Transcript Behavioral & Psychiatric Disorders

Behavioral &
Psychiatric Problems
Scott Marquis, MD
What is a behavioral
emergency?
An unanticipated behavioral episode
 Behavior that is threatening to patient
or others
 Requires immediate intervention by
emergency responders

Abnormal Behavior
No clear definition, but is maladaptive
 Deviates from societies norms and
expectations
 Interferes with individual well-being and
ability to function
 Harmful to self or others

Behavioral Change

Never assume a patient has a
psychiatric illness until all possible
physical causes have been ruled out
‘Clues’
Underlying Physical Illness
Sudden onset
 Visual, but not auditory, hallucinations
 Memory loss or impairment
 Altered pupil size, asymmetry, or
impaired reactivity
 Excessive salivation or incontinence
 Unusual breath odors

Behavioral Change
Possible Causes
Low blood sugar
 Hypoxia
 Inadequate cerebral blood flow
 Head trauma
 Drugs, alcohol
 Excessive heat or cold
 CNS infections

Behavioral Change
Pathophysiology
Biological or organic
 Psychosocial
 Socio-cultural

Organic Causes

Disease


Metabolic disorders, infection, endocrine
disorders, neoplastic disease,
cardiovascular disease, or degenerative
disease
Physical injury

Head trauma
More Organic Causes

Toxins


Drug abuse, medication reactions, carbon
monoxide
Disturbance in cognitive functioning

Delirium, dementia
Psychiatric Disorders
Epidemiology
Mental health problems affect as much
as 20% of general population
 More than all other health problems
combined!
 An estimated 1 in 7 persons will need
treatment for an emotional disturbance
at some time in their lives

Anxiety Disorders
Most common psychiatric problem
encountered in outpatients
 Painful uneasiness, a reaction to difficult
situations or past/present life stressors
 Interferes with effective functioning
 Agitation or restlessness quite often
confused as something else

Anxiety Disorders
Anxiety, generalized
 Panic disorders
 Phobias
 Obsessive-compulsive disorder
 Post-traumatic syndromes

Mood Disorders
Patient mood ranges from extremely
low to euphoric behavior
 May often be more subtle, a loss of
interest or enjoyment in any of his/her
normal pleasures
 Physical complaints are common

Depression
Hopelessness, worthlessness, sleep or
eating disturbances, unable to
concentrate, slowed reaction time
 Always ask about suicide!
 A factor in 50% of suicides

Bipolar Disorder
Manic-depressive cycles
 Manic – euphoric, grandiose, pressured,
may claim to have special powers
 Depressed – sad, hopeless, suicidal,
“crash” after mania
 May be delusional in either phase

Psychotic Disorders
“A break from reality”
 Not always a psychiatric cause; consider
alcohol, drugs, and medication
reactions
 One percent of general population will
be diagnosed with schizophrenia

Schizophrenia
Debilitating distortions of speech and
thought
 Bizarre hallucinations, delusions, or
behavior
 Social withdrawal
 Lack of emotional expressiveness, “flat”

Schizophrenia
Paranoid
 Catatonic
 Disorganized
 Undifferentiated

Substance-Related Disorders
Intoxication
 Dependence
 Withdrawal

A close friend of psychiatric illness
 Particularly tight links to depression and
suicidal behavior!

Violent Patients
Suicide

Never dismiss any suicidal threat, no
matter how well you know the patient
Suicide rate in your prehospital
population is 10 times that of the
general population!
 Women attempt suicide more often
 Men succeed more often

Who is at greatest risk?
White men over 40
 Living alone, divorced, or widowed
 Substance abuse problems
 Severe depression
 Past suicide attempts
 Highly lethal plan
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Suicide

Asking about a specific suicide plan will
not make suicide more likely!
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Having a detailed plan does put your
patient at higher risk
Suicide
Additional Risk Factors
Means are available, low likelihood of
rescue
 Poor physical health; chronic disease or
pain syndrome
 Recent loss of a loved one, anniversary
 Sudden life changes; unemployment,
bankruptcy, imprisonment
 Family history of suicide, especially a
parent
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Managing Behavioral
Emergencies
Guiding Principles
Respect the dignity of the patient
 Assure your own as well as the patient’s
and others safety
 Diagnose and treat organic causes of
behavioral disorders
 Work with law enforcement to improve
patient care outcomes

Scene Size-Up
Pay careful attention to dispatch
information for indications of potential
violence
 Never enter potentially violent
situations without police support
 If personal safety is uncertain, stand by
for police
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Scene Size-Up
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In suicide cases, be alert for hazards
Automobile running in closed garage
 Gas stove pilot light blown out
 Electrical devices in water
 Toxins on or around the patient
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Scene Size-Up
Quickly locate the patient
 Stay between patient and door
 Scan quickly for any dangerous articles
 If patient has a weapon, ask him/her to
put it down
 If he/she won’t, back out and wait for
the police
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Scene Size-Up

Look for…
Signs of possible underlying medical
problems
 Methods or means of committing suicide
 Multiple patients
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General Approach
Do not argue or shout
 Remove disturbing persons or objects
 Provide emotional support
 Explain all procedures carefully to
anxious or confused patients
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Initial Assessment
Rapid assessment of ABC’s
 Identify and treat potentially lifethreatening illness and injuries
 Observe patient’s outward behavior and
body language
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Interview Approach
Communicate in a calm and nonthreatening, nonjudgmental way
 Identify yourself and offer the patient
assistance
 Seek the patient’s cooperation
 Encourage patient to talk; show you are
listening

Interview Approach
Be supportive and limit interruptions
 Respect patient’s space, limit touching
unless given permission
 Be direct and always tell the truth
 Involve trusted family, friends

Focused History
Ask for and acknowledge patient’s
complaints
 Determine onset of behavioral event
 Ask about precipitating factors; remove
patient from these, if possible
 Existing life situation
 Previous psychiatric as well as medical
history

Focused History
Mental status, affect, and behavior
 Current medications and alcohol or illicit
drug use
 Evaluate potential for suicide!
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Assessment
Suicidal Patients
Do not trust “rapid recoveries”
 Do something tangible for the patient
 Do not try to deny that a suicide
attempt occurred
 Never challenge a patient to go ahead,
do it
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Assessment
Violent Patients
Find out if patient has threatened or
has history of violence, aggression,
combativeness
 Assess body language for clues to
potential violence
 Listen for clues to violence in patient’s
speech
 Monitor movements, physical activity
 Be firm, clear
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Physical Exam
Vital signs and general appearance
 Skin exam
 Mental status
 Evidence for medical problem, recent
trauma, or an overdose
 Threat to self or others
 Patient able to provide for needs
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Management Principles

Treat life-threatening medical problems
or traumatic injury first and foremost
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Hypoxic? Hypoperfused? Temperature
extreme? Hypoglycemic? Overdose?
Trauma? Infection?
Management Principles
Maintain scene safety; control any
violent situations
 Never leave the patient alone
 Transport patient against his/her will, if
indicated
 Restrain the patient only as last resort
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Restraining Patients

A patient may be restrained if you have
good reason to believe he/she is a
danger to:
You
 Himself/herself
 Others
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Restraining Patients
Have sufficient manpower
 Have a plan; know who will do what
 Use only as much force as needed;
don’t be punitive
 When the time comes, act quickly; take
the patient by surprise
 Use at least four rescuers, one for each
extremity

Restraining Patients
Use humane restraints (soft leather,
cloth) on limbs
 Secure patient to stretcher with straps
at chest, waist, thighs
 If patient spits, cover his/her face with
surgical mask
 Once restraints are applied, never
remove them!

Chemical Restraints
When physical restraints alone are not
enough
 Establish on-line medical control
 Haloperidol (Haldol), 5-10 mg IV or IM
 Lorazepam (Ativan), 1-2 mg IV or IM
 Diphenhydramine (Benadryl), 25-50 mg
IV or IM or hydroxyzine, 50-100 mg IM
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Chemical Restraints

Haldol and movement disorders do not
mix well
Worsens extrapyramidal effects
 Minimal anticholinergic and cardiovascular
effects


Ativan ideal for agitation due to
withdrawal

Beware of additive CNS depressant effect
Chemical Restraints

Antihistamines
Hydroxyzine useful in drug abusers, little
habituation
 Benadryl can worsen asthma symptoms
and lower seizure thresholds at higher
doses
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Behavioral Emergencies
Pearls
Look carefully for physical causes to
explain behavioral emergencies
 Pay special attention to your own and
others safety
 Ask about suicide or past violent
behavior
 Treat patients fairly and with as much
dignity as possible
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