Psychiatric Emergencies Flashcards
The Precautionary Principle
Prevent or minimize harm before it occurs
Psychiatric Code Team
ED physician, nurse(s), hospital nurse manager,
psychiatric clinical nurse, & security staff
* Ideally “assembled” in a prepped room
before patient arrival
De-escalation protocols:
- Respect Personal Space
– 2 arms length away - Do not provoke
– BE calm (verbal & non-verbal) - Establish Verbal Contact
– Only 1 person - Introduce yourself
– Orient & reassure - Be concise
– Keep it simple - Repetition
– Stay “on message” - Identify the wants & feelings
– Active listening - Read the patient’s communication
– Verbal & Non-verbal
– Active listening to communicate understanding - Miller’s Law
– “To understand what another person is saying, you must assume that it is
true and try to imagine what it could be true of.”
ER Triage Algorithm for psychiatric patients
- Ensure patient & ER safety, then
stabilize the patient - Identification of homicidal, suicidal, and/or
other dangerous behavior - Medical Evaluation
- Psychiatric diagnosis & severity assessment
- Psychiatric diagnosis & severity assessment established?
Seclusion rooms
- Permit rapid exit for staff
- Free of items used in violent
attacks - Panic button
- Door can lock from outside
- Security
Examination Rooms & Seclusion
- Secluded room → door open
- Advise patient of actions to be taken & the expected duration, & explain the
consequences of violent behavior. - If the patient remains agitated → lock the door.
- Monitor with a personal guard, nurse-monitor, or by closed–circuit television
- Give opportunities to show acceptable behavior → release from seclusion
- If violent behavior persists → restraint is justified
- Document all steps in the use of seclusion, medical & physical restraints
Physical Limb Restraints
- Applied by team
– 5 (Team lead, 1 person per limb) - Each carefully restrains the limb to the bed
- Elevate the patient head
- Offer medication first, then administer involuntarily
– Follow hospital protocol for observation & toileting - Removal
– Patient is calm & compliant
Signs & Symptoms of
Medically Related Behavioral Abnormalities
- Abnormal vital sign values
- Disorientation with clouded consciousness
- Abnormal mental status examination findings
- Recent memory loss
- Age >40 y without a previous history of psychiatric
disorder - Focal neurologic signs
- Visual hallucinations
Medically Related Behavioral Abnormalities examples:
- Diabetes Melitus (Hypoglycemia)
- CVD
- Pulmonary disease (Hypercapnia)
- Meningitis
- Drug withdrawal/overdose
- Other causes of delirium
– UTI (esp. elderly), hepatic encephalopathy
Mental Status Examination consists of the following
- Appearance & behavior
- Speech & language
- Mood & affect
- Thoughts & perceptions
- Cognitive function
Assessment of Harm to Self
- Establish rapport
- Assess suicidal intent,
current mental state, &
access to means of
suicide - Ensure a safety plan is in
place before discharge - Arrange f/u before D/C
SAD PERSONS
S Sex - M > F
A Age (13-18 & >75)
D Depression (behavioral health issues) Y or N
P Previous attempt - Y or N
E Ethanol use - Y or N
R Rational thinking loss - Y or N
S Social supports lacking - Y or N
O Organized plan - Y or N
N No spouse - Y or N (includes separation)
S Sickness (poor health) - Y or N
*Each factor is 1 point, & patients who score ≥5 points should be considered at high risk of suicide.
Red Flags for Assessment of Harm to Others
– Hostile behavior, homicidal ideas, fantasies, or
preoccupations
– Verbal aggressiveness, statements about violent intent
– Weapons skill & access
– Motives for violence
– Pre-attack planning & preparation
Involuntary Hospitalization
- Patients may be brought to the ER by the police or by the family because of suicidal ideation, homicidal ideation or due to other aberrant thoughts & behaviors.
- What if they will not consent to treatment?
- “First do no harm”
- A 72-hour involuntary mental health hold can
be obtained for the purpose of acute
evaluation & determination of the patient’s
safety when the evaluator elicits sufficient
information to confirm that a significant risk
exists of danger to self or others
Legal principles of involuntary hospitalization
- Parens Patriae: Latin, “parent of the country”
* Doctrine from English common law that assigns to the
government a responsibility to intervene on behalf of citizens who
cannot act in their own best interest. - Police Power:
1.The state must protect its citizens from injury by another
2.Providers have a duty to people other than their patients in only
very narrow circumstances
– clear & imminent threat to an identifiable person(s)
“Pink Sheet” Utah Law
– Filled out & signed by a Mental Health or Police Officer
* “observes behavior (probable cause) which leads to belief that the
person is mentally ill & there is a substantial likelihood of serious harm
to self or others”
* A Police Officer can detain & transport based on the observations of a
Mental Health Officer’s report to them
* Authorizes hold for up to 24 hours excluding weekends & legal holidays
“Blue Sheet” Utah law
– Filled out & signed by:
* An applicant (responsible citizen with first-hand knowledge of the facts
indicating mental illness & risk of injury)
* A physician or designated examiner within 3 days of having examined
the patient
* Authorizes hold for up to 24 hours excluding weekends & legal holidays
Expiration of Mental Health Hold - Utah law
- Release the patient
- Patient consents to voluntary treatment
- File with District Court (White Sheet)
Acute Anxiety & Panic Attacks
Very common manifestation of mental health &
behavioral disorders, dementia, intoxication, &
withdrawal syndromes
Clinical Presentation of Acute Anxiety & Panic Attacks
- Palpitations, sweating, shaking, shortness of
breath, choking sensation, chest pain or
discomfort, nausea, feeling dizzy,
derealization (feeling of unreality) or
depersonalization being detached from
oneself), fear of losing control/going
crazy/dying, pararesthesias, chills or hot
flashes - Recurring episodes
- Peaks in ~10 minutes
Acute Anxiety & Panic Attacks diagnosis
– Rule out medical causes
* EKG
* CBC
* CMP
* TSH
* UA & drug screen
Acute Anxiety & Panic Attacks management
- Ensure safety of patient & staff
- Place patient in a quiet room with a sitter
- Remove dangerous items
- Possible restraints
- Rx
– Dependent on S/S, risks/benefits
– Appropriate route of administration - Offer oral first
– All antipsychotics have similar
efficacy for acute agitation
Garris S, Hughes C. Acute Agitation. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill; 2016.http://accessmedicine.mhmedical.com/content.aspx?bookid=1658&Sectionid=109448152. Accessed September 23, 2016.
Anxiety disorders clinical presentation: History, mental status examination, physical examination. http://emedicine.medscape.com/article/286227-clinical. Accessed September 23, 2016.
Management of Acute Anxiety & Panic Attacks in special populations (elderly, children, acute withdrawal)
– Elderly
* Use lower doses of antipsychotic agents
* Use short-acting benzodiazapines
* Avoid antihistamines (anticholinergics = delirium)
– Children
* Use antihistamines or benzodiapines
* Pediatric dosing guidelines should be followed
– Acute withdrawal
* Alcohol or substance abuse = Benzodiazepines
* Benzodiazepine withdrawal = treated by tapering
Acute Anxiety & Panic Attacks discharge
- F/U with primary care provider &
behavioral health
– Cognitive Behavioral therapy shows
efficacy - Benzodiazepines should be limited to a
short course, if used - Consider starting SSRI (long-term therapy)
- Patients with suicidal or homicidal ideation
– Emergent psychiatric evaluation
in the ED
Discharge of PTSD
- F/U with primary care provider & behavioral health
– Cognitive Behavioral therapy shows efficacy - Benzodiazepines should be limited to a short course, if
used - Consider starting SSRI (long-term therapy)
- Patients with suicidal or homicidal ideation
– Emergent psychiatric evaluation in the ED
Psychoses
“Fundamental derangement of the mind characterized
by defective or lost contact with reality”
Psychoses clinical presentation
- Hallucinations: subjective perception of an external object or event that does not exist
– Subjective sensory experience → Auditory most common - Delusions: fixed, false beliefs or wrong judgments held despite evidence to the
contrary → Usually thematic
– Grandiose: belief that s/he has exceptional abilities, wealth, or fame
– Persecutory
– Erotomanic: false belief that another person is in love with him/her
– Referential: believes certain gestures, comments, environmental cues, & so
forth are directed at oneself - Disorganized Thinking
- Negative Symptoms (5 As)
Negative Symptoms (5 As) of psychoses
– Avolition: ↓ motivation
– Affect: ↓ emotional expression
– Anhedonia: ↓ ability to experience pleasure
– Asociality: ↓ interest in social interaction
– Alogia: ↓speech
Disorganized Thinking
– Derailment or loose association
* patient switches from one topic to another
– Tangentiality
* answers to questions may be unrelated or loosely
related
What medical conditions need to be ruled out to diagnose someone with psychoses?
– Infections
* Encephalitis, meningitis, or cystitis
– CNS conditions
* Stroke, seizure, Parkinson’s disease, or brain tumor
– Metabolic disorders
* hypoglycemia or hepatic encephalopathy
Psychoses discharge
- F/U with primary care provider & psychiatry
– multicomponent psychosocial interventions that include psychoeducation,
structured psychotherapies, community care, skills training, or family
interventions appear to improve social functioning & may reduce relapse in
schizophrenia - Antipsychotic medications are the main treatment
- Patients with suicidal or homicidal ideation
– Emergent psychiatric evaluation in the ED
Abuse history:
- Subjective information: patient states, “….”
- Objective information: detailed description of
patient’s appearance, behavioral indicators,
injuries, & health complaints
Intimate Partner Violence documentation
– Use body maps
– Photographs (with patient’s consent)
– Radiologic, laboratory findings
– Collect of forensic evidence
* clothes, debris, hair, body fluid
– Any materials & referrals offered
– Results of health & safety assessments
Review SANE/SAFE protocol
:)
Reporting Requirements for abuse
- Vary by state
- Most states do NOT require medical personnel to make a rape report
when they have treated a victim who is a competent adult.
– Exceptions - State laws that require non-accidental or intentional injuries to be
reported - State laws that require injuries caused by criminal conduct or
violence to be reported
– Know the laws specific to your state
“Competent Adult”
– Definition varies from state to state
– Competent adj. 1) in general, able to act in the circumstances, including the ability to perform a job or occupation, or to reason or
make decisions
* Many states require medical personnel to make a report to law enforcement and/or social services following their treatment of a child,
elderly person or vulnerable adult who was the victim of a crime
