior
Flat or inappropriate affect
Psychosis Differential
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Substance – induced
Due to medical condition
Schizophrenia
Mood Disorder (BMD/MDE)
Dementia with delusions
Psychosis Differential (cont.)
• Brief Psychotic Episode
• Schizophreniform
• Delusional Disorder
Mood Disorders – BMD and MDE +/Psychotic Features, Severe Agitation
• Mania - - Decreased need for sleep,
increased energy, agitation, irritability,
liability, projects, missions, hypertalkative,
pressured, racing.
• R/o organic etiology, especially if acute.
Treatment of Acute
Psychotic/Severe Agitation
• Haldol 5 mg, Benadryl 50 mg, Ativan 2 mg
IM. (B52)
• Repeat Haldol 5mg IM +/- Ativan 1-2 mg
q1-2h IM as needed until calm.
Other Guidelines
• Use 25-50% for elderly
• Monitor ECG when possible
• Most calm after 1-2 injections
Treatment of Acute Agitation
Other Options
• Zyprexa 10 mg q 2 h X 1, then q 4 h not to
exceed 30 mg/24 h. Do not give
concomitant Benzos.
• Geodon 10 mg q 2 h or 20 mg q 4 h, not to
exceed 40 mg/24 h.
• Use 25-50% for elderly/medically
compromised.
• Not indicated for dementia-related
psychosis.
Switching to Oral Antipsychotics for
Schizophrenia, BMD, MDE with Psychoses
While Awaiting Admission.
• Haldol 2-5 mg po q daily --BID
• Zydis (melts in mouth): 10-15 mg po q daily
initially.
• Seroquel 50 po BID. Increase by 100 mg/day
to 600 mg/day in divided doses - - more at
night.
Switching to Oral Antipsychotics for
Schizophrenia, BMD, MDE with Psychoses
While Awaiting Admission. (Cont.)
• Risperidol 1 mg po BID. 1st day, 2 mg BID
2nd day, 3 mg 3rd day.
• Geodon 40 mg po BID (usually 2nd line)
• Abilify 10-15mg
• Use 25-50% for elderly/medically
compromised.
Second Generation Antipsychotics:
Long term Side Effects
• Zyprexa, -- most weight gain, metabolic
syndrome (Relative cotraindication in D.M.
Obesity, Cholesterol)
• Risperidol, Seroquel – Second-most
metabolic syndrome issues.
• Geodon, Abilify – least weight gain and
metabolic syndrome.
Second Generation Antipsychotics:
Side Effects
• Risperidol – hyperprolactenemia
• Geodon – Relative QTC prolongation
Relative contraindication in patients with
CVS history. If CVS history, perform EKG.
• Seroquel – most antihistaminic, sedating
Anxiety
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Adjustment d/o with anxious mood
GAD
Panic
OCD
Social Phobia
ER Treatment of Anxiety
• Ativan 1-2 mg po q 4-6 h
• Klonipin 0.5 – 1 mg po BID – TID
• Use SSRI long term.
Borderline P.D.
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Impulsivity
Parasuicidal behavior
Abandonment anxiety
Labile affect
Agitation in Borderline P.D.
• Benzodiazepines may disinhibit
• Seroquel 50 po nightly/BID
Suicide
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Level of intent
Level of lethality
Prior attempts
Late life white divorced male
Living alone
Lack of sleep/agitation
Major Depressive Episode (MDE)
• Depressed mood or loss of interest/pleasure
x 2 weeks.
• Five/nine symptoms – depressed mood,
interest/pleasure,  or  weight,
insomnia/hypersomnia, psychomotor
agitation/retardation, fatigue/  energy, 
selfworth,  concentration, SI
Choice of Antidepressant –
General Issues
• Needs weekly f/u x 4 weeks with new
antidepressant
• Start low, go slow, especially in anxious,
somatisizing patients.
• Early side effects usually diminish in 10-14
days. If tolerable, hang in there.
Choice of Antidepressant –
General Issues
• Activating agent may need sleeping agent –
Trazodone (Priapism), Ambien, Lunesta
• Don’t give if mania hx
Antidepressant Choices–
Selective Variables
• Wellbutrin (150 mg) norepinephrine/dopamine – activating, 
energy,  concentration, no sexual SE’s.
• Effexor (75 mg) - combination serotonin,
norepinephine – monitor BP, especially at
higher dose – good for GAD also.
Antidepressant Choices–
Selective Variables
• Cymbalta (30 mg) – combination
norepinephrine/ serotonin – pain
syndromes, start 30 mg for 7-14 days to
mitigate nausea.
• Remeron (15 mg) – po q nightly –
combination serotonin, norephinephrine,
sedating
Antidepressant Choices –
Selective Variables
• Prozac (10-20 mg) – in some, more
activating, give in am, start 10 mg in
panic/anxiety.
• Paxil (10-20 mg) – in some more sedating,
more wt gain.
Antidepressant Choices –
Selective Variables
• Zoloft (25-50 mg) – activating or sedating,
can be nicely calming
• Celexa/Lexapro (10-20 mg) – most
serotonin - receptor selective.
ER Physician
• R/O underlying medical causes for
presenting delirium, psychosis, or mood
disorder.
• PEC if S/H or G.D.
Mental Status Exam: ARTT SMAJIC
• Appearance – well dressed/disheveled
• Rapport – good/eye contact
• Thought Process – linear, goal
directed, looseness of associations (LOA),
tangential, disorganized
• Thought Content – S/HI, A/VH
• Speech – N/R/R/V/T
Mental Status Exam: ARTT
SMAJIC (Cont.)
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Mood – upset, angry, sad
Affect – blunted, full range, depressed
Judgment – good, poor
Insight – good, poor
Cognition – see MMSE
“MINI-MENTAL STATE EXAM”
Maximum
Score
5
5
Score
Orientation
( ) What is the (year) (season) (date)
(day) (month)?
( ) Where are we? (state) (country)
(town) (hospital) (floor).
MMSE (Cont.)
Maximum
Score Score
Registration
3
( ) Name 3 objects: 1 second
to say each. Then ask the
patient all after you have
said them. Give 1 point for each
correct answer. Then repeat
them until he learns all 3.
Count trials and record.
Trials_________
MMSE (Cont.)
Maximum
Score Score Attention and Calculation
5
( ) Serial 7’s 1 point for each
correct. Stop after 5 answers.
Alternatively spell “world”
backwards.
Recall
3
( ) Ask for the 3 objects repeated
above. Give 1 point for each
correct.
MMSE (Cont.)
Maximum
Score Score
Language
9
( ) Name a pencil, and watch (2 pts)
Repeat the following “No ifs, ands
or buts.” (1 point)
Follow a 3-stage command:
“Take a paper in your right
hand, fold it in half, and put
it on the floor” (3 points)
Read and obey the following:
MMSE (Cont.)
Maximum
Score Score Close your eyes ( 1point)
5
( ) Write a sentence ( 1 point)
Copy design (1 point)
Total Score________________
FIG 6-1. From Folstein MF, Folstein SE, McHugh
PR: J. Psychiatr Res 1975, 12:189-198
Structured Diagnostic Interview
with Psychosocial Assessment
• S.W./Psychiatric Nurse
Practitioner/Psychiatric Resident
- HPI, DSM IV symptoms
- Past psychiatric history
- Family psychiatric history
- Past medical history
- Social history with current social
supports and resources.
- MSE
Psychiatrist Consultant
• Confirm diagnosis
• Medication recommendations
Disposition and Treatment
Recommendations
• Inpatient
• Outpatient
• ER medications
Withdrawal Delirium
(alcohol, benzodiazepine, barbiturates)
• Fixed with symptom triggered schedule.
Ativan 1-2 mg PO, IM or IV, Q 4-6 h;
Ativan 1-2 mg PO, IM, IV; Q 1-2 h prn
P>100, BP> 150/100; hold for sedation
• Or, give symptom – triggered alone, if more
appropriate.
Alcoholism
• Thiamine 100 mg po q daily
• Folate
1 mg po q daily
• MVI
1 taken po q daily
Opiate Withdrawal Evaluation
• Positive Opiate UDS
• Positive history
• Dilated pupils, piloerection, muscle cramps
Opiate Withdrawal Treatment
• Clonidine 1 mg po TID – QID
with 1 mg po q 2 h for BP > 150/100,
p > 100
• Bentyl 20 mg po QID prn abdominal
cramps.
• Pepto-Bismol, Imodium, Maalox, Mylanta
• Robaxin - muscle spasm.
Substance Dependence Disposition
• Medical admission for detoxification if
unstable.
• Psychiatric admission if suicidal.
• Outpatient addiction follow-up and rehab.
Outpatient Detoxification Option
• Patients w/o history of prior seizures or
withdrawal delirium.
• Valium 10 mg po TID-QID with 2-3 prn for
agitation/tremulousness
• Taper over 5-7 days
• MVI
Ativan Outpatient
Detoxification Option
• If patient has increased LFT’s
• Ativan 1-2 mg po q 4-6 h with 2-3 prn’s
• Taper over 10-14 days by dose, while
preferentially maintaining frequency.
MEDICAL DELIRIUM
TREATMENT ISSUES
• CBC, electrolytes, BUN, Cr, LFT’s, UDS,
possible CT scan.
• Admit for medical stabilization of
underlying causes.
Psychosis Due to Medical Condition
• Drugs and Toxins
• Intracranial masses (tumor, abscess,
subdural)
• Anoxia
• Normal Pressure Hydrocephalous
Psychosis Due to Medical
Condition (cont.)
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Neurodegenerative diseases
Infection
Nutritional (B12 , Folate)
Metabolic/Endocrine
Inflammatory/autoimmune
Mood Disorder Due to a
Medical Condition
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Carcinoid
Pancreatic Cancer
Collagen-vascular disease
Endocrinopatheses (Cushings, Addison’s
hypoglycemia, hyper/hypocalcaemia,
hyper/hypothyroid)
• Lymphoma
• Viral illness (mono, hepatitis, flu)
Depressed Mood Due to a
Pharmacologic Agent
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Clonidine
Propanolol
Corticosteroids
Ibuprofen
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Indomethacin
Ampicillin
Teracycline
Cimetidine
Mania Due to
Pharmacologic Agent
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Baclofen
Cimetidine
Corticosteroids
Disulfiram
Isonazid
Levodopa