Tutorial

باطنية – نفسية

د. الهام الجماس

عدد الاوراق (5)

25/9/2012

Psychiatric emergency

Definition
Emergency psychiatry
is the clinical application of psychiatry in HYPER13HYPERLINK "http://en.wikipedia.org/wiki/Emergency_medicine" \o "Emergency medicine"
emergency settings
Symptoms and conditions behind psychiatric emergencies may include HYPERLINK "http://en.wikipedia.org/wiki/Parasuicide" \o "Parasuicide"
attempted HYPERLINK "http://en.wikipedia.org/wiki/Suicide" \o "Suicide"
suicide, HYPERLINK "http://en.wikipedia.org/wiki/Substance_dependence" \o "Substance dependence"
substance dependence, HYPERLINK "http://en.wikipedia.org/wiki/Alcohol_intoxication" \o "Alcohol intoxication"
alcohol intoxication, acute HYPERLINK "http://en.wikipedia.org/wiki/Clinical_depression" \o "Clinical depression"
depression, presence of HYPERLINK "http://en.wikipedia.org/wiki/Delusion" \o "Delusion"
delusions, violence, HYPERLINK "http://en.wikipedia.org/wiki/Panic_attack" \o "Panic attack"
panic attacks, and significant, rapid changes in behavior.
Emergency psychiatry exists to identify and/or HYPERLINK "http://en.wikipedia.org/wiki/Treatment_of_mental_illness" \o "Treatment of mental illness"
treat these symptoms and psychiatric conditions.
In addition, several rapidly lethal medical conditions present themselves with common psychiatric symptoms.
A HYPERLINK "http://en.wikipedia.org/wiki/Physician" \o "Physician"
physician's or a HYPERLINK "http://en.wikipedia.org/wiki/Nurse" \o "Nurse"
nurse's ability to identify and intervene with these and other medical conditions is critical.

The Role of the ED Psychiatrist

First and foremost, a consultant.
An expert, presumably, in the evaluation and treatment of mental illness.
As such, the ED psychiatrist is expected to provide assistance with intractable or complex psychiatric patients. This often means spearheading interventions in the ED itself.
Often, the psychiatrist is also expected to provide input on whether a pt needs to be hospitalized or not, and whether the unwilling pt meets criteria for involuntary admission.


In Preparation for the Meeting
First, one must gather information from the ED resident, as would any other consultant.
Request preliminary lab tests or other diagnostic studies.
Urine toxicology, always. Other tests are ordered depending on the particulars of the case.
Ensure that the patient is searched and gowned, and that her belongings are sequestered, if these things havent been already done.
Review documentation, past and present, if available.

A Run-Through of Common Presentations

Depression
With or without suicidality
Adjustment reactions
Mania
Psychosis
Intoxication
Withdrawal
Medical issues with psychiatric manifestations, including delirium
Anxiety
Dementia
Aggression
With or without homicidality
These problems are by no means mutually exclusive; several issues may present at once.
Generally, there is one thread uniting these different presentations the failure of outpatient or social resources to contain the problem.


A Primer on Particular Problems
Suicide
Latin origins: (sui) self- (cide) death. Ergo, self-injurious behavior sans death-wish is not a suicide attempt.
Eighth leading cause of death in men. (Higher than homicide.)
Third leading cause of death in adolescents (15 to 24 yo).
55% of successful suicides employ a firearm.
Men succeed more often than women, but women attempt more frequently than men.
Very Difficult to Predict

Developing A Sense for Suicidality

There are certain, unequivocal risk-factors
Demographic: male sex; Caucasian; social isolation; in or past middle age (most significantly > 65); occupation (past or present) that involves risk-taking; cultural or religious beliefs that favor suicide in certain situations (e.g., harikiri in Japan); local epidemics (The Sorrows of Young Werther; Kurt Cobains aggrieved idolators).
Historical: previous suicide attempts; history of psychiatric illness (particularly depression), impulsivity, or drug/EtOH abuse; family history of suicide; history of abuse (sexual, physical, or emotional), recent loss, or trauma; characterological vulnerabilities (particularly cluster B).

Risk factors for suicide (cont.)

Immediate: anxiety; impulsivity; aggression; intoxication; EtOH/drug dependence; agitation; hopelessness; depression; psychosis; ideation, with plan (pts perception of its lethality important to clarify); physical or chronic illness; easy access to lethal methods; little access to health care; low rescue potential.
Collateral information can be very helpful at all times, but especially here where the consequences of an incomplete story and a reticent patient can be disastrous.

General Management of Suicidality

Clarify Diagnosis
Assess Risk
Active vs. Passive. Plan or no plan. Perceived lethality.
Ascertain need for inpt or outpt management
Voluntary vs. involuntary admission. Is pt at immediate risk?
If pt at elevated, albeit long-term risk, any outpatient plan should involve imminent, reliable follow up.
The more people willing to be involved in the outpatient plan the better namely, family, friends, coworkers, physicians.


A Primer on Psychosis
Defined loosely as a disturbance in thought process and content, often associated with an impaired ability to relate to others and to intersubjective experience (e.g., reality).
Hallucinations, delusions, disorganized thoughts, and anomalous experiences may be evident.
The etiologies of acute psychosis include:
Affective disorders (MDD, BAD)
Delirium
Dementia
Primary psychotic disorder
Intoxication or withdrawal

Homicidality

Risk Factors:
History of violence; aggression
Impulsivity; intoxication
Sincere plan
Common etiologies include:
Psychosis (command AHs); affective disorders; personality vulnerabilities; substance intoxication or withdrawal

Management of Homicidality

Elucidate Diagnosis
Clarify threat to other(s)
General vs. specific
If threat is deemed serious
Notify police
Make efforts to warn individual(s) (Tarasoff ruling)
Admit pt until threat subsides
Dont hesitate to admit involuntarily even if precise psychiatric diagnosis remains elusive in the ED


Assessing Agitation
An agitated patient shouldnt be restrained or medicated immediately. First, the psychiatrist should determine the pts risk of escalation.
An agitated pt can be placed in one of four stages of agitation, depending on the likelihood of de-escalation.
Stage 1: the agitation is mollified by verbal cues, without limits or boundaries being invoked.
Stage 2: the agitation is contained verbally through limit-setting, but it persists nonetheless.
Stage 3: the agitation subsides during transient physical restraint.
Stage 4: the agitation requires pharmacotherapy. It is otherwise intractable.
Often stages 3 and 4 are conflated.
It takes experience to identify which pt can be safely approached, and how, and when..
NEVER PLAY HERO (INE) AND TAKE THINGS INTO YOUR OWN HANDS!

Personality disorders

Disorders manifesting dysfunction in areas related to  HYPERLINK "http://en.wikipedia.org/wiki/Cognition" \o "Cognition" \t "_parent" cognition,  HYPERLINK "http://en.wikipedia.org/wiki/Affect_(psychology)" \o "Affect (psychology)" \t "_parent" affectivity, interpersonal functioning and impulse control can be considered  HYPERLINK "http://en.wikipedia.org/wiki/Personality_disorder" \o "Personality disorder" \t "_parent" personality  HYPERLINK "http://en.wikipedia.org/wiki/Personality_disorder" \o "Personality disorder" \t "_parent" disorders.
Patients suffering from a personality disorder will usually not complain about symptoms resulting from their disorder. Patients suffering an emergency phase of a personality disorder may showcase combative or suspicious behavior, suffer from brief psychotic episodes, or be delusional. Compared with outpatient settings and the general population, the prevalence of individuals suffering from personality disorders in inpatient psychiatric settings is usually 725% higher. Clinicians working with such patients attempt to stabilize the individual to their baseline level of function.
Hazardous drug reactions and interactions
 HYPERLINK "http://en.wikipedia.org/wiki/Drug_overdose" \o "Drug overdose" \t "_parent" Overdoses,  HYPERLINK "http://en.wikipedia.org/wiki/Drug_interaction" \o "Drug interaction" \t "_parent" drug interactions, and dangerous reactions from psychiatric medications, especially antipsychotics, are considered psychiatric emergencies.
 HYPERLINK "http://en.wikipedia.org/wiki/Neuroleptic_malignant_syndrome" \o "Neuroleptic malignant syndrome" \t "_parent" Neuroleptic malignant syndrome is a potentially lethal complication of first or second generation antipsychotics .If untreated, neuroleptic malignant syndrome can result in fever, muscle rigidity, confusion, unstable vital signs, or even death.
 HYPERLINK "http://en.wikipedia.org/wiki/Serotonin_syndrome" \o "Serotonin syndrome" \t "_parent" Serotonin syndrome can result when  HYPERLINK "http://en.wikipedia.org/wiki/Selective_serotonin_reuptake_inhibitor" \o "Selective serotonin reuptake inhibitor" \t "_parent" selective serotonin reuptake inhibitors or  HYPERLINK "http://en.wikipedia.org/wiki/Monoamine_oxidase_inhibitor" \o "Monoamine oxidase inhibitor" \t "_parent" monoamine oxidase  HYPERLINK "http://en.wikipedia.org/wiki/Monoamine_oxidase_inhibitor" \o "Monoamine oxidase inhibitor" \t "_parent" inhibitors mix with  HYPERLINK "http://en.wikipedia.org/wiki/Buspirone" \o "Buspirone" \t "_parent" buspirone.[Severe symptoms of serotonin syndrome include  HYPERLINK "http://en.wikipedia.org/wiki/Hyperthermia" \o "Hyperthermia" \t "_parent" hyperthermia, delirium, and  HYPERLINK "http://en.wikipedia.org/wiki/Tachycardia" \o "Tachycardia" \t "_parent" tachycardia that may lead to shock. Often patients with severe general medical symptoms, such as unstable vital signs, will be transferred to a general medical emergency room or medicine service for increased monitoring.[

Involuntary Admission

Pt at immediate risk for hurting self or others due to mental illness or mental retardation.
Pt is mentally ill (or mentally retarded) and unable to care for self as to acutely endanger his or her life.


The Emergency management
If agitated, but not psychotic:
Benzos (lorazepam) generally suffice
Beware of paradoxical disinhibition; this often occurs in the elderly
If psychotic:
Antipsychotics generally suffice
Augment with benzos for further control
If medical etiology apparent:
Use antipsychotics for behavioral control, at the same time that underlying medical illness is addressed
If substance withdrawal (sedative/EtOH):
Benzos first-line treatment
PO administration is preferred if pt amenable
Benzos (potentiate GABA)
Lorazepam (fast-acting): 1-2 mg PO/IM
Chlordiazepoxide (long-acting; preferred in EtOH withdrawal): 5-10 mg PO/IM
Adjust dose based on age, hepatic issues, body size, medical conditions, etc. Avoid in delirious patients, as benzos tend to exacerbate.
Antipsychotics
Typicals: Haloperidol, fluphenazine. D2 antagonism. More likely to cause EPS, TD. Older. Haloperidol: 2-10 mg PO/IM.
Atypicals: Risperidone, ziprasidone, aripiprazole, quetiapine, olanzapine. 5HT2A antagonism, D2 antagonism. Z. and A. associated with 5HT1A agonism. Less propensity for causing EPS, TD, or akathisia, but more likely to cause metabolic issues: obesity, DM. Risperidone: 1-4 mg PO.
Adjust dose based on age, body size, previous response to tx, medical issues, etc. Monitor for EPS, TD, conduction issues, metabolic problems.


Intoxication
EtOH, or other sedatives (benzos)
Psychedelics, including MJ, LSD, psilocybin
Opiates
Amphetamines
Cocaine
Phencyclidine
Others: inhalants, butyl nitrate, MDMA, steroids, anti-cholinergics
Intoxication with any of these could lead to affective dysregulation and psychosis.
Pharmacotherapy generally not required for acute management, but agitation and psychosis may be treated with benzos and/or antipsychotics especially for phencyclidine intoxication.
Elucidate extent of use, route of intake, and impairments resulting from use.
Withdrawal
Generally not medically serious, unless the pt is withdrawing from EtOH or benzos, in which case seizures may develop. Treat EtOH and benzo withdrawal with benzos.
Withdrawal from other drugs can feel terrible, no doubt about it but not life-impairing. Cocaine withdrawal, however, is associated with intense dysphoria, sometimes AHs, and occasional active SI.
A suicidal pt withdrawing from cocaine (or other drug) may require acute psychiatric hospitalization.

Other Psychiatric Emergencies

NMS (Neuroleptic Malignant Syndrome)
A medical, as well as a psychiatric emergency
Associated with anti-psychotics and with any dopamine blocking medication
Associated with muscle rigidity, autonomic dysfunction, fever, and altered mental status
Serologic markers include elevated CK, demonstrating rhabdomyolysis; metabolic acidosis; and leukocytosis
Treat by stopping offending agent, maintaining hydration, and encouraging adequate cooling. Dopamine agonists or ECT may play a role
Especially in patients with longstanding psychosis, NMS may be confused with catatonia, which is not associated with autonomic dysfunction nor fever. This can be a fatal oversight, so always keep NMS in mind
Lithium Toxicity
Associated with nausea, vomiting, diarrhea, weakness, fatigue, lethargy, confusion, seizure, and potentially coma
Toxicity not entirely correlated with serum lithium level; toxicity may develop at different levels for different people
Obtain BMP, serum lithium level, and EKG
Encourage hydration; consider hemodialysis in extreme cases










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