Psychiatric Emergencies

Angela S. Olomon, DO

Goals

• Strengthen education on psychiatric emergencies presenting in the medical office

• Identify characteristics of agitated patients

• Identify suicide risk and protective factors

Objectives

• Apply safe assessment to prevent further increase in agitation of patient

• Establish plan for intervention and harm prevention and referral for additional treatment

• Determine patient’s potential for danger or harm to self or others

Summary

• Psychiatric emergencies can arise in any treatment office. Therefore, every physician is responsible for evaluation. Pre-crisis preparation is key to safety as well as empathetic responses.

Psychiatry in Family Practice

• 40% to 60% of general medical patients have comorbid psychiatric conditions

• Primary Care writes more psychiatric medications than psychiatrists

• Most psychiatric patients present to primary care physicians first (you are the first responder)

CS1

• Bang!• Door vibrates and windows rattle• Staff call the police• In walks a 45 year old white male• Sluggish, unkempt, slow and unsteady gait• Speech is slurred and he is a poor historian• He has no appt. and a Hx of noncompliance

Questions?

• What do you want to know?

Key Assessment Data

• Meds

• Alcohol

• Illicit Drugs

• Other Informants / Family

• Recent History

Evaluation

• BA

• Drug Screen

• BP – P

• Pulse Ox

• X-Ray / CT

CS2

• 47 year old white female calls

• Frantically demands to speak to you

• Claims Critical Emergency (like always)

• States “I can’t go on!”

• “I’m going to kill myself, then I won’t have to deal with it!”

Questions?

Key Assessment Data

• Safety: Where is she? Who is with her?

• Does she have a plan? Means?

• Precipitant: Why Now?

• What is the last chapter of this saga?

• Medications / Compliance?

• Alcohol?

• Illicit Drugs?

Evaluation

• Hospital ER vs. Friend vs. 911

• Resources (Therapists, Family)

CS 3

• 40 year old white female in the waiting room, pacing

• Demands urgent appointment

• Unkempt

• Speech rapid and pressured and loud

• Flow of thought circumstantial

• “Infectious” anxiety – talking to everyone and drawing them into her distress

Questions?

Key Assessment Data

• History of past Dx or hospitalizations

• (Bipolar II and Chronic Pain – Spinal Stenosis)

• Medications / Treatments

• (Opioid Analgesic Discontinued)

Evaluation

• Blood levels of medications

• Verify Compliance

• Initiate De-escalation Procedures

• Titrate Medication

• Marshal Resources (Family, Therapists)

CS 4

• 12 year old white male brought by foster mother• Restless in waiting room, demanding to know

how long a wait• Mother is anxious• Patient is Irritable and Sarcastic• Receptionist and Nurse are anxious• Roomed patient and mother yelling and agitated

(you wonder if you paid your office insurance premium)

Questions?

Key Assessment Data

• Initiate safety procedures

• Initiate De-escalation Procedures

• Call in support (possibly police)

• Hx from Mother:– Precipitant / Stressors?– Possible Substance Abuse / Toxicity– Past Episodes?

Interventions

• IM vs. PO Medication

Pre Crisis Planning

• Physical Environment (everybody can get to the door)– Waiting Room (no impromptu weapons)– Reception Desk– Exam Rooms

Staff Training

• Safety Plan

• De-escalation Procedures

• Code Drill

• Practice, Practice, Practice

Aggression Risk Factors

• Intoxication• Hopelessness• Irritability• Disorganized Thought• Disheveled Appearance• Psychomotor Agitation• Verbal Agitation• Behavioral Agitation

Suicide Assessment

• Risk Factors

• Protective Factors

Interventions

• Call for Help!

• Verbal De-Escalation

• Quiet Room – Decreased Stimuli

• Pharmacological– Patient’s Meds– Antipsychotic Meds– Benzodiazepines

Emergency Medications

• PO– Risperdone 2mg– Ativan 2mg– Zyprexa Zydus 5-10mg

• IM– Haldol 5mg– Ativan 2mg

Diagnosis

• TRUMP METHOD

• Ace Medical Disorder

• Joker Substance Induced

• King Mood Disorder w/ Psychosis

• Queen Schizophrenia

• Jack Personality Disorder

ACE

• Delirium– Attention– Concentration– MMSE

Mend A Mind

• Metabolic• Electrical• Nutrition• Drugs / Toxins• Arterial• Mechanical• Infectious• Neoplastic• Degenerative

Joker

• Increased Risk of Suicide

• Alcohol Withdrawal / Intoxication

• Cannabis

• Stimulants

• Cocaine

• Opioids

Blood Alcohol Concentration

• 20-50mg/dL Decreased Fine Motor

• 50-100 Decreased Gross Motor

• 100-150 Difficulty Standing

• 150-250 Difficulty Sitting

• 300 Unresponsive to voice or pain

• 400 Respiratory Depression

Opioid Withdrawal

• Irritability / Agitation

• Nausea / Vomiting / Diarrhea

• Muscle Ache

• Excessive Tears / Runny Nose / Yawn

• Pupil Dilatation / Goose Flesh

• Sweating / Fever / Insomnia