Psychiatric emergenciesPsychiatric

emergenciesfrank ferrucci,pa-c

anna jacques hospitalfrank ferrucci,pa-c

anna jacques hospital

overview

• topics

• disorders

• legal issues

• state dependent

Cases

• 38 y.o. female brought in by EMS for suicidal thoughts

• 15 y.o. male found in basement

• 44 y.o. pregnant female

Why are most psych emergencies

sent to the ED ?

• medical clearance

• evaluation by crisis services (who are they and what do they do?)

• medications

• safety

• placement

• no beds/services

what kinds of psych emergencies do you see

• Depressed

• Manic

• Out of control

• Suicidal

• Psychotic

• Detox placement

What happens when one of these

comes to the ED?

• medical clearance

• stabilize

• keep patient safe

• evaluation by crisis

• disposition

general priniciples of psych emergencies in the ed

• keep yourself and the patient safe

• level any drugs that you are able to

• always keep a high index of suspicion for organic causes

• whenever possible use psych specific rooms

• direct observation

what are the disposition options in the ed?

• d/c home

• outpatient follow up

• CSU bed

• partial hospitalization

• full inpatient hospitalization

review of common disorders

• depression

• suicidal/homicidal ideations

• bipolar

• schizophrenia

• behavioral disorders

• medical conditions that mimic psych conditions

Depression

• Unipolar depression

• typically low energy, low self esteem, loss of interest in enjoyable activities, anxiety, insomnia etc

• serotonin (5-HT)

• overall incidence in US= 20/12%

Depression

• A. At least 5 of the following, during the same 2-week period, representing a change from previous functioning; must include either (a) or (b):

• (a) Depressed mood

• (b) Diminished interest or pleasure

• (c) Significant weight loss or gain

• (d) Insomnia or hypersomnia

• (e) Psychomotor agitation or retardation

• (f) Fatigue or loss of energy

• (g) Feelings of worthlessness

• (h) Diminished ability to think or concentrate; indecisiveness

• (i) Recurrent thoughts of death, suicidal ideation, suicide attempt, or specific plan for suicide

• B. Symptoms do not meet criteria for a mixed episode (ie, meets criteria for both manic and depressive episode).

• C. Symptoms cause clinically significant distress or impairment of functioning.D. Symptoms are not due

to the direct physiologic effects of a substance or a general medical condition.E. Symptoms are not

better accounted for by bereavement, ie, the symptoms persist for longer than 2 months

Depression

• disposition

• depends on acquity

• “Hospital level of care”

• insurance

• psych meds out of the ED??

suicide

• 11th leading cause of death in US

• Definitions:

• suicide attempt

• suicide gesture

• suicide gamble

• suicide equivalent

Suicide

• men more effective, women more determined

• age distribution??

• professions

• US

• dentists

• police

• season

Suicide

• prisoners

• recent discharge from pysch hospital

• socioeconomic issue

• abuse

suicide

• activities associated w/suicide

• will, unexpected visits to family,buying a gun, VISIT TO PCP

• characteristics

• preoccupation with death,few social contacts, isolation/withdrawal, focused on the past, hopeless,

• no goals, thoughts of enjoyable future

suicide

• recent life experiences

• relationships, job, family

• past life experiences

• family hx of suicide

• high school

• abuse

suicide

• mental illness

• bipolar

• major depression (especially when?)

• schizophrenia

• A/V hallucinations

• worst if they have insight

• anxiety disorders

• substance abuse

• SI generally worsening when under the influence

• chronic substance abuse=chronic losses

suicide

• delirium and dementia

• loss of memory, disorientation, hallucinations, delusions, poor judgment

• may occasionally have insight

suicide

• mental status review• Appearance: In addition to the dress and hygiene notes in

people who are depressed (eg, disheveled, unkempt and unclean clothing), the following should be noted

• Affect: One specific emotion of concern is where the patient exhibits a flat affect when describing their thoughts and plans of suicide and self-destructive behavior.

• Thoughts: 1) command hallucinations 2) delusions 3) obsession with their suicide

• Homicidal thoughts

• Judgment

Suicide

• Insight : suicide is final answer to temporary problem

• Intellect: does the person understand the consequences of the behavior?

• Orientation and memory: is the patient delirious or demented?

suicide

• Pt is felt to be high risk...now what?

• 1:1 watch

• remove everything (esp shoes/socks)

• section 12 (in mass)

• evaluation by crisis

• admission

suicide

• medico-legal aspects

• responsibility

• legalities of sec 12

• minors

• what if you disagree with crisis??

Bipolar disorder

• deep depression alternating with excessive highs

• decreased sleep, pressured speech, reckless behavior, grandiosity

• between highs+lows= general high functioning

• bipolar I vs II

bipolar

• 25-50% will attempt suicide

• equal between sexes

• often diagnosis of young people

• diagnostic criteria

bipolar

• mania

• at least 1 week of profound mood disturbance

• 3 or more of:

• grandiosity, decr sleep, pressured speech, racing thoughts, incr goal focused activity, excessive pleasurable activities

• causes impairment of work or danger to patient

• mood is NOT the result of substance abuse or medical condition

bipolar

• major depressive episodes:

• over 2 weeks...5 or more of the following: depressed mood, loss of interest in activities, weight loss/gain, hypersomnia or insomnia, loss of energy or fatigue, indecisiveness, preoccupation with death

• symptoms cause significant impairment and distress

• mood is NOT the result of substance abuse or medical condition

bipolar

• physical exam

• depressed episode= unkempt, unclean, poor hygiene, poor eye contact, flat affect, monotone voice

• manic episode: hyperactive, restless, energized, clothes often garish, euphoric,grandiosity, clothes disorganized,VERY impaired judgement

Bipolar

• indications for inpatient hospitalization

• danger to self/others

• inability to function

• out of control

bipolar

• drugs for manic phase

• geodon, zyprexa, seroquel, risperdal

• drugs for depression

• seroquel

• drugs for maintenance

• lamictal, lithium, abilify

bipolar

• medicolegal pitfalls

schizophrenia

• disorder marked by changes in thinking, behavior and perception

• positive sxs: delusions, hallucinations

• negative sxs: flat affect, social withdrawal, limited vocabulary

dsm-IV defintiion

• sxs for at least 6 mos, with at least 1 mos of active sxs much of the time, and must result in significant impairment of occupational and social functioning

ED concerns

• NEVER diagnose someone with schizophrenia in the ED

• always on guard for organically based delirium

• this is the reason for medical screening exams

demographics

• equal between sexes

• average age of onset 18-25

• completed suicide rate=10%

• science editorial

history

• insidious onset (loss of functioning in home, society, occupation)

• years ahead of diagnosis

• abrupt onset of hallucinations/delusion/disorganized thoughts

diagnosis

• two or more of the following: delusions, hallucinations, disorganized speech, catatonic behavior, poor affect, social withdrawal etc

• loss of occupation, social and self care functioning since onset of illness

• organic causes ruled out

NMS

• fever, rigidity, ams, tachycardia

• often days after starting neuroleptics

• watch for rhabdo

• lytes, ck, urine myoglobin, tox, inr

• tx= fluids, sedatives, restraints, antipyretics, amantidine

TD

• involuntary movements of tongue, lips,truch and extremities

• long term use of antipsychotics

• must differentiate from other movement disorders

• video

ss

• similiar to NMS

• anticholinergic toxidrome

• usually from SSRI OD

• fluids, benzos, watch for rhabdo

physical

• can range from catatonic to wildly combative and everything in between

• paranoid schizophrenics can be extremely dangerous

• exam tailored to rule out organic cause of delirium

• examples of organic based delirium??

schizophrenia

• if you suspect this as a new diagnosis

• level of drugs you can

• tox screen

• FSBS

• lytes

• imaging

detox requests

• very frequent cause of ED visits

• substance of abuse is important

• which withdrawals are dangerous?

• which active drug use is dangerous?

• beds hard to find (esp fri-mon)

• often will d/c home with list

managing withdrawal

• ciwa protocol

• benzos, benzos, benzos

• clonidine

• tough it out big boy...

physical+chemical restraint

• give patient the option

• can often talk pts down

• safety in numbers

• don’t half-ass it

• document, document, document

• watch the mouth

• get police involved

chemical restraint

• exact combination depends on circumstances

• 5-2-1

• droperidol

• zyprexa and zyprexa zydis

psych patients holding in the ed

• beds harder and harder to find

• boredom, agitation, worsening psychosis

• section 12s, restraint orders have to be renewed=documented reevaluations

• dealing with daily medications

medicolegal pitfalls of psych care in ed

• missing the actively suicidal patient

• allowing an intoxicated pt to leave

• documentation, documentation

• missing organic causes of symptoms

• side effects of medications

medicolegal videos