Psychiatry in ER

Question 1

What are some psychiatric mimics?

Answer 1

delirium
infection w/ high fever
metabolic/endocrine abnormalities
medications
substance abuse & withdrawal
CNS disorders

Question 2

Which withdrawals do people die from?
Alcohol Withdrawal
Methadone Withdrawal
Heroine Withdrawal

Answer 2

Alcohol withdrawal can be fatal.

Question 3

What is a clearance exam?

Answer 3

comprehensive exam
substitute for primary care
guarantees no change in medical condition

Question 4

What is a psychiatric medical screening exam?

Answer 4

medical assessment
intoxication evaluation
Risk assess: suicide, homicide, threat to self
dispo: psych

Question 5

T/F A lot of psychiatric medications are teratogenic. Always do a pregnancy test.

Answer 5

True.

Question 6

Indications for more extensive testing in ER?

Answer 6

Abnormal vital signs
Hx suggestive of medical illness
PE abnormalities
Preexisting/new medical complaints
Elderly
Substance abuse
No prior psychiatric hx

Question 7

Is drug testing (routine) in ED according to ACEP?

Answer 7

not indicated
self reporting 91% sensitive
possible that psych will request it.

Question 8

T/F Legal limit to drive car approximates decision making capacity.

Answer 8

False. Observe patients instead of ordering alcohol level to see. Talk to them.

Question 9

T/F Restraints: physical before chemical.

Answer 9

False. Chemical first, not physical.

Can cause rhabdomyolysis if physically restrained.

Question 10

What are some of the complications of physical restraints for psychiatric patients?

Answer 10

hyperthermia
dehydration
rhabdomyolysis
lactic acidosis

Question 11

Talk about halorperidol.

Answer 11

alone or with benzo
2.5-10 mg IM, repeat dose 30-60 min
extrapyramidal symptoms
can be mixed with lorazepam
benefit in methamphetamine intoxication (quick sedation, neuro-protective)

Question 12

Benzos?

Answer 12

rapid onset
reliably absorbed IM
good for cocaine & methamphetamine intoxication

Question 13

Midazolam (versed)?

Answer 13

sometiems hypotension happens
rapid onset & time to arousal
can use a lot of it, at EDC

Question 14

T/F Combo therapy of haloperidol & benzo are better.

Answer 14

True. fewer side effects.

Question 15

Common chemical restraints?

Answer 15

risperidone
olanzapine-BP drop
ziprasidone-no EPS, Prolongs QTc

Question 16

Monotherapy?

Answer 16

1. Benzo

2. Halo

Question 17

72 hour hold?

Answer 17

can hold psych patients for a period of time to work up their condition

Question 18

What is involved in involuntary hospitalization?

Answer 18

danger to self or others
lack of decision making capacity
treatment available
refusal to consent
mental illness