Psychiatric Emergencies

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Psychiatric Emergencies

• Angela S. Olomon, DO

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Goals

• Strengthen education on psychiatric emergencies
  presenting in the medical office
• Identify characteristics of agitated patients
• Identify suicide risk and protective factors

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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 patients potential for danger or harm
  to self or others

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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.

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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)

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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

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Questions?

• What do you want to know?

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Key Assessment Data

• Meds
• Alcohol
• Illicit Drugs
• Other Informants / Family
• Recent History

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Evaluation

• BA
• Drug Screen
• BP P
• Pulse Ox
• X-Ray / CT

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CS2

• 47 year old white female calls
• Frantically demands to speak to you
• Claims Critical Emergency (like always)
• States I cant go on!
• Im going to kill myself, then I wont have to
  deal with it!

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Questions?
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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?

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Evaluation

• Hospital ER vs. Friend vs. 911
• Resources (Therapists, Family)

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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

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Questions?
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Key Assessment Data

• History of past Dx or hospitalizations
• (Bipolar II and Chronic Pain Spinal Stenosis)
• Medications / Treatments
• (Opioid Analgesic Discontinued)

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Evaluation

• Blood levels of medications
• Verify Compliance
• Initiate De-escalation Procedures
• Titrate Medication
• Marshal Resources (Family, Therapists)

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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)

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Questions?
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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?

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Interventions

• IM vs. PO Medication

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Pre Crisis Planning

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

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Staff Training

• Safety Plan
• De-escalation Procedures
• Code Drill
• Practice, Practice, Practice

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Aggression Risk Factors

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

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Suicide Assessment

• Risk Factors
• Protective Factors

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Interventions

• Call for Help!
• Verbal De-Escalation
• Quiet Room Decreased Stimuli
• Pharmacological
• Patients Meds
• Antipsychotic Meds
• Benzodiazepines

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Emergency Medications

• PO
• Risperdone 2mg
• Ativan 2mg
• Zyprexa Zydus 5-10mg
• IM
• Haldol 5mg
• Ativan 2mg

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Diagnosis

• TRUMP METHOD
• Ace Medical Disorder
• Joker Substance Induced
• King Mood Disorder w/ Psychosis
• Queen Schizophrenia
• Jack Personality Disorder

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ACE

• Delirium
• Attention
• Concentration
• MMSE

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Mend A Mind

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

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Joker

• Increased Risk of Suicide
• Alcohol Withdrawal / Intoxication
• Cannabis
• Stimulants
• Cocaine
• Opioids

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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

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Opioid Withdrawal

• Irritability / Agitation
• Nausea / Vomiting / Diarrhea
• Muscle Ache
• Excessive Tears / Runny Nose / Yawn
• Pupil Dilatation / Goose Flesh
• Sweating / Fever / Insomnia

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