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
16
Q
Causes of Delirium
A
- Metabolic: electrolyte imbalance, hypoglycemia, hypoxia
- Infection: sepsis, meningitis, UTI or pneumonia
- Medications: steroids, opioids, Parkinson’s meds, anticholinergics
- Stroke, TIA
- Psychological stress: post-op state, ICU stay, on ventilator
- Head injury
- Substance abuse or withdrawal
- Psychological disorders (e.g, mania)
17
Q
ETOH-related causes of Altered Mental Status
A
- Intoxication
- Withdrawal
- Delirium tremens
- Alcoholic hallucinosis
- Dementia – long term use
18
Q
Evaluation of the ED Psych Patient
A
- Is the patient stable or unstable?
- Is the abnormal behavior/thinking due to a medical condition?
- Is psychiatric admission necessary?
- Is patient a danger to self or others?
- Is a 72-hour hold necessary?
- Is outpatient referral adequate?
19
Q
History
A
- Thorough medical/psychiatric hx
- History from patient, as well as family/friends/coworkers/police
- Behavior changes: change in behavior, mood, thought
- Recent stressors (family, job, relationships)
- Complete ROS: recent illnesses, head injury, fever, dizziness, syncope, exposures to toxins
- Associated neuro sx? speech changes, focal sx, confusion, headaches
- Previous psychiatric hx and medical hx
- Meds: prescribed and OTC
- ETOH or other substance abuse
20
Q
Mental Status Exam
A
- Behavior: what is pt doing? level of consciousness? engaged? withdrawn? agitated?
- Affect: what feelings are pt displaying? normal, depressed, anxious, angry, flat, tearful
- Orientation
- Language: clear, appropriate, disorganized, slow, fast, pressured, nonverbal
- Thought content: is pt making sense? or disorganized, tangential? delusions? suicidal or homicidal thinking?
- Perception: normal, or hallucinations
- Judgment: is pt able to make rational decisions ?
- Insight: does pt have an understanding of why they are there, what is wrong?
21
Q
Approach to the potentially violent pt
A
- Non-threatening posture and tone of voice
- Avoid sudden movements or excessive eye contact
- Allow pt to vent feelings, avoid argument or condescension
- Location that allows retreat from room
- Adequate force nearby visible to pt
- Set limits on behavior, tell pt that certain behaviors will result in restraint
- Pt should be disrobed, gowned, searched for weapons, dangerous objects removed
22
Q
Chemical Restraint
A
Indications
- Significantly agitated or violent pt
- Does not respond to verbal deescalation
- May be used with or without physical restraints
Options
- Lorazepam
- First generation anti-psychotics: halperidol, droperidol
- Atypical antipsychotics: risperidone, olanzapine
23
Q
Physical Restraint
A
Indications
- Actual or threatened violent behavior
- Imminent harm to self or others
- Significant disruption of important treatment
- Verbal deescalation has been unsuccessful
Technique
- Initial show of force: team of at least 5
- Approach from different directions
- One team member on each limb and leader assigned to head
- Legal documents signed
Removal
- As soon as possible, based on pt’s condition and behavior
- Remove in stepwise fashion, from 4 restraints to 2, to none
24
Q
72-Hour Emergency Hold
A
- Legal document signed by ED provider if patient is deemed to be mentally ill or chemically dependent and in danger of causing injury to self or others
- Patient can be held against their will for up to 72 hours
- Reasons for hold need to be clearly documented
- Err on side of caution: courts have come down in favor of provider placing hold
25
Admit vs Referral
Admit all patients felt to be at risk of harm to self or others
- Suicidal
- Homicidal
- Acute psychosis
Acute intoxication: options
- Transfer to detox
- Send home with responsible family member/friend
- Keep in ED until sober
Stable patients: assure outpatient referral
