Psychiatric Emergencies

Question 1

Broad general steps in evaluating a patient who may aggressive or violent

Answer 1

1) self-protection
2) prevent harm to patient, self and others
3) rule out organic mental disorders
4) rule out impending psychosis

Question 2

Violence in healthcare in general

Answer 2

50% of health care provides experience violence at some point in their careers

ED is the highest risk place in the healthcare system

Substance abuse is the most likely risk factor for violence. psychosis is the most likely reason for being victims of violence

Most patients who are becoming agitated can be successfully deescalated with verbal interventions

Question 3

Signs for when a patient is escalating towards violence

Answer 3

Progressive psychomotor agitation

Intoxication/withdrawal symptoms

Paranoia. Especially if

• psychosis about being kept in a confined setting
• psychosis about being threatened by star/patients

Manic states

Command auditory hallucinations

Question 4

How to assess violence in patients

Answer 4

1) ask patient about HI

2) ask/ log about any medical symptoms. Especially:
- confused
- acute pain
- irritable
- boisterous
- verbally/physically threatening
- attacking objects

3) ask about/look into history violence in patient history
4) is patient involuntarily admitted?
5) ask about withdrawal or intoxication

Question 5

Last line medication and restraints

Answer 5

1) oral medications = lorazepam/olanzapine, haldol, diphenhydramine.
- *exception is benzo or alcohol intoxication/withdrawal

2) restraints
- if cant maintain safety
- MUST ALWAYS tell them why you are putting them in restraints
- MUST ALWAYS tell them how they can get out of restraints

• most common medical combo = haldol/lorazepam/diphenhydramine IM*

Question 6

Malignant Catatonia

Answer 6

Catatonia with autonomic instability and signs of end organ damage

Similar to NMS however there is a little bit differentiating
- can be without exposure to neuroleptic (NMS requires neuroleptic medications)

patients with catatonia should not be given antipsychotics because of a higher risk of developing malignant Catatonia

Tx: supportive care usually

Question 7

Delirium tremens

Answer 7

20% mortality without treatment
- 1% with treatment

DONT focus on alcoholic history to make diagnosis (50% dont have a known history)

Symptoms:

• delirium*
• agitation
• tachycardia
• seizures*
• HTN
• hypokalemia*
• fever
• diaphoresis*

signs:
- AST and ALT will be elevated usually

Tx:

• supportive care and fluids/electrolytes
• benzos or phenobarbitals

Question 8

Why should you never give antipsychotics to a patient experiencing catatonia?

Answer 8

Increases risks of malignant catatonia