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”
homocidality/violence: risk factors
-History of violence: MOST important risk factor!!!
-Psychosis: schizophrenia, depressive disorder, mania
-Substance abuse: alcohol, cocaine, heroin, PCP
-Personality disorder: paranoid, antisocial, borderline
-Neurological impairment: TBI, delirium, dementia
-Chaotic family environment: history of violence, mental illness, substance abuse
-Physical/Sexual abuse
-Poor coping skills, impulsivity
-Proximity to weapons
Tarasoff Precedent (1976)
Duty to Protect: Mental health providers are obligated to protect third parties from dangerous acts of their clients.
Criteria to report to third parties or law enforcement:
- threat made to identifiable victim
- pt has capacity to carry out threat
- It is more likely than not that the patient will act on the threat in the near future
- psychiatrists must assess whether a threat is valid.
mania/psychosis: tx options: pharmacology
Haloperidol (Haldol): 2.5-5.0 mg IM q 2-4 hours PRN acutely
- used as a mood stabilizer in pregnancy
- Given with Cogentin (Benztropine) 2.0 mg IM or Benadryl 50.0 mg IM to counteract extrapyramidal sx
-Geodon (ziprasidone) 10.0-20.0 mg IM. May give q 2hrs PRN (Cogentin or Benadryl not needed)
-Neuroleptics also FDA approved
Long term consider Mood stabilizer: Lithium or valproate (Depakote)
panic attack definition
-Discrete episode of intense fear or discomfort
-Onset is sudden. Duration between 5 and 30 minutes
-May or may not have stressor
-Has psychological and physical symptoms
psychotic disorder presentation: define delusions, hallucinations
delusions: false beliefs that are not susceptible to argument
hallucination: perceptual disturbances that occur in absence of external stimuli
panic attack/anxiety attack tx
-Calm environment
-Supportive therapy
-Ativan (Lorazepam) 1.0-2.0 mg PO/IM/IV q 30 min PRN
-SSRI first line long term therapy
-Prescribe benzodiazepines only on a short term basis
-Refer for cognitive behavioral therapy
psychotic disorder presentation: define disorganized speech and behavior
disorganized speech
-disturbance in organizing ideas and speaking in a comprehensible fashion
disorganized behaviors
-unusual, purposeless, or seemingly illogical actions
acute psychosis or aggression: tx protocol
Best: Geodon 10.0-20.0 mg IM. May give q 2hrs PRN
- Cogentin, Benadryl or Ativan not needed for EPS, favorable SE profile
-can give haloperidol 2.5-5.0 mg IM q 2-5 hours PRN but give
with Cogentin (benztropine), Benadryl or Ativan (counteract EPS)
-Consider long term antipsychotic therapy
-Consider need for mood stabilizer
-hospitalize: urine tox
neuroleptic malignant syndrome: def, sx, labs
-rare, life threatening reaction to a neuroleptic med
-sign and symptoms- fever, rigidity, AMS, and autonomic dysfunction (tachy, hypo/hypertension)
-labs- leukocytosis, increased CPK, myoglobinuria
