psychiatric emergencies Flashcards
psych emergencies: sx
-Suicidality
-Violence/Homicidality
-Intoxication
-Depression
-Anxiety
-Panic
-Psychosis
-Drug Withdrawal
-Significant rapid changes in behavior
role of PA provider
-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
evaluation
-History (medical and psychiatric)
-Medication review
-Physical examination
-Psychiatric interview
-Mini-MSE
-Labs and Imaging studies
standard labs and imaging
-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
physical exam
-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
suicide
-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
suicidality assessment
-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”
suicide risk factors
-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
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
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!
management of suicidality
-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: consider discharge with arranged FU if:
-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
-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”
homocidality/violence: risk factors
-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