Psych Emergencies - Exam 3 Flashcards
What is an important step if you suspect a psych cause of the patient’s symptoms?
need to screen them for weapons
always need to ensure provider and staff are safe at all times
What are the elements of the ED evaluation for a psych cause?
Perform screening assessment
Look for organic causes : rule out something medical
Assess for drug/alcohol use
Complete a psychiatric safety check
agitated or distressed patients, those with ____ should not be allowed to leave the ED prior to ____ and ____ exam
SI/HI
medical and psychiatric
What are important history questions to ask a psych pt?
Inquire about:
previous psychiatric treatment
seizure disorders
polysubstance abuse
and any recent suicidal attempts including possible ingestions.
**What are visual hallucinations more suggestive of? **auditory hallucinations?
Visual hallucinations are more suggestive of medical etiology
Auditory hallucinations often suggest a psychiatric etiology
What are red flag signs for medical dysfunction?
lability of affect
simple questions need repeated
irritability
disorientation
uncooperative
What are the The American College of Emergency Physicians published guidelines with regards to UDS?
NOT necessary for patients who are awake, alert and cooperative
What is a medical clearance? What are the components?
ensure no organic pathology that would require medical intervention BEFORE transfer to psychiatric facility
CBC, CMP, UDS, UA, TSH,acetaminophen level, salicylate level, EtOH level, EKG
if using cocaine/meth: add CK and trop
What are early warning signs of a violent patient?
threatening statements
loud voice
agitated movements
fighting posture
clenched fists
striking inanimate objects
What is the SAFEST approach to the violent patient? Which one is the most important?
Spacing: 2 arms lengths away
Exchange: most important!
need to be able to have a calm conversation and figure out why they are angry
What are the 2 ways to stabilize a violent patient?
either with sedation or physical restraints
______ is used to sedate a violent pt. When are physical restrains used? What do you need to do next?
lorazepam 1-2mg IM/IV
**Used only when patient poses immediate threat to self or others and is obstructing evaluation or treatment
DOCUMENT the events that lead up to the decision to restrain and record safety checks performed on the restrained patient. Need to re-eval need for restraints every hour
______ are used as chemical restraints in the violent patient who are NOT responding to sedation. What are the SEs? How frequently can you repeat dosing?
haloperidol (Haldol)
extrapyramidal symptom and QT prolongation
Dosing may be repeated every 30 minutes until the patient is in more control
What are the 3 key managements points for the suicidal patient?
The management of suicidal ideations include:
recognizing the problem
assessment of risk
development of a treatment plan.
What is the best screening approach for the suicidal patient?
The best screening approach involves GENERAL questions about the patient’s emotional state.
need to figure out passive vs active suicidal ideation
What is the assessment tool used in suicidal pts?
Suicide Prevention Resource Center Decision Support Tool
Columbia-Suicide Severity Rating Scale (C-SSRS)- on MD calc
What are 6 questions that if “yes” warrant an immediate psych consult
Thoughts of carrying out a plan.
Suicide intent.
Past suicide attempt.
Significant mental health conditions.
Substance use disorder.
Irritability/agitation/aggression
If your pt is deemed a high suicide risk per the risk stratefying tools, what happens next?
require hospital admission to psychiatric service or to medical service with psych consult
voluntary or involuntary admission
What is the protocol for an involuntary hold?
follow hospital protocol
Contact magistrate or social services
Mental hygiene commissioner must perform an evaluation (via telephone or in person) in order to determine if there are grounds for issuing an involuntary hold
An involuntary hold will allow the patient to be held in the ED until a hearing can be scheduled (usually within 24 hours or next business day)
ED provider filing the mental hygiene warrant may have to testify at the hearing
**If a pt is deemed a high suicide risk, ______ protocol is usually initiated
**One-on-one suicide prevention protocol is usually initiated
What is the plan of care for a moderate suicide risk pt? What parameters would make the pt more inclined to be treated on an outpt basis?
consult psychiatry to discuss disposition
May attempt outpatient therapy if:
Establish therapy immediately with close follow up and ED provider should rx up to 2 weeks of medication
develop a safety plan with pt and pt’s family
What are 2 things that should be included in a safety plan for a suicidal pt?
Remove all means of suicide (firearms, drug supplies)
Family should manage patient medications
What is the tx of a low suicidal risk pt?
What qualifies a pt as a low suicide risk?
patients who present with suicidal ideation, threats, plans, or minor attempts which occur in a definable external crisis
Great family/social support is present!!
aka a major life event just happened and they have good family support!!
What is important to note about the homicidal pt?
Attempt to elicit the patients plan should be made
ER staff should notify the police - who will notify the third party
Who should monitor the homicidal pt? What extra measures? What is mandatory?
The patient should be closely monitored by SECURITY personnel
ENSURE STAFF safety at all times!!!
use restraints if indicated and remove all potential weapons
IMMEDIATE hospitalization and psychiatric consultation is MANDATORY
What are some examples of things a homicidal pt might use as weapon?
Neckties (staff or patient)
Large earrings
Patient belts or belt buckles
Shoes/shoelaces
Stethoscopes
Blood pressure cuffs
Cutting instruments
What is the disposition of a homicidal pt based on?
is based upon the presence of danger to self or others and the ability to care for oneself. In addition, the desire and ability to cooperate with treatment and available support systems should also be considered
Who can involuntary commit someone?
Any adult can APPLY to have an individual involuntarily committed if they have reason to believe that the individual meets criteria for emergency evaluation
