Transcript ADOLESCENTEMERGENCIES

ADOLESCENT
EMERGENCIES
ANITA ROBINSON, M.D.
ADOLESCENTEMERGENCIES
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Suicide
Drug Intoxication
Pregnancy
rape
Suicide Background
• Third leading cause of death for teens and
young adults
• Persons more likely to commit suicide
-Older adolescents
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-Males (4x more than females)
• Persons more likely to attempt suicide
-females
Etiology and Pathogenesis
• Normal stresses of adolescence
-Biological
-Psychological
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-Social/environmental
• Society’s view of adolescence
• Role of socioeconomic factors
Etiology of Suicide Attempt
Predisposing
factors
Vulnerable
= Adolescent
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Acute
Stressors
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Suicide
Attempt
Predisposing Factors
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Abuse – Physical/Sexual
Chronic Diseases
Chronic substance abuse, teen/parent
Family disorganization
Poor school performance
Family hx of suicide
Age/ firearm in the house
Predisposing Factors (cont.)
• Recent behavioral changes
• Feeling of….HALERS
• Psychiatric illness
ADHD
Affective Disorder
Conduct/ Anxiety Disorder
Depression
Acute Stressors
• Early/Late psychological maturation
• Sexuality
Anxiety about beginning sex
homosexuality
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pregnancy
• Death of someone close
• Recent loss (person/relationship)
Acute Stressors (cont.)
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Changes in school performance
Victimization, assault,rape
Substance use experimentation
Major changes in social environment
Onset of psychiatric disorder
Media
Vulnerable Adolescent
• Late adolescent
• Depression
• Low self esteem coupled with multiple
failures
• Not fitting in, no friends
Signs of suicide
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Changes eating/sleeping habits
Withdrawal
Chronic drug use
Frequent somatic complaints
Giving away favorite possessions
Feelings of hopelessness,guilt,poor
concentration,boredom,school grade drop
Case
Jessie is a 17 y.o. female who you are seeing
in the ER at 4PM on a Saturday afternoon.
She presents with a known Tylenol
overdose earlier that day. She ‘s somewhat
drowsy, but is coming to and able to answer
basic questions. She is medically stable. Her
mother comes with the Tylenol bottle and
states that it was recently brought and that
Case (cont.)
10 pills were missing (325mg each). After 4
hours, Tylenol levels are in a safe zone, and
you have to determine her disposition.
What specific points from the hx are
important to ask Jessie?
What criteria should you use to hospitalize?
Risk Assessment Factors
• Low
• Moderate
• High
Factor
PRECIPATATING EVENT
• LOW, argument with friend, teacher
• MODERATE, fight with close friend,school
failure,difficult home situation
• HIGH, break-up important
relationship,thrown out of home,pregnancy
discovery,death close relationship,thinking
disorder,hallucinations
FACTOR
INTENDED PURPOSE
• LOW, unknown, impulsive
• MODERATE, attention seeking, to
punish,escape,cannot face shame or failure
• HIGH,to be dead, no purpose in living, to
join deceased one
FACTOR
PLAN - PERCEIVED LETHALITY
• LOW, small amount of pills, perceived low
toxicity
• MODERATE,small amount of
pills,perceived as toxic, slash wrist
• HIGH, violent method, large amount of
pills, perceived toxic
FACTOR
PLAN – REAL LEATHALITY
• LOW, relative innocuous
• MODERATE.moderately harmful but
perceived recovery
• HIGH, significant potential for death
FACTOR
PLAN – SPECIFICITY
• LOW,no solid plan
• MODERATE, specific plan, not
rehearsed,several plans, method readily
available
• HIGH, one method chosen and steps in
place, may have rehearsed plan
FACTOR
PLAN - DISCOVERY POTENTIAL
• LOW,announces intent, someone at home
• MODERATE, someone expected at home,
calls someone, location highly visible
• HIGH, isolated location or situation,tells no
one
FACTOR
LIFE STRESSORS – CURRENT
• LOW, none
• MODERATE, environmental changes,
physical changes, failure to achieve
• HIGH, death of close individual, thrown out
of home, rejection by boyfriend
FACTOR
MOOD - AFFECT – BEHAVIOR
• LOW, optimistic, able to verbalize
• MODERATE, depressed,but mood
lightens,few friends
• HIGH, flat, distant affect, no friends, no
change in mood after talking
FACTOR
PAST COPING AND MENTAL HEALTH
• LQW, good coping and support, no mental
health issues
• MODERATE, distorts reality, impulsive,
uses peers for support, some
depression,mood swings
• HIGH. loose reality,victim of fate,depressed
FACTOR
FAMILY STRUCTURE – FUTURE PLANS
• LOW, supportive, good coping.,definite
future goals
• MODERATE, overburden family but tries
to be supportive,wants to be somebody but
no plans
• HIGH, overburden family,no coping,no
plans, alienated
SUMMARY
• PRECIPITATING EVENT
• INTENDED PURPOSE
• PLAN
METHOD-PRECEIVED LETHALITY
REAL LETHALITY
SPECIFICITY
DISCOVERY POTENTIAL
SUMMARY (cont.)
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LFE STRESSORS – CURRENT
MOOD – AFFECT – BEHAVIOR
PAST COPING AND MENTAL HEALTH
FAMILY STRUCTURE/FUTURE PLANS
DRUG EFFECTS
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THERAPEUTIC
INTOXICATION
OVERDOSE
WITHDRAWAL
DRUGS OF ABUSE
• Illicit and nonillicit
• Combination of both
• Alcohol, #1 followed by smoking cigarettes
and marijuana
• Rise in stimulant use
• Inhalant use popular with early adolescents
• Cocaine, opiate, and othe drug use stable
CLASSES OF DRUGS
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Opioids – Depressants type 1
Stimulants
Sedatives,hypnotics –Depressants type2
Inhalants – Depressants type 3
Hallucinogens
Marijuana
Phencyclidine - PCP
CASE
Ann is a 17 y.o. who present in your clinic
with a 2 day hx of cough, rhinorhea, sore
throat, and generalized muscle aches. She
also has had abdominal pain with vomiting
and diarrhea. Her temp is normal and pulse
slightly elevated. She appears agitated. Her
P.E. is normal except for dilated pupils.
OPIOID CLASS
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Morphine
Heroin
Codeine
Oxycodone and hydromorphone
Merperedine and methodone
Talwin, darvon, ultram
Nsaids
OPIOID SYMPTOMS
• V.S. – depressed
• Mental Status – euphoria, stupor
• Physical – miosis, decreased reflexes,
analgesia,amnesia, constipation, pulmonary
edema, respiratory depression and coma
OPIOID WITHDRAWAL
• V>S> - rapid pulse
• Mental status – anxious, paranoid
• Physical – mydriasis, flu like symptoms,
abdominal pain, increased reflexes
STIMULANT/ANTICHOLINER
GIC SYMPTOMS
• V>S> - increased
• Mental status – euphoria, anxious
• Physical – mydriasis,reflexes increased,
arrythmia,increased muscle tone, seizures,
pulmonary edema, coma
STIMULANT CLASS
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Cocaine
Amphetamines (designer drugs)
Ritalin
Caffeine, nicotine
STIMULANT WITHDRAWAL
• V.S. – depressed
• Mental status – severe depression and
paranoid state, suicide high
• Physical – decreased reflexes, marked
fatigue,difficult to awake,constipation
SEDATIVE/HYPNOTIC
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Alcohol
Benzodiazepine
Barbiturates
SSRI
Tricyclic antidepressants
Anticonvulsants
SEDATIVE/HYPNOTIC
SYMPTOMS
• V.S. – decreased
• Mental status – euphoria, stupor
• Physical – marked respiratory depression,
slurred speech, staggering gait, decreased
reflexes,nystagmus, seizures, arrythmis.
coma
FLUMAZENIL
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Benzodiazepine antidote
Use with caution
May cause vomiting
May not totally reverse respiratory depress.
Seizures in physical dependence and mixed
overdoses
• Arrythmia with tricyclics and mixed
overdoses
INHALANTS
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Aromatic and aliphatic types
Benzene, moth balls kerosene, gasoline
Airplane glue, correction fluid
Amyl nitrate, butyl nitrate, nitrous oxide
Feon
INHALANT SYMPTOMS
• V.S. – decreased
• Mental status – euphoria, stupor
• Physical – respiratory depression,
hypoxia,,arrythmia, renal and muscle
damage, coma
HALLUCINOGENS
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Lsd
Mescaline
Pilocybin,, peyote cactus
Mushrooms
Nutmeg
Ergots
HALLUCINOGEN
SYMPTOMS
• V.S. – increased
• Mental status – euphoria with hallucinations
• Physical – impaired senses,synesthesia,
sweating, dilated pupils,palpitations,tremors
and poor coordination
PHENYCYCLIDINE
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PCP
V.S. – may be normal, increased B.P. ,temp,
Mental status – confusion, anxiety, amnesia
Physical – vertical nystgmus,and may see
horizontal or rotary, muscle rigidity.
Catatonia,ataxia,sweating, extreme muscle
strength, seizures
PREGNANCY - DIAGNOSIS
• LABORATORY
Urine HCG- + 7-10 days after conception
severe renal damage interferes
Serum HCG- + 6-12 days after ovulation
peaks 10-12 weeks
PREGNANCY-PHYSICAL
EXAM
• Always perform pelvic exam,including
GC/CHL
• Bimanual exam
Less than 12 weeks enlarged globularr
uterus below the symphysis pubis
16 weeks midway umbilicus/pubic bone
20 weeks umbilicus
PREGNANCY PSYCHOSOCIAL
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Concrete vs. abstract thinking
Sexual history
Parental knowledge
Ability to communicate with parents
Partner awareness and what pt. Wants to do
Pregnancy outcome options
Support status and safety to go home
RAPE
• Under age 18 and less than 72 hours – rape
kit,, family advocacy, commanding
officer,Dr. Craig’s group
• Over age 18 and less than 72 hours,above
but refer to SAVI, Cindy Stewart, 202 6851171,for navy family advocacy other
branches
RAPE
• Under age 18 and greater than 72 hours,do
standard STD work up,HEADDS, family
advocacy – central contact Jackie
Richardson, 202 685-1182 or county rape
crisis center
• Over age 18 and greater than 72 hours,
work up as above but refer to SAVI, contact
Cindy Stewart 202 685-1171
STATUTORY RAPE
• DC law, sexual acts or sexual contact
between a child under 16 and any person
four or more years older.
• Maryland, Sexual contact with another
person who is under 14 and the person
performing the sexual contact is four or
more years older than the victim or.
STATUTORY RAPE (cont.)
• A sexual act with another person who is 14
or 15 years of age and the person
performing the act is at least 21 years of age
• Or, vaginal intercourse with another person
who is 14 or 15 years of age and the person
performing the act is at least 21 years of
age
STATUTORY RAPE
VIRGINIA
Carnal knowledge of a child younger than 13
is automatically considered to be rape and
falls under the code of Virginia 18.2-61
An adult over age 17 who has sex with a child
over age 14, but under age 18, can be guilty
of contributing to the delinquency of a
minor