chapter 28 psychiatric emergencies. national ems education standard competencies medicine integrates...

Chapter 28Chapter 28

Psychiatric Emergencies

National EMS Education Standard CompetenciesNational EMS Education Standard Competencies

Medicine

Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression and implement a comprehensive treatment/disposition plan for a patient with a medical complaint.


Psychiatric

• Recognition of− Behaviors that pose a risk to the EMS provider,

patient, or others

• Assessment and management of− Basic principles of the mental health system

− Suicidal/risk


Anatomy, physiology, epidemiology, pathophysiology, psychosocial impact, presentations, prognosis, and management of

− Acute psychosis

− Agitated delirium

− Cognitive disorders

− Thought disorders

− Mood disorders

− Neurotic disorders


Anatomy, physiology, epidemiology, pathophysiology, psychosocial impact, presentations, prognosis, and management of (cont’d)

− Substance-related disorders/addictive behavior

− Somatoform disorders

− Factitious disorders

− Personality disorders

− Patterns of violence/abuse/neglect

− Organic psychoses

IntroductionIntroduction

• The mind and body are inseparable.− Illness affects a person’s behavior.

− Changes in mental state affect physical health.

Definition of Behavioral Emergency


• Most experts define behavior as the way people act or perform. − Overt behavior is generally understood by those

around the person.

− Covert behavior has hidden meanings or intentions.



• Behavioral emergency− Some disorder of

mood, thought, or behavior that interferes with ADLs

• Psychiatric emergency− Behavior that

threatens a person’s health or safety and the health and safety of another person



• A behavioral or psychiatric emergency is defined by the person who dials 9-1-1.

• It can be difficult to understand the patient’s confused and frayed feelings.

PrevalencePrevalence

• Average number of mentally unhealthy days for Americans has increased− 1993: 2.9 days/month

− Today: 3.5 days/month

• 45.1 million US adults with any mental illness in the past year

Medicolegal Considerations Medicolegal Considerations

• When behavior, speech, and thoughts are erratic, it can be difficult to communicate.− Spend time with the patient.

− Obtain consent when possible.

− Be clear in your explanations.

Causes of Abnormal BehaviorCauses of Abnormal Behavior

• Four broad categories− Biologic or organic in nature

− Resulting from the environment

− Resulting from acute injury or illness

− Substance-related


• Biologic or organic − Organic brain syndrome

− Conditions alter the functioning of the brain


• Environmental − Psychosocial and sociocultural influences

• When consistently exposed to stressful events patients develop abnormal reactions.

• Sociological factors affect biology, behavior, and responses to the stress of emergencies.


• Injury and illness − Illness results in

stress on coping mechanisms.

− Acute trauma creates stress. • Post-traumatic

stress disorder (PTSD)

Courtesy of Captain David Jackson, Saginaw Township Fire Department


• Substance-related − Alcohol

− Cigarettes

− Illicit drugs

− Other substances

Psychiatric Signs and Symptoms


• When mental health is challenged, mechanisms or behaviors work to return homeostasis.− Present as psychiatric signs and symptoms

Patient AssessmentPatient Assessment

• Assessment of the patient with a behavioral emergency differs from other methods. − You are the diagnostic instrument.

− The assessment is part of the treatment.

Scene Size-UpScene Size-Up

• Situations with a strong behavioral component may have a sudden and unexpected turn of events.− Determine whether it is dangerous to you and

your partner.


• The environment can give clues.− Social history

− Living conditions

− Availability of support

− Activity level

− Medications

− Overall appearance

− Attitude/well-being

Primary AssessmentPrimary Assessment

• Clearly identify yourself.

• Form a general impression.− Assess appearance, posture, and pupils.

− Limit the number of people around the patient.

− Stay alert to potential danger.


• Airway and breathing− Assess the airway and evaluate breathing.

− Provide interventions based on your findings.


• Circulation− Assess the pulse rate, quality, and rhythm.

− Obtain systolic and diastolic blood pressures.

− Evaluate for shock and bleeding.

− Assess the patient’s perfusion level.


• Transport decision− Disturbed patients should see a physician.

− If a patient withholds consent, they may be taken against their will at the request of:• Police

• County mental health physician


• Transport decision (cont’d)− The same applies to the use of forcible restraint.

• Law enforcement officers should be summoned.

• Consult medical command as necessary.

History TakingHistory Taking

• Mental status examination − Key part of

assessment

− Check each system using COASTMAP.

COASTMAPCOASTMAP

• Consciousness− Level

− Concentration

• Orientation− Year/month

− Location

• Activity− Behavior

− Movement

• Speech− Rate, volume,

flow, articulation, and intonation

COASTMAPCOASTMAP

• Thought− Is the patient

making sense?

• Memory− Recent

− Remote

− Immediate

• Affect and mood− Do the inner

feelings seem appropriate?

• Perception− “Do you hear

things others can’t?”

Secondary AssessmentSecondary Assessment

• Obtain vital signs.

• Examine skin temperature and moisture.

• Inspect the head and pupils.

• Note unusual odors on the breath.

Secondary AssessmentSecondary Assessment

• In examining the extremities, check for:− Needle tracks

− Tremors

− Unilateral weakness or loss of sensation

ReassessmentReassessment

• Routinely performed during transport

• Your radio report should include:− Medical and mental health history

− Medications prescribed

− Assessment findings

− Information from the mental status examination

ReassessmentReassessment

• Discuss with the hospital the need for restraints or medications.− If the patient is aggressive or violent, provide

advance notice to the emergency department.

Emergency Medical CareEmergency Medical Care

• If the erratic behavior could be caused by a medical disorder: − Treat that before presuming the behavior is due

to an emotional or psychiatric cause.

Communication TechniquesCommunication Techniques

• Begin with an open-ended question.

• Let the patient talk.

• Listen, and show that you are listening.

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• Don’t be afraid of silences.

• Acknowledge and label feelings.

• Don’t argue.

• Facilitate communication.

• Direct the patient’s attention.− Confrontation


• Ask questions.− Avoid “yes-no” or leading questions.

− Use “how” and “what” questions.

• Adjust your approach as needed.

Crisis Intervention SkillsCrisis Intervention Skills

• Be as calm and direct as possible.

• Exclude disruptive people.

• Sit down.− Preferably at a

45-degree angle


• Maintain a nonjudgmental attitude.

• Provide honest reassurance.

• Develop a plan of action.− Once the plan is

set, allow the patient to exercise some control.


• Encourage some motor activity.

• Stay with the patient at all times.

• Bring all medications to the hospital.

• Never assume that it is impossible to talk with any patient until you have tried.

Physical RestraintPhysical Restraint

• Improvised or commercially made devices

• Be familiar with restraints used by your agency.

• Make sure you have sufficient personnel.− Minimum of four trained, able-bodied people


• Discuss the plan of action before you begin.− Include law enforcement.

− Use the minimum force necessary.

− Don’t immediately move toward the patient.


• If the show of force doesn’t calm the patient, move quickly.− Grasp at the elbows, knees, and head.

− Apply restraints to all four extremities.

− The best position is supine.


• Never:− Tie ankles and

wrists together

− Hobble tie

− Place a patient facedown in a Reeves stretcher

• Once in place:− Don’t remove

restraints.

− Don’t negotiate or make deals.

− Place a mask over the face of a spitting patient.


• Continuously monitor the patient.

• Never place your patient face down.

• Check peripheral circulation every few minutes.

© Jones & Bartlett Learning. Courtesy of MIEMSS.


• Be careful if a combative patient suddenly becomes calm.

• Document everything in the patient’s chart.

• You may defend yourself against an attack.

Chemical RestraintChemical Restraint

• Use of medication to subdue a patient− Only use with approval from medical control

− Follow local protocols and guidelines.


• Haloperidol− Administered either IM or IV

− Should not be administered to: • Patients younger than 14 years

• Those with a suspected head injury

• Those who may be pregnant


• Benzodiazepines − Shorter-acting ones may be given intranasally.

− Only midazolam and lorazepam have reliable intramuscular absorption.

− Side effects are usually mild and easily treated.


• Closely monitor the patient’s:− Pulse rate

− Blood pressure

− Respiratory rate

• Be prepared to support ventilation.

Pathophysiology, Assessment, and Management of Specific EmergenciesPathophysiology, Assessment, and

Management of Specific Emergencies

• Many factors contribute to disturbances of behavior.

Acute PsychosisAcute Psychosis

• Pathophysiology− Person is out of touch with reality

− Occur for many reasons

− Episodes can be brief or last a lifetime.


• Assessment− Characteristic: profound thought disorder

− A thorough examination is rarely possible.

− Transport the patient in an atraumatic fashion.

− Use COASTMAP.


• Consciousness− Awake and alert

− Easily distracted

• Orientation− Disturbances

more common in organic disorders

• Activity− Most commonly

accelerated

• Speech− Neologisms


• Thought− Disturbed in

progression and content

• Memory− Relatively or

entirely intact

• Affect and mood− Mood is likely to

be disturbed.

− Affect may reflect mood or be flat.

• Perception− Auditory

hallucinations


• Management− Reasoning doesn’t always work.

− Explain what is being done.

− Directions should be simple and consistent.

− Keep orienting the patient.


• Management (cont’d)− Before pharmacologic treatments, try:

• Maintaining an emotional distance

• Explaining each step of the assessment

• Involving people the patient trusts


• Management (cont’d)− When methods fail, it may be appropriate to:

• Safely restrain the patient.

• Administer a medication to help the behavior.

Agitated DeliriumAgitated Delirium

• Pathophysiology− Delirium: a state of global cognitive impairment

− Dementia: more chronic process

− Patients may become agitated and violent.

Agitated DeliriumAgitated Delirium

• Assessment− Try to reorient patients.

− Perform a thorough assessment.

• Management− Identify the stressor or metabolic problem.

Suicidal IdeationSuicidal Ideation

• Pathophysiology− Suicide: any willful act designed to end one’s

life


• Assessment− Every depressed

patient must be evaluated for suicide risk.

− Most patients are relieved when the topic is brought up.


• Assessment (cont’d)− Broach the subject in a stepwise fashion.

− Higher-risk patients include patients who have:• Made previous attempts

• Detailed, concrete plans

• A history of suicide among close relatives


• Management− Don’t leave the patient alone.

− Collect implements of self-destruction.

− Acknowledge the patient’s feelings.

− Encourage transport.

Patterns of Violence, Abuse, and Neglect


• Abuse and neglect− Assess the following:

• The patient

• The environment

• Other persons involved

− Document your findings, and report your concerns according to local protocols.



• Violence− Most angry patients can be calmed by a trained

person who conveys confidence.

− EMS personnel should prepare to deal with hostile or violent behavior.• Preventive action is best to ensure no harm.



• Identify situations with the potential for violence.− Preventive action starts with being prepared for

a possible violent encounter.

− Develop “survival awareness.”



• Warning signs include:− Posture: sitting tensely

− Speech: loud, critical, threatening

− Motor activity: unable to sit still, easily startled

− Clenched fists, avoidance of eye contact

− Your own feelings



• Management of the violent patient− Assess the whole situation.

− Observe your surroundings.

− Maintain a safe distance.

− Try verbal interventions first.

Mood DisordersMood Disorders

• Unipolar mood disorder: mood remains at one pole of the continuum

• Bipolar mood disorder: mood alternates between mania and depression


• Manic behavior− Patients typically have abnormally exaggerated

happiness with hyperactivity and insomnia.• Pressured and rapid speech

• “Tangential thinking”

• Grandiose and unrealistic ideas


• Manic behavior (cont’d)− Be calm, firm, and patient.

− Minimize external stimulation.

− If the patient refuses transport, consult medical control.


• Depression− Leading cause of disability in people 15- to

44-year olds

− Can occur in episodes with sudden onset and limited duration

− Onset can also be insidious and chronic.


• Depression (cont’d)− Diagnostic features (GAS PIPES)

• Guilt

• Appetite

• Sleep disturbance

• Paying attention

• Interest

• Psychomotor abnormalities

• Energy

• Suicidal thoughts

SchizophreniaSchizophrenia

• Typical onset occurs during early adulthood.

• Experience may include:− Delusions

− Hallucinations

− A flat affect

− Erratic speech

Neurotic DisordersNeurotic Disorders

• Collection of psychiatric disorders without psychotic symptoms− Includes anxiety disorders

• Mental disorders in which dominant moods are fear and apprehension


• Generalized anxiety disorder (GAD)− Patient worries for no particular reason or

worrying prevents decision-making abilities.

− Treated with pharmacologic agents and counseling


• Generalized anxiety disorder (GAD) (cont’d)− When dealing with a patient with GAD:

• Identify yourself in a calm, confident manner.

• Listen attentively.

• Talk with the person about their feelings.


• Phobias− Unreasonable fear, apprehension, or dread of a

specific situation or thing• Simple phobias focus all anxieties on one class of

objects or situations.


• Phobias (cont’d)− When managing a patient, explain each step of

treatment in detail.


• Panic disorder− Sudden feelings of fear and dread

− If allowed to continue, panic attacks can cause severe lifestyle restrictions.• Agoraphobia: fear of going into public places


• Panic disorder (cont’d)− Signs and

symptoms usually peak in 10 minutes.


• Panic disorder (cont’d)− Separate from panicky bystanders.

− Provide a calm environment.

− Be tolerant of the disability.

− Reassure the patient.

− Give the symptoms a name.

− Help the patient regain control.

Substance-Related DisordersSubstance-Related Disorders

• Regarded on four levels: − Substance use

− Substance intoxication

− Substance abuse

− Substance dependence

• Determining the most effective treatment requires an integrative approach.

Eating DisordersEating Disorders

• Persons may experience severe electrolyte imbalances.

• Two thirds report anxiety, depression, and substance abuse disorders.


• Bulimia nervosa− Consumption of large amounts of food

− Compensated by purging techniques


• Anorexia nervosa− Weight loss jeopardizes health and lives

− Typical patient:• Decreased body weight based on age and height

• Intense fear of obesity

• Experience amenorrhea

Somatoform DisordersSomatoform Disorders

• Preoccupation with physical health and appearance − Hypochondriasis: Anxiety or fear that the person

may have a serious disease

− Conversion disorders: a physical problem results from faking a physical disorder

Factitious DisordersFactitious Disorders

• Patient produces or feigns physical or psychological signs or symptoms.− Symptoms are under voluntary control.

• Factitious disorder by proxy: a parent makes a child sick for attention and pity

Impulse Control DisordersImpulse Control Disorders

• Lack of ability to resist a temptation

• Examples include:− Intermittent explosive disorder

− Kleptomania

− Pyromania

− Pathologic gambling

Personality DisordersPersonality Disorders

• Maladaptive patterns of thinking about the environment and one’s self − Cause functional impairment or subjective

distress

• Be calm and professional.

Medications for Psychiatric Disorders and Behavioral Emergencies

Medications for Psychiatric Disorders and Behavioral Emergencies

• Patients may be taking any of several types of psychotropic drugs.

• During your assessment, determine:− Which medications have been prescribed

− Whether they are being taken

Psychiatric Medication TypesPsychiatric Medication Types

• Antidepressants− Combat the

symptoms of depressive illness

− Alter levels of neurotransmitters in the autonomic nervous system


• Antidepressants (cont’d)− Fluoxetine: the most commonly prescribed

• Side effects are minimal.

− Heterocyclic: used for major depression• Side effects are common.


• Antidepressants (cont’d)− Monoamine oxidase inhibitors: recommended

for atypical major depressive episodes• Potential side effects


• Benzodiazepines− May be prescribed for severe emotional distress

− Contraindicated in patients with:• Known hypersensitivity to benzodiazepines

• Acute, narrow-angle glaucoma

• First-trimester pregnancy


• Antipsychotics− Newer medications have less risk of adverse

effects and are more effective.• Known as atypical antipsychotic (AAP) drugs

− Relieve delusions and hallucinations.

− Improve symptoms of anxiety and depression.


• Antipsychotics (cont’d)− May cause metabolic side effects

− Cardiovascular effects depend on medication.

− May cause an acute dystonic reaction

− May cause atropine-like effects


• Amphetamines− CNS and PNS stimulants

− Help with ADHD.

− Raise systolic and diastolic blood pressure.


• Amphetamines− Psychological

effects depend on:• Dose

• Mental state

• Personality

− Results include:• Alertness

• Elevated mood

• Increased motor and speech activities

Problems Associated with Medication NoncomplianceProblems Associated with Medication Noncompliance

• Increases the likelihood that a person with mental illness will commit a violent act

• When obtaining medication history, include:− Previously prescribed medications

− Missed doses

Emergency Use of MedicationsEmergency Use of Medications

• Emergency use of medications are often required with violence.− The potential danger is too great not to

intervene.

Emergency Use of MedicationsEmergency Use of Medications

• Before administering chemical restraint, complete your assessment with:− A thorough understanding of the chief complaint

− Attention to allergies

− Medical and medication history

Pediatric Behavioral ProblemsPediatric Behavioral Problems

• 50% of childhood mental illnesses will present by age 14 years.− More likely to have

coexisting problems

− Difficult to diagnose

© Leah-Anne Thompson/ShutterStock, Inc.

Pediatric Behavioral ProblemsPediatric Behavioral Problems

• Mental status assessment is similar to that of an adult.− Exception: Consider developmental level.

• Abnormal findings are often related to adjustment disorders and stress.

Geriatric Behavioral ProblemsGeriatric Behavioral Problems

• Distress and pain may be caused by:− Exposure to new

experiences

− Alterations to routines

© Leah-Anne Thompson/ShutterStock, Inc.

Geriatric Behavioral ProblemsGeriatric Behavioral Problems

• Anxiety and depression are too often considered a “normal part of aging.”− Ageism: discrimination against older people

• Take stock of your own attitudes.

SummarySummary

• Behavioral emergencies can present unique challenges in patient management. Focus on reducing the patient’s stress without exposing yourself to unnecessary risks.

• A behavioral or psychiatric emergency is any reaction to events that interferes with activities of daily living.

SummarySummary

• Behavioral emergencies can be a temporary response to a traumatic event.

• Calls for behavioral emergencies have special medical and legal considerations.

• You have limited legal authority to require a patient to undergo care in the absence of a life-threatening emergency. Always involve law enforcement personnel when you are called to assist a patient with a severe behavior or psychiatric crisis.

SummarySummary

• If a patient poses an immediate threat, leave the area until law enforcement personnel secure the scene.

• Underlying causes of behavioral emergencies fall into four categories: biologic (organic) causes, causes resulting from the person’s environment, causes resulting from acute injury or illness, and causes that are substance related.

SummarySummary

• Psychiatric signs and symptoms occur when mental health is challenged and psychological mechanisms or behaviors mobilize to return the person’s mental state to homeostasis.

• Assessment of a disturbed patient differs from other assessment methods in that you are the diagnostic instrument. Assessment is also part of the treatment.

SummarySummary

• When providing care, be direct, honest, and calm; have a definitive plan of action; stay with the patient at all times; and express interest in the patient’s story.

• When sizing up the scene, pay special attention to potential dangers and objects that may be used as potential weapons, hazardous chemicals, etc. Remove potentially harmful objects.

SummarySummary

• Primary assessment includes identifying yourself, forming a general impression of the patient’s condition and the nature of the problem, assessing the ABCs, making a decision about transport, and taking a history via the mental status examination.

• Secondary assessment involves looking for signs of an organic cause of the behavioral emergency.

SummarySummary

• Management is focused on ensuring scene safety and maintaining awareness of life-threatening conditions, while treating the patient for any medical disorders.

• Effective communication techniques include beginning with an open-ended question, showing that you are listening, allowing silence when appropriate, avoiding argument, facilitating communication, and asking questions.

SummarySummary

• Crisis intervention skills include staying calm and being direct, excluding disruptive people from the scene, maintaining a nonjudgmental attitude, developing a plan of action, encouraging motor activity, and assuming that the patient can hear and understand everything you say.

• Use of chemical or physical restraints is reserved for times when verbal intervention fails to reduce severe agitation.

SummarySummary

• Pathophysiologic factors that contribute to behavioral disturbances include cognitive impairment, thought disorders, mood disorders, neurotic disorders, substance-related disorders and addictive behavior, somatoform disorders, factitious disorders, impulse control disorders, and personality disorders.

SummarySummary

• You may encounter patients with psychosis, a thought disorder characterized by a statue of delusion in which the person is out of touch with reality.

• You may encounter patients with agitated delirium. This is impairment of cognitive function that can present with disorientation, hallucinations, or delusions, and is characterized by restless and irregular physical activity.

SummarySummary

• The threat of suicide requires immediate intervention. Depression is the most significant risk factor for suicide.

• Situations involving violence, abuse, and neglect can have the potential for escalation and the possibility of evoking emotional responses in you.

SummarySummary

• Patients with psychiatric emergencies may be taking any of several types of psychotropic drugs. During assessment, determine which medications have been prescribed and whether the patient is actually taking them.

CreditsCredits

• Chapter opener: © Mark C. Ide

• Backgrounds: Orange—© Keith Brofsky/Photodisc/Getty Images; Blue—Jones & Bartlett Learning. Courtesy of MIEMSS; Blue—Courtesy of Rhonda Beck; Green—Courtesy of Rhonda Beck; Purple—Courtesy of Rhonda Beck.

• Unless otherwise indicated, all photographs and illustrations are under copyright of Jones & Bartlett Learning, courtesy of Maryland Institute for Emergency Medical Services Systems, or have been provided by the American Academy of Orthopaedic Surgeons.

chapter 28 psychiatric emergencies. national ems education standard competencies medicine integrates...

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