PSYCHIATRIC EMERGENCIES

Question 1

You have a violent patient. You recall the SAFEST acronym and use it to deal with the patient appropriately. What does it stand for?

Answer 1

Spacing – keep safe distance and allow both you and Pt access to door. Don’t touch them.
Appearance –Empathic, use one person to build rapport, have security available and visible.
Focus – watch hands and for potential weapons.
Exchange – practice empathy avoid judgment,
Stabilization – refers to restraints if necessary
Treatment

Question 2

What are some organic causes of psychiatric emergencies?

Answer 2

Infection (Neurogenic Syphillus, sepsis), 
Endocrine (Thyroid), 
Degenerative disease (Alzheimer’s),
Metabolic (hypoglycemia), 
TBI, 
Drugs (ETOH, etc.),
Nutritional (B12)

Question 3

what are some risk factors for suicidal patients?

Answer 3

• S: Male sex
• A: Age
• D: Depression
• P: Previous attempt
• E: Excess alcohol or substance use
• R: Rational thinking loss
• S: Social supports lacking
• O: Organized plan
• N: No spouse
• S: Sickness

Question 4

When does serotonin syndrome usually present?

Answer 4

within 24 hours of starting a new SSRI/TCA/TRAMADOL etc.

Question 5

James has been on his Paxil for several months now and feels great…so great that he’s decided to stop taking it without a taper. What might happen and how would it present?

Answer 5

Serotonin discontinuation syndrome: abrupt stop of antidepressants causes
FINISH: flu-like, insomnia, nausea, imbalance, sensory disturbance, hyperarousal.
TX resolves in 2weeks. Start antidep. and taper.

Question 6

Curt shows up to the ED and can’t stop shaking. He’s sweating and has cramps too. He has a seizure so you decide to observe him for a few days. Seizures stop after 48 hours, but he starts to hallucinate and becomes febrile. What is the cause of this?

Answer 6

EtOH withdrawal:

Tremulous, anxiety 5-10
hallucination (usually auditory) 12-24
6-48 seizures
48-72 delirium tremens: night terrors, agitation, hallucinations, HTN, tachycardia.
Monitor, Benzos as needed (esp. to prevent aspiration)

Question 7

Mike went to a party over the weekend and drank until he passed out. He woke up in a hospital and asks the nurse why he’s in the hospital and what was done to him while there… she tells him he had alcohol toxicity and explains that his treatment consisted of:

Answer 7

ABC, dextrose (hypoglycemia), thiamine (wernicke korsikoff), dialysis (met acidosis), wait for liver to clear EtOH.

Question 8

Phil has decided to stop using heroin and decides to fly to North Dakota to keep from using it again. Its been six hours since his last bump and he is just getting off the plane in North Dakota….he starts going through withdrawal. How will this present?

Answer 8

Mydriasis, yawning, increased BS, piloerection. MS normal., myalgias, cramps, N/V/D, htn, tachyC.

TX: methadone 10mg, fluids,etc. for support.

Question 9

A young girl comes to your clinic and tells you that she was just raped. Name some key components of your exam and how you handle this situation. What labs will you order? What sort of prophylaxis will you offer? What sort of evidence can you gather? What will you give to prevent pregnancy?

Answer 9

• inform police
• obtain consent to perform exam
• detailed HPI
• obtain and label evidence (finger nail scrapings, pubes, blood, semen.., photo lesions w/ consent)
• no UA, douches, etc.
• labs: syphilis, blood type, hep b/c, HIV, HCG
• Prophylaxis: offer: against gonorrhea, c. trichomatis, syphilis, Hep B vac, Levonogestrel to prevent preg.

Question 10

Name some risk factors for patients who may be victims of domestic violence

Answer 10

Women w/ chronic HA, abd pain, prego, trauma, elderly neglect or injuries.

Question 11

Michelle had a wild night and once she sobers up she realizes she may have slept with someone and not used any protection. What are three kinds of emergency contraceptives she can use?

Answer 11

• copper IUD more effective than oral and continues to protect, more effective in overweight (up to 5 days).
• ulipristal (antiprogestin) up to 5 days
• levonorgestrel (OTC), less effective. Single dose w/in 72 hrs

Question 12

If you suspect child abuse do you have to report? If you report should you tell the parents?

Answer 12

Mandated reporting of physical abuse/neglect in all 50 states to CPS/DSS/Police

• report w/in 3-5 days to 1-800-4-A-CHILD
• duty to report supercedes client-professional confidentiality
• parents should be informed of report
• document, photograph (labeled) etc. in case of future subpoena

Question 13

name some red flags that make you suspect child abuse

Answer 13

• Hx inconsistent w/ injury or vague
• injuries in various stages of healing
• imprint bruises/burns or immersion burns
• injuries to trunk, ear and neck
• injuries inconsistent w/ child’s ability to inflict them on self
• parent aloof, rough, delays care