psychiatric emergencies

Question 1

psych emergencies: sx

Answer 1

-Suicidality
-Violence/Homicidality
-Intoxication
-Depression
-Anxiety
-Panic
-Psychosis
-Drug Withdrawal
-Significant rapid changes in behavior

Question 2

role of PA provider

Answer 2

-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

Question 3

evaluation

Answer 3

-History (medical and psychiatric)
-Medication review
-Physical examination
-Psychiatric interview
-Mini-MSE
-Labs and Imaging studies

Question 4

standard labs and imaging

Answer 4

-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

Question 5

physical exam

Answer 5

-Perform a thorough physical examination-most important initial step
-All systems are potentially important
-Pay particularly close attention to Vital Signs, HEENT, and Neurologic systems

Question 6

suicide

Answer 6

-Psychological autopsy studies done in various countries from over almost 50 years report the same outcomes.
-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

Question 7

suicidality assessment

Answer 7

-Primary Rule For Assessment: Know the difference between:
-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”

Question 8

suicide risk factors

Answer 8

-Previous Attempt: Consider this the 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

Question 9

SADPERSONS: suicide risk factors

Answer 9

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

Question 10

suicide evaluation

Answer 10

-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!

Question 11

management of suicidality

Answer 11

-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

Question 12

management of suicidality: consider discharge with arranged FU if:

Answer 12

-Positive response to initial intervention
-Good social support
-Medically stable
-Impulsive action while under the influence of substances; stable after extended observation.

Question 13

protective factors: suicide

Answer 13

-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.

Question 14

homicidality/violence assessment

Answer 14

-Primary rule for Assessment of Homicidality: 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”

Question 15

homocidality/violence: risk factors

Answer 15

-History of violence: Consider this the 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

Question 16

Tarasoff precedent

Answer 16

-Based on 1976 CA rulings – Mental Health Providers have a duty to protect third parties from the dangerous acts of their clients.
-Tarasoff Precedent- Psychiatrists should contact third parties or law enforcement if a threat is made to an identifiable victim, the pt has the capability to carry out such an act and is more likely than not to do so in the near future.
-Psychiatrists have to make determination if threat is valid
-if someone says they are going to beat someone up -> dont report
-if someone is specific with a plan -> report

Question 17

mania/psychosis: tx options: pharmacology

Answer 17

-Haldol 2.5-5.0 mg IM q 2-4 hours PRN acutely
-Long term consider Mood stabilizer(Lithium vs Depakote)
-Given with Cogentin 2.0 mg IM or Benadryl 50.0 mg IM (counteract EPS)
-Geodon 10.0-20.0 mg IM. May give q 2hrs PRN (Cogentin or Benadryl not needed)
-Neuroleptics also FDA approved.
-Haldol used as a mood stabilizer in pregnancy

Question 18

panic attack

Answer 18

-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

Question 19

anxiety/panic attack treatment

Answer 19

-Calm environment
-Supportive therapy
-Ativan 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

Question 20

psychotic disorder presentation: delusions

Answer 20

false beliefs that are not susceptible to argument

Question 21

psychotic disorder presentation: disorganized speech

Answer 21

-disturbance in organizing ideas and speaking in a comprehensible fashion

Question 21

psychotic disorder presentation: disorganized behaviors

Answer 21

-unusual, purposeless, or seemingly illogical actions

Question 21

psychotic disorder presentation: hallucinations

Answer 21

-perceptual disturbances that occurs in the absence of external stimuli

Question 22

psychosis or aggression: tx protocol

Answer 22

-Haldol 2.5-5.0 mg IM q 2-5 hours PRN
-Given with Cogentin, Benadryl or Ativan (counteract EPS)
-Geodon 10.0-20.0 mg IM. May give q 2hrs PRN (Cogentin, Benadryl or Ativan not needed)
-Consider long term antipsychotic therapy
-Consider need for mood stabilizer
-Admit if indicated

Question 23

neuroleptic malignant syndrome

Answer 23

-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

Question 24

neuroleptic malignant syndrome: tx

Answer 24

-Treatment: Discontinue antipsychotic immediately!!!.
-Supportive treatment: IV hydration, cooling blankets, monitoring ventilation.
-Muscle Relaxant: Dantrolene: 2-3 mg/kg per day by IV in TID or QID doses.
-Dopamine Agonist: Bromocriptine: 5 mg QD-QID, Amantadine: 100 mg BID

Question 25

physical restraints: primary rules

Answer 25

-Restraints should be considered only a temporary solution to a problem.
-In most cases, staff must first attempt structure (cueing & redirecting patient to more appropriate behavior) and medication before restraint can be legally applied
-If patient strikes another person, s/he is legally considered a danger to himself and/or others and a restraint may be applied
-Every attempt must be made to explain to the patient and family members the purpose of the restraint and obtain informed consent
-Once applied, remove the restraints at least every 2 hours to reassess and allow for activities of daily living

Question 26

protocol for physical restraint

Answer 26

-Restraints are considered “prescription devices” and require a physician’s orders
-Documentation: description of patient’s behavior, type of restraints applied, circulation status of the extremities, patient’s vital signs, medical reason for applying restraints, length of time restraints were used, and any other alternatives that were tried
-Circulation checks: At least every two hours, fluids and foods given, and care for personal hygiene
-Renewal of order every 2 hours.
-Often remains on 1:1 during this duration

Question 27

inpatient admissions

Answer 27

-CPEP (comprehensive psychiatric emergency program)
-voluntary/involuntary

-CPEP:
-Standard for Admissions: Person may have a mental illness for which immediate observation, care and treatment in a CPEP is appropriate; illness must carry a “likelihood of serious harm”
-Duration of Stay: Up to 72 hours involuntarily (with VALID DOCUMENTATION AND justification) -> after which the patient must be discharged or admitted involuntarily for further observation and treatment
-After initial 24 hours patients are switched to extended observation beds

Question 28

inpatient admission: NYS volunteer status

Answer 28

-Standard for Admissions: Person has a mental illness for which care and treatment in a mental hospital is appropriate; person is suitable for admission on a voluntary basis.
-Pt needs to make a written request for admission and discharge.
-Duration of Stay: Indefinite. If hospital feels pt needs to stay involuntarily, must apply to judge within 72 hours for authorization to keep patient

Question 29

xanax withdrawl

Answer 29

-going from 3 to 2 wont make a difference BUT
-going from .5 to .25 -> pt will feel this