Emergency Psychiatry
E. Prost
Outline
1. Emergency Room Assessment
2. Behavioural Emergencies:
Assessment
3. Behavioural Emergencies:
Interventions
Excluding Physical Illness:
Factors for Increased Risk
1.
2.
3.
4.
5.
Older Age
Substance Abuse
No prior psychiatric history
Known/New physical complaints
Lower socioeconomic level
Gregory et al, General Hospital Psychiatry. 2004;26:405.
New Psychiatric Complaints
• 63% has a medical reason for
behaviour
– 13% had fever
– 37% had tachycardia
– 60% were disoriented
Henneman et al, Annals of Emergency Medicine. 1994; 24:672.
Identifying Physical Illness
• Only 4% of patients admitted to
psychiatry required acute medical
treatment within 24 hrs of admission.
• In 83%, history and physical should
have indentified the problem.
Tintinalli et al, Annals of Emergency Medicine. 1994; 23: 859.
Question
• What testing is necessary in order to
determine medical stability in alert,
cooperative patients with normal vital
signs, a noncontributory history and
physical examination, and psychiatric
symptoms?
Answer
In adult ED patients with primary
psychiatric complaints, diagnostic
evaluation should be directed by the
history and physical examination.
Routine laboratory testing of all
patients is of very low yield and need
not be performed as part of the ED
assessment. (level B)
Lukens et al, Clinical Policy: critical issues in the diagnosis and management of the
adult psychiatric patient in the emergency department. Annals of Emergency
Medicine. 2006;47(1):79-99.
Urine Toxicology Screen
• Almost half of ER physicians thought
urine toxicology for “medical
clearance” unnecessary.
• Psychiatrists use the results to
determine cause of symptoms,
treatment, and disposition.
Lukens et al.
Question
• Do the results of urine toxicology
screens for drugs of abuse affect
management in alert, cooperative
patients with normal vitals, a
noncontributory history and physical
examination, and a psychiatric
complaint?
Answer
1. Routine urine tox screens do not
affect management and need not
be performed as part of the ED
assessment.
2. Tox screens obtained in the ER for use
by psychiatry should not delay patient
evaluation or transfer. (level C)
Lukens et al.
Alcohol Levels
1. The patient’s cognitive abilities, rather
than a specific blood alcohol level,
should be the basis on which we begin
the psychiatric assessment.
Alcohol Level
However,
2. Consider using a period of
observation to determine if psychiatric
symptoms resolve as the episode of
intoxication resolves.
Lukens et al.
Outline
1. Emergency Room Assessment
2. Behavioural Emergencies:
Assessment
3. Behavioural Emergencies:
Interventions
Behavioural Emergencies:
The Goal
• To facilitate the resumption of a more
typical patient-physician relationship,
with an emphasis on informed consent
and long-term treatment outcome.
Allen et al. The Expert Consensus Guideline Series: Treatment of Behavioral
Emergencies. A Postgraduate Medicine Special Report, May 2001.
Behavioural Emergencies:
Assessment
1.
2.
3.
4.
5.
6.
Vitals
Medical History
Visual Examination
Urine Toxicology
MMSE
Pregnancy Test
Restraint vs Treatment
Treatment:
an intervention that follows from an
assessment of the patient and a plan
of care intended to improve the
patient’s underlying condition.
Choosing an Action 1
• Verbal interventions
• Offering food and beverage
• Other Assistance
• Voluntary medication
Choosing an Action 2
• Show of force
Choosing an Action 3
• Emergency medication
• Seclusion
• Physical Restraints
• >80% of patients managed without the
above.
Outline
1. Emergency Room Assessment
2. Behavioural Emergencies:
Assessment
3. Behavioural Emergencies:
Interventions
Choosing an Action:
What’s the Cause?
• General Medical Condition
• Substance Intoxication
• Primary Psychiatric Disorder
General Medical Condition
•
•
•
•
•
Vitals
Collateral history
Interview patient if possible
Emergency Medicine consultation
Basic bloodwork, toxicology screen
General Medical Condition:
Behavioural Emergency
1. Physical Restraints
2. Conventional Antipsychotic, benzo,
or combination.
3. If oral medication, use Risperidone.
Substance Intoxication:
Medication
1. Benzodiazepine alone
- with stimulants, risk of seizures, EPS
- with hallucinogens, risk of
anticholinergic effects
- with alcohol
2. Benzodiazepine with conventional
antipsychotic
- D2 blockers with amphetamine abuse
Primary Psychiatric Diagnosis
• What is the provisional diagnosis?
• Oral or Parenteral?
– Schizophrenia
– Mania
– Psychotic Depression
– Personality Disorder
– PTSD
Primary Psychiatric Diagnosis:
Schizophrenia or Mania
• Benzodiazepine plus conventional or
atypical antipsychotic
• Monotherapy with conventional or
atypical antipsychotic
• Benzodiazepine alone an option for
mania
Choosing Medication
•
•
•
•
•
•
Availability of IM or liquid route
Speed of onset
History of response
Useful sedation
Side-effects
Patient preference
Choosing a Medication:
Does “5 & 2” work?
• Combinations:
– More effective early in treatment
– Faster onset
– Reduced side-effects
– Can use lower doses of components
Speed of Onset
• IV has effect in 1 – 5 minutes
• IM Haloperidol has effect in 30 – 60
minutes
– Effect still increasing at 1 hour
• Good for transfer and admission
Clinton et al. Annals of Emergency Medicine 1987; 16(3): 319.
Haloperidol and Lorazepam
• Some studies show equal effects in
reducing agitation with lorazepam as
with haloperidol.
• Some show the combination is superior
than either alone.
Foster et al. Int Clin Psychopharmacol. 1997; 12(3): 175.
Droperidol?
• Fewer repeat doses needed
• Shorter ER stays
• Much used in some states over years
• But, only IM or IV
Richards et al, J Emerg Med. 1998; 16: 567.; Chase and Biros, Acad Emerg Med. 2002; 9: 140.
Atypicals: Olanzapine
• IM Olanzapine may decrease agitated
behaviour more quickly than IM Haldol
at 15 and 45 mins.
• More acute dystonia with Haldol
• More hypotension with Olanzapine
Wright et al. Gen Psychiatry 2001; 158: 1149.
Atypicals: Olanzapine
• Greater reduction in agitation in
mania with Olanzapine vs Lorazepam
at 2 hrs.
Atypicals: Risperidone
• Oral Risperidone 2mg with Lorazepam
2mg comparable to IM Haldol 5mg
and Lorazepam 2mg
• Similar benefits over similar time period
Currier et al. J Clin Psychiatry 2004; 65(3): 386; Currier et al. J Clin Psychiatry 2001; 62(3): 153.
Summary
1. What evaluation is necessary?
2. Use all resources in behavioural
emergencies.
3. Use the least intrusive medications to
maintain safety and restore the
doctor-patient relationship.