Psych and EtOH Emergencies Flashcards
Med Clearance considerations:
- Is the patient stable?
- Does the patient have a serious organic ( ie, medical) condition causing abnormal behavior?
- If the cause is functional (ie psychiatric), what is the diagnosis and severity?
- Is psychiatric consultation necessary
- Should that person be forcibly detained and put on a mental health hold?
- If M-1 hold already in place, needs psych clearance
Medical Clearance in the ED there are a few possible results:
- No physical illness found in a psychiatric patient
- Known co-morbid conditions are stable and not related to the presenting symptoms
- An acute medical condition is identified and
Patient is cleared for psychiatry OR…
Patient needs further work up
for the 72 Hour mental health hold, one of three criteria must be met:
- Gravely disabled
- Imminently dangerous to self
- Imminently dangerous to others
Who can initiate and discontinue a mental health hold
- Physician
- Officer of the law
- any licensed mental health therapist, social worker, or nurse (not a PA!)
*Only by a licensed physician or psychologist can discontinue the hold
A patient on a hold must be evaluated by ____
a mental health provider
Life Threatening Conditions Which May Present as Behavioral Changes
- CNS infection
- Intoxication
- hypoglycemia
- ICH
- Seizure disorder
- CNS trauma
- EtOH/drug withdrawal
- Hypoxia
- Poisoning
- acute organ system failure
Clues for organic disease (medical)
- Age <12 years >40 Years old
- Sudden onset and fluctuating course
- Disoriented
- Visual hallucinations
- Emotional liability
- Abnormal Physical exam
- History of substance abuse or toxins
- No previous psychiatric history
Clues for functional disorders (psychiatric)
- Age 13 to 40 years
- Gradual onset and continuous course
- Scattered thoughts
- Awake and alert
- Auditory hallucinations
- Flat affect
- Psychiatric history
- Normal Physical exam
Describe the medical clearance exam
- Goal is to exclude organic/medical causes of a psychiatric problem
- But First: Scene safety and stabilization
- ABCs
- Treat any acute medical problems (Hypoglycemia? Hypoxia?)
- Laboratory testing, Toxicology screens
- Determine the disposition (M1 hold requiring psych eval or not)
Barriers to a complete evaluation for medical clearance
- Provider discomfort or bias
- Other patients are sicker
- Patient takes too much time
- Patients may mistrust the medical staff
- Patients may have a cognitive impairment or hallucinations interfering with the evaluation
Important Hx when assessing medical clearance
- Be patient; don’t laugh
- Gather history from friends, family, EMS
- Always ask, “why now”? Why today? What has happened to their coping skills?
- What is acute and what is chronic about the situation?
- pts current/historical stressors
- resources (therapist)
- previous psychiatric illness
- Any deterioration in physical, mental or emotional functioning
When assessing medical clearance always ask these 3 questions:
- Auditory / visual hallucinations
- Drug / alcohol abuse and patterns
- Suicidal/ homocidal intentions
Key Components of the Physical Exam for medical clearance
- Vital signs: No one is medically cleared with (unexplained) abnormal vitals
- Appearance: dress, grooming, hygiene, interactions with staff and family
- Speech pattern: slurred, tangential, flight of ideas, rapid pressured?
- HEENT: Pupils, EOM’s, nystagmus, proptosis, goiter?
- Skin: diaphoretic, flushed, dehydrated?
Key Components of the neurological Exam for medical clearance
- Focal deficits are not psychiatric
- Cranial nerves, motor, sensory, cerebellar functioning, tremors/withdrawals
- Mental status exam:
- Why are you here?
- How did you get here?
- What is the day/date/year?
- Who is the current president/governor/current events?
- Inappropriate responses warrant a full MMSE
What labs could you get with a medical/psych eval.
-
No routine tests
1. (however, urine tox, breathalyzer is often minimum)**
2. Check medication levels - Lithium, Valproic Acid, etc.
3. Check glucose prn - esp. w/ diabetics, drug overdoses, elderly
4. Explore relevant medical considerations - thyroid, DM
What are different Toxicology screens and what do they screen for
*Tests vary hospital to hospital
Serum Tox:
Ethanol, Acetaminophen, Salicylates
Urine Tox: (drugs of abuse)
amphetamines, benzodiazepines, cannabinoids, barbiturates, cocaine, opiates, MDMA (ecstasy)
*No designer drugs on standard tox screens
What is delirium
global impairment in cognitive functioning that is SUDDEN in onset and presents with diminished level of consciousness, inattention, visual hallucinations
Causes of delirium
- infection,
- electrolyte abnormality,
- substance intoxication/withdrawal,
- head injury
*usually reverisble
presentation of delirium
- rambling speech,
- poor attention,
- visual hallucinations,
- disorientation
- Markedly disturbed sleep wake cycle
What are some medical conditions that cause acute delirium
- Hypoxia
- Hypoglycemia
- Acute intoxication or withdrawal/ wernicke’s
- Meningitis/ encephalitis
- Intracranial injury
- Hypo/hypernatremia
- Drug side effects
Pervasive disturbance primarily in memory, generally gradual in onset
dementia
Presentation of dementia
- other cognitive deficits such in language, attention, judgment may occur
- Non fluctuating course– gradual onset
- Maintain normal level of consciousness
Cause of dementia
- drug reaction
- depression
- metabolic endocrine disorders
- may lack other underlying medical condition
*Less likely to be reversible
What is psychosis
Impaired contact with reality”, characterized by symptoms, such as:
Hallucinations, delusions, impulsive, a range of emotions from apathy to fear and rage; may have positive or negative symptoms
Presentation of psychosis
- Hallucinations,
- delusions,
- impulsive,
- a range of emotions from apathy to fear and rage;
- may have positive or negative symptoms
*Ask about family history in patients with new onset psychosis
Causes of psychosis
Often drug ingestions or discontinuation of meds is the problem
basic management of a violent patient
- Provider safety first: security presence, know where door is
- Your approach: Calm, active listening, hands in neutral position. Avoid prolonged eye contact. Let patient know violence and aggression is not tolerated. Keep questions clear and simple.
- Behavioral Modifications:
- Restraints Options include soft/hard; 2 or 4 point; side rails
- quiet dark room; supine/ not prone; downgrade prn
What are some pharmacological agents that can be used to manage a violent patient
- Benzodiazepines:
- Ativan 1-2mg PO/IV/IM; Valium 5-10mg PO/IV/IM - Traditional Antipsychotics:
- Haldol 5-10mg PO/IM/IV - Atypical Antipsychotics:
- Zyprexa (olanzapine) 5-10mg po/IM.
- Less sedating than traditional antipsychotics
* ** antipsychotics can cause QT prolongation and EPS
“B-52”
Benadryl 50MG
Haldol 5mg
Ativan 2mg
Major depression in the elderly frequent co-morbid conditions include:
Alzheimer’s, Parkinson’s, vascular dementia
Symptoms for major depression have to present at least
daily for two weeks
what is the criteria for major depressive disorder
- Depressed Mood OR
- Loss of interest or pleasure in activities PLUS
- Five or more of the SIG E CAPS
Sleep, Interest, guilt, energy, concentration, appetite, psychomotor changes, suicidal feelings
How do you dx bipolar disorder
A manic episode is defined as at least 1 week marked by abnormally elevated or irritable mood PLUS three or more of the following symptoms
- inflated self esteem
- decreased need for sleep
- flight of ideas
- increased risk taking
- distractibility
- pressured speech
- psychomotor agitation
Signs of borderline personality
- mood instability
- aggression
- tendency to intense anger
- impulsivity
- frequent self injury
*person you spend way too much time with, can’t make happy, get under your skin
Fourth greatest risk factor for suicide
borderline personality
*(after depression, schizophrenia and addiction)
More likely to attempt than complete suicide
How do you dx panic attack
An episode of intense fear or discomfort in which 4 of the following symptoms develop abruptly and peak with in 10 minutes
- SOB
- palps
- sweating
- Nausea/abdominal distress
- hot flashes
- fear of going crazy or dying
- dizziness
- trembling
- choking
- CP
- parestehsias
Panic Attack Definitions
- Resolution of symptoms usually in 30 minutes
- May be unexpected or situational; explained or unexplained
- In the ED this is a diagnosis of exclusion –symptoms can mimic life threatening conditions
evaluation of a pt with panic disorder
- HX: sx, PMH, meds, abuse/withdrawal, context of sx, ROS
Lab testing/evaluation of panic disorder
- First time patients; testing depends on symptoms, risk factors (age over 40 years), medical conditions
- Consider TSH, EKG, chem 8, Utox, CBC, Trop, glucose
*remember that certain conditions (hypoxia, ischemia) may cause panic feelings and should be ruled out
DDX for panic attack
pneumothorax, dehydration, MI, hypoglyemica, PE,
Management of panic disorders
- Take the patient seriously
- Relaxation techniques especially breathing
- Psychiatric evaluation
- Medications- Benzodiazepines acutely prn
Most common causes of suicide
- firarms (60%)
- hanging- MC for men
- poisoning- MC for women
Risk factors for sucide
- Gender (W try 3x as men but M are 4x more successful)
- white, elderly, male
(>85yo WM, 6x national average suicide rate) - Lack of social support
-divorced, widowed, unmarried, living alone - Mental Health D/o
-90% of people who commit suicide have depression or another mental health disorder - Recent humiliation, grief or loss
- Medical Illness: chronic or severe
- Fhx of attempted or completed suicide
- Psychiatric disorder: major depression, schizophrenia, or prior attempts
- Addictive disorders: 25% are alcohol dependant
How do you assess lethality
- Passive suicidal ideation-absence of a specific plan
- Active suicidal ideation- specific plan regardless of viability of the plan
- Suicide attempt- act of self harm with intent to die
- Suicidal gesture
what are suicidal gestures
- self inflicted harm without the expectation of death
- At risk for serious injury or accidental death
- Typically impulsive and poorly tolerant of frustration
when evaluating suicidal patients always ask:
- Always ask about mood
- Always ask about suicidal ideation
- Always ask about a plan
*Asking does not “give them the idea”
When do you place pts on a 1:1 observation/security watch
- Unable to commit to safety
- Patient is agitated or impulsive
- Patient is delirious, disoriented, or cognitively impaired
- Provider is intuitively uncomfortable with the patient leaving the department
- Err on the side of safety
- Provide a safe environment
Treatment for a suicide patient
- Treat anxiety, agitation, psychosis or pain
- Offer to contact family, friends, therapist
- Consult Psychiatric services
- Admit if concerned about the patient’s safety or safety of others, gravely disabled, or inadequate follow-up or living conditions
- Suicide “contracts for safety” in the ED offer no legal protection, but are often employed
New onset psychiatric illness carries a high index of suspicion for __ and should be worked up as altered mental status
organic disease
The elderly and patients on multiple meds should raise suspicion for __, __ or __
organic disease, medication interaction or medication intoxication
Acute Psychosis + Physical Finding =… (don’t miss these)
- fever + psychosis
- alcoholism + psychosis
- HA + psychosis
- Abdominal pain + psychosis
- Sweating + psychosis
- Autonomic sings + psychosis
- Fever and psychosis : Meningitis
- Alcoholism and psychosis : Wernicke’s
- Headache and psychosis : Tumor/ICH
- Abdominal Pain and psychosis : Porphyria
- Sweating and psychosis: Hypoglycemia, DTs
- Autonomic signs and psychosis: Toxic or metabolic encephalopathy
- Dizziness, sweating, palpitations, etc.
Pitfalls for psych disorders
- Inadequate evaluation
- Failure to recognize acute worsening of a chronic condition that may be organic
- Failure to treat the treatable
- Failure to look at the medication list
What meds can have behavioral manifestations
- Steroids
- TCAs
- Anticonvulsants
- Benzodiazepines
- Amphetamines/related drugs
- Narcotics
- Street drugs – alcohol, cocaine, meth
3rd largest health problem in US (after CA and heart disease)
alcohol
Physiologic Effect and Blood Alcohol Level 20-50mg/dl 50-100 100-150 150-250 300 400 500
20-50mg/dl: diminished fine control, loss of inhibition, slurred speech
50-100: impaired judgment and corrdination, impaired driving
100-150: difficulty w/ gait and balance
150-250: lethargy and difficulty sitting upright
300: coma in a novice drinker
400: resp. depression
500: potentially fatal
legal limit <80
describe the metabolism of alcohol
- Primarily absorbed in the proximal small bowel; food causes delayed and diminished concentration
- CNS effects 5 minutes, peak 15-60 min
- Metabolized by the liver, by alcohol dehydrogenase
- Steady state of elimination 15-40 mg/hour**
- Improved elimination in practiced consumers
describe females and BAC
- Women have less alcohol dehydrogenase, so slower metabolism
- Women have less gastric metabolism than men
- Conclusion, women should drink less than men.
- One drink a day considered safe, unless high risk breast cancer
Signs of low levels of acute intoxication
- clouded judgment,
- ataxia,
- nystagmus,
- altered personality,
- slurred speech,
- hypotension and
- tachycardia
signs of high levels of acute intoxication
- Obtundation,
- hypoventilation,
- hyporeflexia,
- hypothermia,
- severe hypotension
What is the evaluation/management of severe intoxication
- May need physical restraints
- Screen for life threatening problems (don’t believe the history)
- Observe until clinically sober
- No practical therapies to reverse alcohol
- Alcohol is dialyzable
tx of severe intoxication
- Treat dehydration with IV fluids
- Hypoglycemia is common
- Screen for electrolyte abnormalities, esp. Mg
- “Banana bag” for chronic alcoholics :
- D5 NS or D5 1/2NS,
- 2 gm Mg sulfate
- MVI with folate,
- 100mg thiamine
* ** Mg/Folate/Thiamine: Can be done PO
What is a banana bag
for chronic alcoholics and someone not eating
- D5 NS or D5 1/2NS,
- 2 gm Mg sulfate
- MVI with folate,
- 100mg thiamine
- ** Mg/Folate/Thiamine: Can be done PO
what is Wernicke’s - Korsakoff encephalopathy caused by
severe thiamine deficiency
severe thiamine deficiency have two distinct syndromes on a continuum
- Wernicke’s is acute and reversible
2. Korsakoff’s is persistent and irreversible
Wernicke’s Encephalopathy vs Korsakoff Dementia
Wernicke’s Encephalopathy:
- Nystagmus
- Ataxia
- Confusion
Korsakoff Dementia:
- Persistent learning and memory deficits
- usually irreversible
tx of Wernicke’s Encephalopathy
patients with severe thiamine deficiency may precipitate Wernicke’s if given glucose w/o thiamine; classically, give Thiamine first
How can you discharge someone with alcohol intoxication
- In chronic alcoholics, Etoh blood level does not dictate discharge, may be “clinically sober”
- Road test/ can walk independently
- Minors only get released to parents or guardians
- Adults get discharged to a sober adult or go to detox
Describe alcohol withdrawal
- Syndrome caused when a patient who is chronically habituated stops drinking
- Onset 6-96 hours after last drink
- Why did they stop drinking? Will they restart?
PE findings in alcohol withdrawl
*hyperadrenergic state:
HTN, tachycardia, diaphoresis, agitation, tremor, mild fever, hallucinations (visual) and possibly seizures
4 categories of alcohol withdrawal
- Minor withdrawal
- Major withdrawal
- Withdrawal seizures
- Delirium tremens (DTs)
describe minor withdrawal
- withdrawal tremulousness
- onset 6-24 hours after drinking
- Duration < 48 hours
- Anxiety, N/V, tremor, clear sensorium
describe major withdrawal
- alcohol hallucinosis
- Onset 10-72 hours after drinking; up to 5 days
- whole body tremor, vomiting, HTN, hallucinations, diaphoresis, fever
describe withdrawal seizures
- Occur w/in 6-48 after last drink
- Generalized, brief
- 30-40% go on to DTs
What is delirium tremens
the most severe form of ethanol withdrawal manifested by altered mental status (global confusion) and sympathetic overdrive (autonomic hyperactivity), which can progress to cardiovascular collapse
describe delirium tremens
- Life threatening 15% mortality
- Onset usually > 3 days since last drink
- Profound global confusion is hallmark of dx
- Tremor, fever, incontinence, autonomic hyperactivity, hallucinations are common findings
treatment of alcohol withdrawal
- Evaluate for co-morbidities
- Correct fluid and electrolyte imbalances
- Meds: BENZODIAZEPINES. May require large doses.
- Ativan 1-4 mg IV q hour to effect.
- Tranxene 15-30 mg PO Q 6-8 hours for discharge
- May require Beta-blockers or Clonidine to blunt adrenergic effects
- Haldol to help with hallucinations, prn
- (Phenytoin/dilantin is NOT indicated)
What is evaluation/tx of DTs
- Rule out Infection or other neurological abnormalities; consider head CT, LP and CXR
- Hemodynamic support
- Thiamine/glucose/electrolytes
- May require benzodiazepines, beta-blockers, haldol
what is the typical presentation of alcoholic ketoacidosis
- binge drinking followed by days of starvation, vomiting, occ SOB/ Kussmaul resps
- N/V/abdominal pain; can have gastritis, pancreatitis
what are PE findings of alcoholic ketoacidosis
- tachycardia,
- tachypnea,
- abdominal tenderness are suggestive but non specific
Evaluation of AKA
- ABG/VBG: Acidotic, low bicarbonate and increased anion gap
- Glucose: Usually normal or low; in contrast to DKA
- Etoh: usually zero or low
- Urine dipstick : may not show ketones, due to type of ketones involved
Tx of AKA
- IV fluids w/ glucose to clear the ketones
- No insulin; bicarbonate rarely needed
- Antiemetics to control vomiting; benzos for withdrawal
*Usually corrects in 12-16 hours
Toxic alcohols
- isopropyl alcohol: Rubbing alcohol, mouthwash
- Methanol: found in windshield wiper fluid , antifreeze
- Ethylene Glycol: found in anitfreeze, detergents
presentation of isopropyl alcohol intox.
- similar to Ethanol, but longer duration and CNS effects are more profound,
- “twice as intoxicating” as alcohol
- Smells of rubbing alcohol or fruity odor of ketones
lab findings of isopropyl alcohol intox.
- None to only minimally elevated anion gap
- Negative Ethanol level
- Large osmolal gap
tx of isopropyl alcohol intox.
- IVF
2. observe
methanol metaboilzes to _
formaldehyde
PE findings of methanol intox.
- often delayed; 12-24 after ingestion
- Accumulates in the retina, causes edema; visual “snowstorm”** (SNOWSTORM BLINDNESS)
- GI irritant
- CNS changes
Lab findings of methanol intox.
- High anion gap metabolic acidosis
2. Elevated osmolal gap
tx of methanol intox.
4-MP fomepizole; (ethanol), dialysis
PE findings of ethylene glycol intox.
- often delayed 12-24 h.
- Renal Failure: Flank Pain, ATN, ARF
- Calcium Oxalate Crystals in the urine
lab findings of ethylene glycol intox.
- Elevated osmolal gap
2. High anion gap metabolic acidosis
Tx of ethylene glycol intox.
4-MP/ Fomepizole; , (ethanol) dialysis
Describe the classifications of seizures
Generalized (diffuse brain involvement); always with LOC
- Tonic-clonic / grand mal
- Absence / petit mal
- Others – myoclonic, tonic, clonic, atonic
- Focal: with or with out impairment of consciousness (used to be called partial)
What are the phases of grand Mal or tonic clonic seizures
- Tonic (rigid) phase
- clonic phase
- post-ictal stage
Describe the tonic (rigid) phase of grand Mal or tonic clonic seizures
LOC, respiratory arrest, fall, lasts <1 min
Describe the clonic phase of grand Mal or tonic clonic seizures
rhythmic jerking of the extremities for 1-3 minutes. +/- incontinence, tongue biting, aspiration
Describe the post-ictal phase of grand Mal or tonic clonic seizures
- Usually 5-15 min; usually lasts up to 60 min. Patient is sleepy, may c/o HA, N/V, myalgias
- Fatigue, some confusion may persist for several hours
DDX of seizures
- Syncope
- Hyperventilation syndrome
- Psychogenic seizures
- Atypical migraine
- Movement disorders
Common secondary causes of seizures
- trauma
- intracranial (Mass, aneurysm, bleed)
- ecclampsia
- HTN encephalopathy
- Infection (meningitis, abscess)
- drugs (cocaine, MJ, etoh, withdrawal, and more)
- Metabolic (hyponatremia, hypoglycemia, hypocalcemia, uremia, hepatic failure)
What are metabolic causes of seizures
- Hyponatremia
- Hypoglycemia
3 . Hypocalcemia - Uremia
- Hepatic Failure
Work up of a first time seizure in an adult
- Head CT/ (MRI?– usually outpatient)
- EKG (arrhythamia?)
- Labs: CBC, chem 7 (Na and Glucose specifically),Ca/Mg, pregnancy; Urine tox
- Lumbar puncture- febrile, immunocompromised, or ? SAH
If patient has a known seizure disorder, and presents with a normal pattern, you may just need to check ___ and ask about __
glucose and anticonvulsant levels
Do ask about triggers, pattern (same? Different?), recent changes in meds, illnesses, etc.
treatment of isolated first seizure
- with normal workup and return to baseline MS
- generally do not initiate any anti-epileptics
- out patient neurology follow up; EEG
- no driving x 3 months at least, or until cleared by neurology
___ level may be elevated for 15-60 min s/p true seizure
Prolactin
Often, a transiently elevated ___ for about an hour s/p seizure
anion gap
*low bicarb
What is Todds paralysis
a transient focal neuro deficit s/p seizure
can indicate a focal cerebral lesion as the cause
status epilepticus treatment (≥5 minutes of continuous seizure activity, or more than one seizure without recovery in between)
- ABC’s, IV, O2, monitor, labs, utox, temp,
- BENZOS! Lorazepam 2- 4 mg IV repeat in 10 min
- Diazepam 5-10mg IV and repeat as an option - Phenytoin (Dilantin) 10-20 mg IV
- Fosphenytoin - If refractory , consider: propofol, barbiturates, midazolam
Describe simple seizures in febrile pediatrics
- Generalized tonic-clonic
- lasts <15 minutes,
- Temp > 38C / 100.4 F
- 6mo - 5 year of age
- just one seizure in 24 hours
Describe complex seizures in febrile pediatrics
- With focality
- Seizure >15 min
- postictal period
- outside of 6m-5yr age group
- multiple seizures
Treatment of simple febrile seizures
- Identify and treat any fever sources (AOM, PNA, UTI)
- Antipyretics (rectal Tylenol 15mg/kg, Advil 10 mg/kg)
- Lorazepam .05-0.1mg/kg if seizing during visit
(Phosphenytoin 2nd line)
Febirle seizure pearls/ education points
- Usually occur on first day of illness
- May be related to rate of rise of fever
- Reassure Family
- very good prognosis, 1% risk of developing epilepsy (almost general public risk) - Recurrence – between 15%-70% likely
