Emergency Psychiatry

Emergency Psychiatry
Marcela Almeida, MD
Department of Psychiatry
A Hot One
You get paged by the ED resident to evaluate a
patient who is apparently wreaking havoc.
“He’s a hot one,” the resident says. “He’s screaming
insults at every one and smashing his fists against
the walls. We’re this close to pumping him with
Vitamin H [haloperidol]”.
“You’ll find him waiting for you in the seclusion
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
• 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 haven’t been already done.
• Review documentation, past and present, if
The Hot One: A Tentative Sketch
24 yo African American male with no significant
past psychiatric history and a past medical history
significant for asthma who is brought to the ED by
paramedics contacted by the pt’s girlfriend, who
arrives with the pt. She relates a two week period
of escalating aggression, insomnia, agitation,
bizarre behavior, and non-sensical, incoherent
ideas culminating in a nearly violent altercation
today in which the pt accused the girlfriend of
being in league with possibly demonic forces bent
on sucking out his gray matter.
A Run-Through of Common
• Depression
• With or without suicidality
Adjustment reactions
A Run-Through (Cont.)
• 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
• Etymology. Latin origins: (sui) self- (cide) death. Ergo,
self-injurious behavior sans death-wish is not a suicide
Eighth leading cause of death in men. (Higher than
Third leading cause of death in adolescents (15 to 24
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
• 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 Cobain’s 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).
Developing A Sense (Cont.)
• Risk factors for suicide (cont.)
• Immediate: anxiety; impulsivity; aggression;
intoxication; EtOH/drug dependence; agitation;
hopelessness; depression; psychosis; ideation, with plan
(pt’s perception of its lethality important to clarify);
physical or chronic illness; easy access to lethal
methods; little access to health care; low rescue
• 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
• 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
• 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.
“Dying is an art, like
everything else. I do it
exceptionally well. I
do it so it feels like
hell. I do it so it feels
real. I guess you could
say I've a call”.
Sylvia Plath
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)
Primary psychotic disorder
Intoxication or withdrawal
Developing A Hunch for
• Risk Factors:
• History of violence; aggression
• Impulsivity; intoxication
• Sincere plan
• Common etiologies include:
• Psychosis (command AHs); affective disorders;
personality vulnerabilities; substance intoxication or
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
• Don’t hesitate to admit involuntarily even if precise
psychiatric diagnosis remains elusive in the ED
Back to the Hot One
• ED evaluations should be just as comprehensive
as they would be anywhere else, though the exam
should be focused to address the particular
• You find the patient banging away at the walls of
his seclusion room. He is clearly agitated.
• Near the door to his room, a young woman is
crying – his girlfriend. You speak with her at
length in order to flesh out the history.
• You then proceed to enter the seclusion room.
Assessing Agitation
• An agitated patient shouldn’t be restrained or medicated immediately.
First, the psychiatrist should determine the pt’s “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. It is best to err on the side of caution: always have an
exit strategy, and ensure that others can quickly come to your
assistance, in case that’s required.
Things Heat Up
You enter the pt’s room and immediately notice the wild-eyed expression,
the psychomotor agitation, and the hands curled into fists. He starts to
approach you, screaming, “The soul! The gray matter! The Israelis!
Cannibals! Where’s your pumpkin, Uncle Sam?” He waves his arms
You say, calmly, “I’m your doctor and I’m here to evaluate you.”
He screams – “Gutter!” – and rushes towards you.
You close the door, having identified him as a stage 3 or 4; he bangs
loudly on the door, yelling “Doctor Gutter Doctor Gutter!” You obtain
He clearly needs to be hospitalized for apparent psychosis.
Furthermore, he meets criteria for involuntary admission given his
aggressive, violent tendencies.
Involuntary Admission
• Pt at immediate risk for hurting self or
others due to mental illness or mental
• Pt is mentally ill (or mentally retarded)
and unable to care for self as to acutely
endanger his or her life.
The Emergency Armamentarium
• 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
A Run-Down of Meds
• Benzos (potentiate GABA)
• Lorazepam (fast-acting): 1-2 mg PO/IM
• Chlordiazepoxide (long-acting; preferred in EtOH withdrawal): 5-10 mg
• 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.
The Low-Down on Drugs
• 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
• 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.
The Low-Down (Cont.)
• 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 Sundry Psychiatric
• NMS (Neuroleptic Malignant Syndrome)
• A medical, as well as a psychiatric emergency
• Associated with anti-psychotics and with any dopamine blocking
• 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
Other Emergencies (Cont.)
• 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