Lecture 13: Emergency Psych

Question 1

Emergency Psych

Answer 1

urgent, emergent evaluation and management of patients with active symptoms

Question 2

Goals Emergency Psychiatry (5)

Answer 2

1. triage
2. assessment
3. DDX
4. management of acute symptoms
5. Appropriate discharge planning

Question 3

Triage (4)

Answer 3

1. correctly identify patients that are in need of psychological evaluation

a. medical
b. neurological
c. tox (drugs/etch)

3. medical evaluation including history and physical exam
4. ensure safety of patients until full psychological evaluation can be completed

Question 4

Assessment (4)

Answer 4

1. quickly evaluate the pertinent aspects of the patient’s presentation, with special attention to life threatening issues
2. may need to security to look for weapons
3. focus on
   - acute or recent physiological stressors
   - past and current medical problems, including prior psychiatric hospitalizations
   - medications and compliance (any recent changes in medication or dosing)
   - substance abuse (historical and current)
   - social situations (housing, finances, etc)
   - relationhips
4. physical exam
   - neuro exam*
   - mini mental status exam
   - labs

Question 5

Differential Diagnosis (4)

Answer 5

1. is the disordered affect, thought, or behavior the product of detectable pathophysiology, especially that assoc. with a medical problem or substance induced toxicity ?
2. if not, is the disordered affect, thought, or behavior of psychotic quality, especially that associated with schizophrenia or manic states?
3. if not is the disordered affect, though, or behavior compatible with some other formal diagnostic entity, especially anxiety states, depression, personality disorder?
4. if not, is the disordered affect, though, or behavior contrived to obtain an advantage or to avoid an undesirable consequence? e.g. incarceration

Question 6

Initial Treatment

4 categories

Answer 6

1. In some cases, treatment may be necessary before you have gathered your information
   - in the event that you cannot get close to the patient due to agression
2. 4 categories
   a. environmental management
   b. medication
   c. crisis intervention
   d. education

Question 7

Environmental Management (2)

Answer 7

1. safe environment in quiet room
   - safe psych rooms in ER with minimal equipment
2. modify home environment
   - physical living space
   - family members around
   - etc.

Question 8

Medication Interventions (4)

Answer 8

1. use caution*
   - may not have labs, radiology etc. to give full picture
2. may mask a medical condition
   - consider manipulation in addicts
3. benzodiazepines: ativan, valium
4. antipsychotics
   - Haldol
   - Geodon
   - Zyprexa

Question 9

Crisis Intervention

5 de-escalation techniques

Answer 9

1. using psychological strategies to de-escalate a crisis

a. breathing
b. identification of alternatives
c. clarification of interpersonal roles
d. interpretation of meaning
e. empathetic listening

Question 10

Educate (3)

Answer 10

1. educate about nature of disorder
2. clarification of disorder to avoid unwarranted guilt or confusion
3. understand prognosis

Question 11

Discharge Planning (5)

Answer 11

consider

1. initial level of care (inpatient vs. outpatient)
2. patient’s willingness to seek treatment
   - 72 hour hold
3. timing of initial follow up care
4. interval provisions
   - hydroxyzine commonly given if patient needs something to take home
   - -low toxicity, non addictive
5. communication with patient and subsequent caregivers

Question 12

Suicide (2)

Answer 12

1. 30,000 deaths each year in US alone
   - more attempts
2. up to 80% of those have seen a health care worker in 2 weeks leading up to death

Question 13

Suicide Risk (13) **

Answer 13

1. age: esp adolescents and other adults
2. marital status
3. sex; F>M
   - males succeed more
4. ethnicity
   - caucasian most likely
5. economical status (unemployment, economic reverses)
6. hx prior attempt
7. family hx
8. recent separation or loss
9. presence of a plan and available means to accomplish it
10. lethality of prior attempt
11. diagnosis: MDD, schizophrenia, etoh or other substance abuse and borderline personality d/o
12. specific symptoms
    - hallucinations, delusional thinking, profound depression with hopelessness
13. lack of social support

Question 14

Homicidal Ideation and Violence

8 factors

Answer 14

1. can be seen more in those with psychotic paranoid component or auditory hallucination that voices are telling them to kill/hurt someone
2. factors
   - age (younger)
   - M>F
   - criminality: violate social rules with psychological impairment
   - history: abuse as a child, fire setting/cruelty to animals
   - proposed victim is family member or close associate
   - environmental influence (violent subcultures beget violence)
   - diagnosis (manic staes, schizophrenia, etoh, substance abuse, conduct d/o, antisocial personality, intermittent explosive d/o
   - specific symptoms: command hallucinations, agitation, hostile suspiciousness

Question 15

Disaster Reactions (3)

Answer 15

1. terrorist attack, earthquakes, floods, hurricane, infectious disease outbreaks
2. initial attention directed at “new” casualties or general population that has suffered
3. must* also address: responders and those that received mental health treatment prior to the event

Question 16

Domestic Violence

Answer 16

1 in 4 women will be a victim of domestic violence in her lifetime

Question 17

Delirium

Answer 17

acute* change in mental status (acute changes in concentration) which may be accompanies by another cognitive changes, perceptual changes like hallucinations or delusions and behavior changes like psychomotor retardation or agitation

Question 18

Causes of Delirium (6)

Answer 18

1. UTI or other infection
2. onset or acute worsening of a neurological condition
3. adverse drug interactions
4. etoh/substance abuse
5. drug side effects (bactrim, etc. )
6. renal falilure

Question 19

AMS (altered mental status) Treatment/ Discharge Planning (3)

Answer 19

1. treat underlying disease process
2. treat with medical team-most likely will require medicine admission
   - but many times better to have patient return home in known environment
3. low dose haldol (1mg) best is absolutely needed
   - try to avoid

Question 20

NMS

-Neuroleptic Malignant Sydrome

Answer 20

1. 3 sets of symptoms appear rapidly and can be life threatening in response to antipsychotic medications**
   a. altered level of conciousness

b. autonomic symptoms
- hyperthermia
- tachycardia
- labile
- tachypnea

c. neuromuscular symptoms
- lead pipe rigidity
- elevated CPK leukocytosis

Question 21

NMS treatment (4)

Answer 21

1. stop antipsychotic medication
2. supportive care
   - IVF, cooling methods
3. anti-hypertensives
4. dantrolene for those not responding to supportive measures

Question 22

Cataonia

2 subtypes
treatment

Answer 22

1. withdrawn
2. excited

• look for schizophrenia, mood disorders, medical disorders
• tx: inpatient care, ativan (lorazepam)

Question 23

Panic Attacks

symptoms (5)
treatment (2)

Answer 23

1. chest pain
   - SOA
   - lips/fingers/toes tingling or numb
   - carpodedal spasm
   - lighteadedness
   - nasuea
2. treatment
   - elevate ADLs and may require admission if ADL affected
   - ativan
   - hydroxyzine

Question 24

72 hour hold (4)

Answer 24

1. involuntary hold for those that are at risk of harming themselves or others
2. does not include holidays or weekends
3. sign/ordered by MD
4. laws vary by state

Question 25

Casey’s Law (2)

Answer 25

1. Matthew Casey Wethington Act for substance abuse intervention
   - effective in KY 2004
   - Casey Wethington died of heroin OD age 23
2. allows parents, relatives, friends, to lawfully intervene and request involuntary court ordered addiction treatment for their addicted loved one