psych emergencies Flashcards
subjective or objective info? what should you do?
subjective
Want to try reassurance, redirection and if that fails -> chemical restraint
- chemically restrain the pt with an injection of antipsychotic and begin PE
- Cant do a mental exam at this point
- Don’t do physical restraint -> can injure the team or the pt -> disruptive and doesn’t work
psych emergencies: sx
-Suicidality
-Violence/Homicidality
-Intoxication
-Depression
-Anxiety
-Panic
-Psychosis
-Drug Withdrawal
-Significant rapid changes in behavior
role of PA provider during emergencies
-Identify and Neutralize threat to self or others
-Identify acute psychiatric conditions (presumptive diagnosis)
-Identify and address acute medical conditions that present with psychiatric symptoms
-Provide short term treatment for acute psychiatric conditions
-Develop initial long term treatment plan for acute/chronic psychiatric conditions, i.e., inpatient admission, extended observation, release with initial Rx, f/u appointment with psychiatrist/therapist/clinic
3
psych emergency evaluation - what workup
-History (medical and psychiatric)
-Medication review
-Physical examination
-Psychiatric interview
-Mini-MSE
-Labs and Imaging studies
psych emergency evaluation - what labs
-CBC with diff- infection
-chemistry- electrolyte imbalance, hypoglycemia, hyperglycemia
-TSH- hypo/hyper
-B12 and folate
-U-tox: substance abuse
-UA- UTI
-chest x ray- infection
-EKG- acute MI, arrythmia, QTC
-RPR- syphilis
-Beta HCG- pregnancy
5
90% of people who die by suicide are suffering from one or more psychiatric disorders:
-Major Depressive Disorder
-Bipolar Disorder, Depressive Phase
-Alcohol or Substance Abuse
-Schizophrenia
-Personality Disorders such as Borderline Personality Disorder
(from autopsy studies from various countries for over 50 yrs)
physical exam: what should you look out for and what is important
-Perform a thorough physical examination: most important INITIAL step***
-All systems are potentially important but pay particularly close attention to Vital Signs, HEENT, and Neurologic systems
suicidality assessment: what is the primary rule for assessment?
know: ideation vs intent vs plan!!!!!
-Ideation: “I wish I were dead “
-Intent: “When no one is home, I’m going to kill myself”
-Plan: “I am going to hang myself with the garden hose my father keeps in the garage”
suicide risk factors
-Previous Attempt: MOST important risk factor!!! Increased risk if attempt occurred within the last 2 years
-Psychiatric Disorder: >90% of completers had mental illness
-Age: Highest prevalence under 19 years of age and over 45 years of age. Men over 65 years of age have the highest rate of completion
-Gender: 75% of suicide completers are male. However, women make 3x more attempts than males
-Marital status: Single, widowed, or divorced at higher risk
-Support system: Solitary lifestyle at higher risk
-Family History of Suicide: Up to 10% of completers had a 1st degree relative who committed suicide
-Substance Abuse: Approximately 10% of illicit drug users/alcoholics attempt suicide
-Recent loss: Loved one, job, relationship, pet, or status
-Chronic medical condition: TBI, AIDS, Fibromyalgia, Late stage cancer
-Weaponry: Presence of firearms in the home increases the risk
-Season: Most suicides occur in the Spring
-Stigma associated with help-seeking behavior
-Barriers to accessing health care, especially mental health and substance abuse treatment
-Certain cultural and religious beliefs (for instance, the belief that suicide is a noble resolution of a personal dilemma)
-Exposure to, including through the media, and influence of others who have died by suicide
suicide evaluation
-ASK!!!
-Any thoughts of hurting self or others?
-Any plans?
-Any means to carry out the plan?
-Any preparations?
-Any access to weapons/instruments?
-Any past attempts?
-When in doubt go with your gut!
SADPERSONS: suicide risk factors
S ex: Male
A ge: <19 >45
D epressive Symptoms: sadness, anhedonia
P revious attempt, psychiatric history
E Excessive substance abuse
R ational thinking deficit: psychosis, dementia
S eparated, divorced, widowed
N o social supports
S tated intent
management of suicidality: general tips and when to consider hospitalization
-Never leave the patient unattended
-Remove sharp objects, belts, and other objects the patient can use to hurt self or others
Consider hospitalization if:
-High risk of act
-Strong intent
-Substance abuse
-Access to lethal ways to harm self
-Delirium
-Dementia
management of suicidality: when to consider discharge with arranged f/u
-Positive response to initial intervention
-Good social support
-Medically stable
-Impulsive action while under the influence of substances; stable after extended observation.
protective factors: suicide
Protective factors reduce the likelihood of suicide; they enhance resilience and may serve to counterbalance risk factors.
-Effective clinical care for mental, physical, and substance use disorders
-Easy access to a variety of clinical interventions and support for help-seeking
-Restricted access to highly lethal means of suicide
-Strong connections to family and community support
-Support through ongoing medical and mental health care relationships
-Skills in problem solving, conflict resolution and nonviolent handling of disputes
-Cultural and religious beliefs that discourage suicide and support self-preservation.
homicidality/violence assessment: what is the primary rule for assessment?
Primary rule: Know the difference between:
-Ideation: “I wish my father were dead”
-Intent: “I’m going to kill my boyfriend”
-Plan: “Tomorrow, I am going to walk into work with my gun and shoot my boss”
