Psyc Emergencies - MH Flashcards
1
Q
Psychiatric Disorders in the ED
A
- May be the primary reason for presentation
- Presenting injury/illness may be due to psychiatric disorder
- Overdose in suicidal pt.
- Traumatic injuries in agitated psychotic pt.
- Hypothermia in schizophrenic pt. who doesn’t seek shelter
- May be part of PMH, but little relevance to presenting problem
- May be previously undiagnosed
- ED may be entry point into health care system
- Many don’t seek medical attention until a crisis happens
ED care
- Recognition of disorder
- Crisis intervention
- Stabilization
- Decision to admit vs outpatient referral
2
Q
Most Serious Presentations
A
Suicidal
Acute psychosis
Violent
Intoxication: ETOH or drugs
3
Q
Altered Mental Status:Medical Mimics
A
- CNS infection – meningitis
- Head trauma
- CVI, intracranial hemorrhage
- Intracranial mass lesion
- Hypertensive encephalopathy
- Seizure
- Intoxication: drugs, ETOH
- Withdrawal: drugs, ETOH
- Poisoning: intentional or inadvertent overdose
- Hypoxia
- Hypoglycemia or other metabolic abnormality
- Endocrine (e.g., hypo-, hyperthyroidism)
- Acute organ system failure (e.g., hepatic encephalopathy)
4
Q
Major Depression
A
Persistent sad mood
Hopelessness, worthlessness
-Loss of interest in usual activities, anhedonia
-Vegetative symptoms: loss of appetite, fatigue, sleep disturbance, inability to concentrate
-Vague somatic complaints: fatigue, insomnia, generalized weakness, diffuse pain
-Suicidal ideation (15% lifetime risk of successful suicide)
5
Q
Suicide Risk Factors
A
- Depression
- Substance abuse: Alcoholics have up to 50x the risk, 25% of suicides associated with ETOH intoxication
- Schizophrenia (10% kill themselves)
- Have a plan
- Access to lethal weapons
- Overdose with lethal drug, large amount
- Violent attempt (shooting, jumping, hanging)
- Advancing age
- Chronic illness
- Social isolation
- Single, divorced, widowed, unemployed
- Psychosis- respond unpredictably to distorted perceptions
- Prior attempts
6
Q
Approach to Suicidal Patient
A
- Empathic, non-judgmental is best
- Directly ask about suicidal thinking
- Take all suicidal behaviors seriously
- Great caution in attributing suicidal ideation to “cry for help” or attention-seeking
7
Q
Suicide Precautions
A
- Dangerous objects removed from patient (belts, belt buckles, shoelaces)
- Safe room: no telephone cords, glass, sharp objects
- Staff to watch pt closely
- Pt not allowed to leave exam room unaccompanied
- Security staff, if available
- 72-hour hold
8
Q
Acute Psychosis
A
Delusions
- Fixed false beliefs not amenable to facts to the contrary
- Grandiosity, hyper-religiosity, special powers, paranoia, thought control
Hallucinations
- False sensory perceptions
- Auditory and visual most common
- Deterioration in functioning
- Disorganized thinking: loss of normal thought connections
- Speech: vague, rambling, disjointed or nonsensical
- Disheveled appearance
- Catatonia: curled up in a ball not moving
9
Q
Causes of Acute Psychosis
A
- Schizophrenia: most common
- Schizoaffective disorder
- Bipolar (mania)
- Drugs (cannabis, meth, cocaine, LSD, PCP)
- Alcohol: intoxication and withdrawal
- Medical conditions/delirium
Brief psychotic disorder
- Occurs after exposure to traumatic event (e.g., death of loved one, natural disaster)
- Emotional turmoil, confusion, bizarre behavior/speech
10
Q
ED Presentations of Schizophrenia
A
- Worsening psychosis, often due to stress or med noncompliance
- Disruptive behavior
- Suicidal ideation
- Assaultiveness
- Extrapyramidal side effects of drugs
- Schizophrenics seldom seek mental health care on their own: do not realize their thoughts and behavior are abnormal
11
Q
Bipolar Disorder
A
- Mania, with episodes of depression
- Elated mood, rapid pressured speech, racing thoughts
- Decreased need for sleep
- Grandiosity: delusions of fame, special powers, grand business plans, run for office)
- Spending sprees, sexual promiscuity
- Lack insight; can be argumentative, hostile, sarcastic, esp. when plans are thwarted
- Complications: marital/occupational disruption, substance abuse, suicide
12
Q
Anxiety
A
- Apprehension, fears and excessive worry
- Autonomic activity out of proportion to any real danger
- Physical symptoms common
- Racing thoughts
- Often accompanied by depression
- Need to exclude medical illness (e.g, pulm emoblus, dysrhythmia, sepsis)
13
Q
Panic Disorder
A
- Recurrent attacks of severe anxiety
- Sudden surge of anxiety and dread
- Autonomic signs: palpitations, tachycardia, shortness of breath, chest tightness, dizziness, sweating, tremors
- May be unprovoked or brought on by stimulus (e.g, crowds, closed space)
- Frequently seek evaluation in ED
- Must exclude organic etiology
14
Q
Somatoform Disorders
A
- Physical symptoms with no medical explanation
- Conversion disorder: loss of function (e.g. paralysis, blindness, numbness) deemed to be due to psychological factors
- Make diagnosis with extreme caution, if at all (pt may eventually be found to have a physical disorder)
- Somatization disorder: wide variety of complaints (“positive review of systems”), long complicated histories of medical problems involving many organ systems with no apparent medical cause
- Receives much unnecessary testing and treatment
- Avoid making dx in ED: profound implications→if medical cause, deprives pt of appropriate medical treatment
- Remember: pt with somatoform disorders still get real medical disorders
15
Q
Delirium
A
- Acute confusional state
- Severe confusion, disorientation, clouding of consciousness, reduced awareness of external environment
- Abnormal psychomotor activity: ranging from restlessness/hyperactivity to drowsiness to stupor
- Sensory misperception; vivid hallucinations (often visual) are common
- Typically, acute onset, rapid deterioration in hrs-days
- Elderly are at particular risk, often with medical cause
