Psychiatric Emergencies Flashcards
acute changes in behavior that negatively impact a patient’s ability to function in his or her environment
Psychiatric emergencies
screening assessment - For psychiatric emergencies, perform an effective ______, probing for ______ and completing a ________
- screening assessment
- organic causes
- psychiatric safety check
difference between screening assessment vs psychiatric safety check?
- Screening: r/o underlying medical cause
- Psychiatric safety check: looks for suicidal ideation, homicidal ideation, or pts’ inability to care for themselves
what type of pt would disposition them to not leave the ED prior to medical and psychiatric exam?
agitated/distressed pts
suicidal/homicidal
what type of hallucinations are more suggestive of a medical cause vs a psychiatric cause?
- Visual hallucinations = medical etiology
- auditory hallucinations = psychiatric etiology
PE of a psychiatric emergency involves what?
- disrobed, gowned, and searched
- Thorough PE + neuro assessment
- Look for physical clues to source of an AMS - head injury, drugs, infection or toxidromes.
- Assess for adverse consequences of behavior - malnutrition, mutilation or dehydration.
red flag signs of medical dysfunction?
- lability of affect
- simple questions need repeated
- irritability
- disorientation
- uncooperative
when would a urine/serum drug screen and BAC not be warranted when evaluating a pt?
psych emergencies
if pt is awake, alert and cooperative
Early warning signs of impending violence:
- threatening statements
- loud voice
- agitated movements
- shifting body positions toward a fighting posture
- clenched fists
- striking inanimate objects
what is the S.A.F.E.S.T. Approach?
- Spacing
- Appearance
- Focus
- Exchange
- Stabilization
- Treatment
Spacing when you are dealing with a violent pt?
- Maintain distance - 2 arm’s length
- Do not touch
- equal access to the door
how is the appearance when managing a violent pt?
- empathetic professional detachment.
- Use one primary contact person
- Have security staff available
what are you focusing on when managing a violent pt?
- Watch pt’s hands
- Look for potential weapons and escalating agitation
how should the Exchange be when managing a violent pt?
- Calm, continuous talking - crucial to verbal de-escalation
- Avoid punitive or judgmental statements.
- Use good listening skills.
- discuss current problem to develop a non-life-threatening resolution and to elicit pt’s cooperation with tx.
methods to stabilize when managing a violent pt?
physical restraints, sedation or chemical restraints - Attempt compliant sedation first
medication for sedation?
lorazepam (Ativan) 1–2 mg IM/IV
Dosing may be repeated to achieve effect while monitoring for side effects including respiratory depression
when are physical restraint needed?
Used only when pt poses immediate threat to self or others and is obstructing evaluation or tx
when is chemical restraint used?
what is used?
- for patients not responding to sedation
- Neuroleptics, such as haloperidol (Haldol) 5 mg IM q 30 mins until pt is in more control
SE of haloperidol
Monitor frequently for extrapyramidal sx and QT prolongation
The best screening approach to recognize suicidal ideation involves ?
general questions about the pt’s emotional state.
“What are your feelings about living and dying?”
“What has stopped you from killing yourself so far?” (protective factors)
high risk factors for suicide?
scoring?
- S - sex - males
- A - age - middle age (45-64 years)
- D - depression
- P - previous attempt
- E - ethanol use
- R - rational thinking loss
- S - social support lacking
- O - organized plan
- N - no spouse
- S - sickness
≥5 points = high risk of suicide
Pt indicates remorse, shame, or embarrassment at suicide attempt
would this be a low or high risk for suicidial attempt?
low risk
Pt sits quietly; engages poorly with physician; voices regret at surviving; expresses feelings of hopelessness, helplessness, or exhaustion, refuses to provide additional information
would this be a low or high risk for suicidial attempt?
high risk
approach after an involuntary admission of a suicidal patient?
follow hospital protocol
- Contact magistrate or social services
- Mental hygiene commissioner must perform an eval (via telephone or in person) in order to determine if there are grounds for issuing an involuntary hold
- involuntary hold in ED until hearing can be scheduled (24 hrs or next business day)
- ED provider filing mental hygiene warrant may have to testify at the hearing
disposition for high risk suicidal pt
- voluntary vs involuntary admission
- one-on-one suicide prevention
mgmt for moderate risk suicidal pt?
- consult psychiatry to discuss disposition
- Responds well to initial intervention and have good social support
- +/- outpatient therapy
when can a moderate suicidal risk pt attempt outpatient therapy?
- No medical intervention is needed
- Establish therapy w/ close f/u (psych, counselor and PCP) - 2 wks of meds
- Develop a safety plan
- Remove all means of suicide (firearms, drug supplies)
- Family manages pt medications
patients who present with suicidal ideation, threats, plans, or minor attempts which occur in a definable external crisis
Great family/social support is present
what is the severity of suicidal risk is this pt
low risk
criteria for DC for low suicidal risk pt?
- medical treatment isn’t needed
- no previous suicide attempt
- not actively suicidal
- reliable adult in home in which pt has a good relationship with who agrees to monitor pt - remove all means of suicide (guns/medications)
- Info on return precautions if pt worsens
- F/u PCP or psychiatry arranged
a verbal or written agreement initiated by the provider in which the suicidal patient agrees not to harm or kill themselves
“No-Harm/Suicide Prevention” Contracts
components of “No-Harm/Suicide Prevention” Contracts
- Family member who will assume responsibility of patient
- Actions family and patient will take to reduce risk of suicide
- Agreed-upon help-seeking behaviors if a crisis arises
T/F: “No-Harm/Suicide Prevention” Contracts have MC shown that they prevent suicidal behavior
F - No evidence supports that developing this contract prevents suicidal behavior
an agreement to treatment and proper follow up
Joint Safety Plan
disposition of a homicidal pt?
- Immediate hospitalization and psychiatric consultation is mandatory
- Should be closely monitored by security personnel
disposition of psychiatric emergency is based upon on the presence of ? (4)
- danger to self or others
- the ability to care for oneself
- the desire and ability to cooperate with tx
- available support systems should also be considered
what is Involuntary commitment?
legal process by which a person is confined in a psychiatric hospital because of a treatable mental disorder, against his or her wishes.
