Medical stability &
Substance related
emergencies
M. Nadeem Mazhar
MBBS, MRCPsych, FRCPC, DABPN
Objectives
• Review issues regarding “medical clearence” in ED
• Assess common medical causes of agitation
• Evaluate assessment substance related emergencies
“MEDICAL CLEARANCE”
Medical clearance
“There is no way to rule out every possible medical illness
a patient may have prior to admission to a psychiatric unit”
(Zun 2005)
Medical stability
Making a reasonable investigation to exclude the
possibility of patient having an illness that:
1. Would be better treated in a medical setting (e.g.,
infection requiring IV antibiotics)
2. Will cause the acute decompensation in the next few
hours requiring a higher level of care (e.g., severe
alcohol withdrawal)
3. Causing behavioral symptoms but should be treated by
something other than psychiatric medications (e.g.,
delirium due to an underlying infection)
4. Worsening the psychiatric process (e.g., untreated pain
that is causing the agitation)
(Clinical Manual of Emergency Psychiatry)
Physical examination
• Evaluation of patient’s general medical status
necessitates that a physical examination be performed
• Physical examination may be performed by the
psychiatrist, another physician, or a medically trained
clinician
• Particular caution in examination of patients with
histories of sexual abuse- “All but limited examination of
such patients should be chaperoned”
(APA Practice Guidelines for Psychiatric Evaluation of Adultssecond edition, 2006)
Physical examination
Specific elements may include the following:
• General appearance, height, weight, BMI & nutritional
status
• Vital signs
• Head and neck, heart, lungs, abdomen, and extremities
• Neurological status, including cranial nerves, motor and
sensory function, gait, coordination, muscle tone,
reflexes, and involuntary movements
• Skin e.g., stigmata of self injury or drug use
• Any body area or organ system specifically mentioned in
the HPI or ROS
(APA Practice Guidelines for Psychiatric Evaluation of Adults- second
edition, 2006)
General appearance
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Cachexia- suspicion of cancer, HIV, TB, malnutrition
Obvious respiratory distress
Obvious physical distress or agitation
Grossly dishevelled or malodorous patient
Rashes- allergic or infectious diseases
HEENT
• Dry mucous membranes- dehydration
• Pupils and eye movements- focal neurological deficits,
evidence of drug intoxication/withdrawal
• Scleral icterus- jaundice
• Proptosis- hyperthyroidism
• Bruises, lacerations- evidence of head/facial trauma
• Poor dentition- nutritional status
Neck
• Thyromegaly- goiter, hyperthyroidism
• Neck rigidity- meningitis, encaphalitis
Chest
• Rales- congestive heart failure
• Rhonchi- pneumonia
Cardiovascular
• Rate, rhythm, regularity of heartbeat
• Vascular disease- any absent peripheral pulses
Abdomen
• Hepatomegaly- undiagnosed liver disease
• Acute tenderness- acute pathology that needs to be
addressed in ED
Extremities
• Any deficits, limps or pain
Neurological
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Any focal deficits indicating stroke
Festinating gait, rigidity- parkinsonism
Tremors- EPSE, Parkinson’s disease
Broad based gait- hydrocephalus, tertiary syphilis
Evidence of tardive dyskinesia
Diagnostic tests in Psychiatry
1. Detect or rule out presence of condition that has
treatment consequences
2. Determine the relative safety and appropriate dose of
potential alternative treatments
3. Provide baseline measurements before instituting
treatment
4. Monitor blood levels of medication when indicated
(APA Practice Guidelines for Psychiatric Evaluation of Adultssecond edition, 2006)
Laboratory tests
CBC:
• Macrocytic anemia- vitamin B12/folate deficiency,
alcohol abuse
• Microcytic anemia- iron deficiency
• Normocytic anemia- acute bleeding or chronic
inflammatory disease
• Leukocytosis- acute infection
• Leukopenia- advanced HIV disease, leukemia,
carbamazepine
• Low platelets- Valproate, ITP
Laboratory tests
Electrolytes & Creatinine:
• Elevated creatinine- renal failure
• Hyponatremia- SSRI’s
• Hypernatremia- dehydration, renal failure
• Hypokalemia- risk for arrhythmia, bulimia, diuretic use
• Hyperkalemia- risk for arrhythmia, renal failure
• Low bicarbonate- acidosis, aspirin ingestion
Laboratory tests
Liver enzymes:
•Elevated AST: ALT ratio- alcohol abuse
•Elevated ALT & AST: liver failure due to multiple causes
e.g., acetaminophen ingestion, hepatitis
Laboratory tests
TSH:
• Elevated- hypothyroidism leading to depression,
cognitive changes
• Low- hyperthyroidism leading to manic like symptoms,
agitation
Laboratory tests
Vitamin B12 & Folate:
• Low B12- neurological changes, memory problems
• Low folate- evidence of general malnutrition, association
with depression
Laboratory tests
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Syphilis serology/HIV testing
Medication levels
Blood alcohol levels
Fasting blood glucose or hemoglobin A1c
Pregnancy test
Urinalysis
Urine drug screen
Other investigations
Chest X-ray: Considered for all homeless people, any
patients with suspicion of TB, and elderly patients
Head CT: In patients with altered mental status or newonset psychosis- to rule out SOL or bleeding
EEG: Evidence of metabolic encephalopathy (delirium),
nonconvulsive status epilepticus
ECG: Medications that may influence cardiac function
Lumbar puncture: Any patient with new mental status
changes, fever, and/or meningeal signs- to rule out
meningitis, encephalitis, bleeding, cryptococcal infection
Agitation- medical causes
Delirium:
• Waxing and waning level of consciousness
• Fluctuation in vital signs
• Confusion
• Can be irritable or passive and detached
• More common in elderly
Agitation- medical causes
Hypogylcemia:
• Altered mental status
• Sweating
• Tachycardia
• Weakness
Agitation- medical causes
Post-ictal states:
• Altered level of consciousness
• Confusion
• Ataxia
• Todd paralysis
• Neurological signs such as slurred speech
• Evidence of tongue biting or incontinence
Agitation- medical causes
Structural brain abnormality:
• Varies by lesion
• Altered mental status
• Headache
• Meningeal signs
• Focal neurological deficit or progressive neurological
deterioration
Agitation- medical causes
Toxicologic emergency:
• Varies by substance
• Mental status changes
• Pupillary changes
• Vital sign changes
• Sweating
SUBSTANCE RELATED PSYCHIATRIC
EMERGENCIES
Initial evaluation
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Thorough history using available resources
MSE
Physical examination
Laboratory tests
Imaging studies
Urine drug detection- ELISA, gas chromatography- mass
spectrometry
The depressed patient
MSE suggestive of depression or psychomotor slowing:
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Alcohol intoxication
Sedative-hypnotic toxicity
Opioid toxicity
OTC cough & cold medication
Inhalant intoxication
CNS stimulants withdrawal
Alcohol intoxication
• Most common cause of substance related emergencies
• Studies showing up to 40% of ED patients having alcohol
detected in their blood
• CNS depressant effect by increasing responsivity of GABA
type A receptors to GABA and inhibiting effects of
glutamate at its receptors
• Disinhibition at onset resulting agitation, combativeness
and rarely psychosis
• Dose-dependent CNS depression: Diminished
coordination→ slurred speech/ataxia→ respiratory
depression/coma
• Legal limit: 0.05%- 0.08% (50mg/dl – 80mg/dl or 10.85
mmol/L – 17.36 mmol/L)
Alcohol intoxication
• Treatment of alcohol intoxication- supportive
• Gastric lavage not useful due to rapid absorption of
alcohol from gastrointestinal tract
• Serial monitoring of toxic blood alcohol levels for
expected gradual drop
• Chronic alcoholics metabolize ETOH at a rate of 15-20
mg/dl per hour
• In case of persistent alteration in consciousness→
exclude other causes e.g., other toxins, metabolic
dysfunction or subdural hematoma
Sedative-hypnotic toxicity
• Can occur in acute overdoses, patients exceeding
scheduled doses or with concomitant administration of
other CNS depressants
• Accumulation can also result in liver disease, advanced
age and pharmacokinetic drug interactions
• Temazepam, oxazepam, lorazepam & alprazolam
metabolized primarily by conjugation- less likely to
accumulate in liver impairment
• Dose dependent effects on coordination, cognition and
consciousness
• Paradoxical agitation/excitement can also result from
drug induced disinhibition
Sedative-hypnotic toxicity
• Vomiting, diarrhea and urinary retention can occur in
BZD toxicity
• Flumazenil ≤ 1mg reverses BZD effects- may precipitate
seizures in dependent individuals
• BZD’s rarely lethal by themselves
• Synergism with other CNS depressants e.g., alcohol &
opioids
• Can worsen ventilation in patients with preexisting
cardio-respiratory conditions e.g., OSA, COPD & CHF
• High index of suspicion in patients with history of ETOH
abuse
• BZD misuse also likely in patients on opioids & cocaine
users
Opioid toxicity
• Miosis + CNS & respiratory depression
• Slow, shallow respiration, absent GI sounds & urinary
retention
• Toxicity can also result from acetaminophen or NSAIDs
frequently combined with prescription opioids
• Naloxone is a specific antidote→ can precipitate opioid
withdrawal
• Repeated doses may be required due to naloxone’s short
half life
OTC cold & cough medications
• Frequently abused by adolescents to get “high”
• May contain mixtures of various antihistamines,
sympathomimetics with or without dextromethorphan
• Difficult to detect in urine→ pseudoephedrine may
screen positive for amphetamine
Inhalant intoxication
• Include a variety of hydrocarbons including toxic solvents
• Initial stage of disinhibition, excitement, or a sense of
drunkenness→ restlessness, ↓consciousness, ataxia,
respiratory depression, coma and death with ↑inhaled
concentrations
• Risk of arrhythmias, possible hepatic injury and longterm effects on cognition
CNS stimulant withdrawal
• The cocaine “crash”
• Dysphoria that may be accompanied by suicidal ideation,
sleep disturbance and cravings
• Increased appetite as a rebound to appetite-suppressant
effects of stimulants
Agitated, aggressive &
psychotic patient
Agitated behavior ranging from belligerence to physical
aggression to full blown psychosis:
• Alcohol withdrawal
• Sedative-hypnotic withdrawal
• Opioid withdrawal
• CNS stimulant intoxication
• Hallucinogen intoxication
• Marijuana intoxication
Alcohol withdrawal
• Combativeness and aggression could be seen in both
alcohol intoxication and withdrawal
• BAL at which withdrawal occurs varies from patient to
patient
• Can begin in as little as 6 hours from the last drink
• Autonomic instability: ↑BP, tachycardia & sweating
• GI symptoms: Nausea, vomiting & diarrhea
• CNS activation: Anxiety & tremor
• Serious withdrawal: Hallucinations & seizures
• Delirium tremens: After 48-72 hours, about 5% of
patients in alcohol withdrawal, develop DTshallucinations (usually visual), delirium and severe
autonomic instability
Alcohol withdrawal & CIWA
1) Nausea and vomiting: 0-7 score
2) Tremor: 0-7
3) Paroxysmal sweats: 0-7
4) Anxiety: 0-7
5) Agitation: 0-7
6) Tactile disturbances: 0-7
7) Auditory disturbances: 0-7
8) Visual disturbances: 0-7
9) Headache: 0-7
10) Orientation: 0-4
CIWA & Medication
Cumulative Score
Medication Requirement
0-8
No medication
9-14
Medication optional
15-20
Medication treatment
>20
Strong risk of DT
67
Maximum possible cumulative score
Structured medication
regimens
1) Chlordiazepoxide:
• 50 mg Q6H X 4
• Followed by 25 mg Q6H X 8
2) Diazepam:
• 10 mg Q6H X 4
• Followed by 5 mg Q6H X 8
3) Lorazepam:
• 2 mg Q6h X 4
• Followed by 1 mg Q6H X 8
4) Carbamazepine:
• 400 mg BID on day 1
• Tapering down to 200 mg as a single dose on day 5
Pharmacological treatment of
alcohol withdrawal
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Benzodiazepines
Anticonvulsants
Beta- blocking agents
Alpha-adrenergic agonists
Thiamine
Neuroleptic agents
Sedative-hypnotic withdrawal
• Occurs within the first few hours to days after
discontinuation following a period of regular use
• Similar to alcohol withdrawal except: extended over days
to weeks (instead of hours to days)
• Anxious prodrome→ tremor, tachycardia, hypertension,
diaphoresis, GI upset, mydriasis, sleep disturbance &
nightmares, tinnitus, ↑sensitivity to sound, light &
tactile stimuli
• Confusion, delirium, hyperthermia & GTCS can occur in
severe withdrawal
• Significant anxiety, sleep disturbance and mild autonomic
symptoms may persist for many months
Sedative-hypnotic withdrawal
• Switch to longer acting agent & gradually taper
(10%/week)
• Carbamazepine 200 mg t.i.d. for 7-10 days (gabapentin
and divalproex are alternatives)
Opioid withdrawal
• Heralded by anxiety, craving/preoccupation & vague
discomfort (hyperalgesia)
• Pupillary dilatation, lacrimation, rhinorrhea, diaphoresis,
piloerection, arthralgia/myalgia, diarrhea, yawning &
sneezing
• Rarely causes change in mental status except for
↑anxiety
• Onset: 6-72 hours after last use/dose
• Peak: 2-4 days
• Resolution: 7-10 days
• Not life threatening in otherwise healthy patient
• Miscarriage in pregnancy
Clinical Opiate Withdrawal
Scale (COWS)
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Resting pulse rate (0-4 score)
Sweating (0-4 score)
Restlessness (0-5 score)
Pupil size (0-5 score)
Bone or Joint aches (0-4 score)
Runny nose or tearing (0-4 score)
GI upset (0-5 score)
Tremor (0-4 score)
Yawning (0-4 score)
Anxiety or irritability (0-4 score)
Gooseflesh skin (0-5 score)
Severity of withdrawal: 5-12= mild, 13-24= moderate,
25-36= moderately severe, >36= severe
Opioid withdrawal treatment
Drug
Dose
Withdrawal
Symptoms
Clonidine
0.1-0.2 mg P.r.n.
b.i.d.- q.i.d.
Agitation,
diapohresis
Dimenhydrinate
50 mg p.o. or p.r.
p.r.n.
nausea
Ibuprofen
200-400 mg p.r.n.
t.i.d.
myalgia
Immodium
2 mg p.r.n. max 6
tabs/day
diarrhea
Trazodone
50-100 mg q.h.s.
p.r.n.
insomnia
Benzodiazepines
p.r.n.
anxiety
CPSO MMT Guidelines-2011
CNS stimulant intoxication
• Amphetamines, cocaine & MDMA
• Physical signs: tachycardia, tachypnea, hypertension,
mydriasis, myoclonus, hyperreflexia, tremor, vomiting,
hyperthermia & possible seizures
• Psychosis: paranoid delusions, tactile or visual
hallucinations. Rarely FTD or bizarre delusions. Appear
abruptly & resolve quickly (i.e., within days). More likely
to have insight
• Stimulant toxicity fatal in severe cases, often from
cardiovascular or cerbrovascular causes
• Treatment: minimization of stimulation, sedation with
BZD, caution with neuroleptics due to the potential for
lowering seizure threshold and avoiding physical
restraints if possible
Hallucinogen intoxication
• Physical symptoms: hyperthermia & seizures
• Psychological symptoms: prominent anxiety symptoms
with “bad trips” including panicky feelings & fear of
losing one’s mind. Psychosis is typically accompanied
with relatively preserved insight
• Treatment: Similar to management of stimulant
intoxication
Marijuana intoxication
• Common presentation in chronic high-dose marijuana
users is the experience of hypervigilance,
depersonalization& derealization
• Physical symptoms/signs: conjunctival injection,
orthostatic hypotension, dry mouth & tachycardia
Drug seeking patient
• BZD’s for anxiety
• Opioids for the treatment of pain (often out of
proportion to objective findings)
• Suspect drug seeking behavior:
1. When a specific medication is asked for
2. Stating that prescription was “lost” and provider not
immediately available
3. Claims allergy to alternate medications
4. Threaten to be suicidal unless get prescription for
specific medication
SUBSTANCE RELATED PSYCHIATRIC
EMERGENCIES- CASE DISCUSSION
History
• 35 years old with diagnoses of GAD, panic disorder with
agoraphobia and antisocial personality traits presents to ER
with worsening anxiety (thinks his chest and head are going to
explode), diffuse muscle aches, diarrhea, nausea and sweating
Medications
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Effexor XR 75 mg QD
Epival 500 mg BID
Risperidone 0.5 mg BID
Clonazepam 1 mg TID + 1 mg PRN daily (concerns about
abusing)
Physical examination
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Temp 36.7
Pulse 101
Resp 20
BP 145/97
Oxygen sats 98%
Dilated pupils
Diagnosis & Treatment
• Most likely substance related diagnosis?
• Pharmacological treatment options?
DSM-IV Sedative/Hypnotic
Withdrawal
Two or more of the following:
• Autonomic hyperactivity (sweating or pulse rate greater than
100)
• Increased hand tremor
• Insomnia
• Nausea or vomiting
• Transient visual, tactile or auditory hallucinations or illusions
• Psychomotor agitation
• Anxiety
• Grand mal seizures
DSM-IV Opioid Withdrawal
Three or more of the following:
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Dysphoric moods
Nausea or vomiting
Muscle aches
Lacrimation or rhinorrhea
Pupillary dilatation, piloerection or sweating
Diarrhea
Yawning
Fever
Insomnia
Reference
• APA Practice Guidelines for Psychiatric Evaluation of Adults- second
edition (2006).
• Riba M., Ravindranath D. (2010). Clinical Manual of
Emergency Psychiatry. Washington DC:
American Psychiatric Publishing Inc.
• Zun LS. Evidence-based evaluation of psychiatric
patients. J Emerg Med 2005; 28: 35-39.