Transcript Psychiatric Emergencies

Psychiatric Emergencies
Angela S. Olomon, DO
Goals
• Strengthen education on psychiatric
emergencies presenting in the medical
office
• Identify characteristics of agitated patients
• Identify suicide risk and protective factors
Objectives
• Apply safe assessment to prevent further
increase in agitation of patient
• Establish plan for intervention and harm
prevention and referral for additional
treatment
• Determine patient’s potential for danger or
harm to self or others
Summary
• Psychiatric emergencies can arise in any
treatment office. Therefore, every
physician is responsible for evaluation.
Pre-crisis preparation is key to safety as
well as empathetic responses.
Psychiatry in Family Practice
• 40% to 60% of general medical patients
have comorbid psychiatric conditions
• Primary Care writes more psychiatric
medications than psychiatrists
• Most psychiatric patients present to
primary care physicians first (you are the
first responder)
CS1
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Bang!
Door vibrates and windows rattle
Staff call the police
In walks a 45 year old white male
Sluggish, unkempt, slow and unsteady gait
Speech is slurred and he is a poor historian
He has no appt. and a Hx of noncompliance
Questions?
• What do you want to know?
Key Assessment Data
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Meds
Alcohol
Illicit Drugs
Other Informants / Family
Recent History
Evaluation
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BA
Drug Screen
BP – P
Pulse Ox
X-Ray / CT
CS2
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47 year old white female calls
Frantically demands to speak to you
Claims Critical Emergency (like always)
States “I can’t go on!”
“I’m going to kill myself, then I won’t have
to deal with it!”
Questions?
Key Assessment Data
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Safety: Where is she? Who is with her?
Does she have a plan? Means?
Precipitant: Why Now?
What is the last chapter of this saga?
Medications / Compliance?
Alcohol?
Illicit Drugs?
Evaluation
• Hospital ER vs. Friend vs. 911
• Resources (Therapists, Family)
CS 3
• 40 year old white female in the waiting
room, pacing
• Demands urgent appointment
• Unkempt
• Speech rapid and pressured and loud
• Flow of thought circumstantial
• “Infectious” anxiety – talking to everyone
and drawing them into her distress
Questions?
Key Assessment Data
• History of past Dx or hospitalizations
• (Bipolar II and Chronic Pain – Spinal
Stenosis)
• Medications / Treatments
• (Opioid Analgesic Discontinued)
Evaluation
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Blood levels of medications
Verify Compliance
Initiate De-escalation Procedures
Titrate Medication
Marshal Resources (Family, Therapists)
CS 4
• 12 year old white male brought by foster mother
• Restless in waiting room, demanding to know
how long a wait
• Mother is anxious
• Patient is Irritable and Sarcastic
• Receptionist and Nurse are anxious
• Roomed patient and mother yelling and agitated
(you wonder if you paid your office insurance
premium)
Questions?
Key Assessment Data
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Initiate safety procedures
Initiate De-escalation Procedures
Call in support (possibly police)
Hx from Mother:
– Precipitant / Stressors?
– Possible Substance Abuse / Toxicity
– Past Episodes?
Interventions
• IM vs. PO Medication
Pre Crisis Planning
• Physical Environment (everybody can get
to the door)
– Waiting Room (no impromptu weapons)
– Reception Desk
– Exam Rooms
Staff Training
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Safety Plan
De-escalation Procedures
Code Drill
Practice, Practice, Practice
Aggression Risk Factors
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Intoxication
Hopelessness
Irritability
Disorganized Thought
Disheveled Appearance
Psychomotor Agitation
Verbal Agitation
Behavioral Agitation
Suicide Assessment
• Risk Factors
• Protective Factors
Interventions
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Call for Help!
Verbal De-Escalation
Quiet Room – Decreased Stimuli
Pharmacological
– Patient’s Meds
– Antipsychotic Meds
– Benzodiazepines
Emergency Medications
• PO
– Risperdone 2mg
– Ativan 2mg
– Zyprexa Zydus 5-10mg
• IM
– Haldol 5mg
– Ativan 2mg
Diagnosis
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TRUMP METHOD
Ace
Medical Disorder
Joker Substance Induced
King
Mood Disorder w/ Psychosis
Queen Schizophrenia
Jack
Personality Disorder
ACE
• Delirium
– Attention
– Concentration
– MMSE
Mend A Mind
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Metabolic
Electrical
Nutrition
Drugs / Toxins
Arterial
Mechanical
Infectious
Neoplastic
Degenerative
Joker
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Increased Risk of Suicide
Alcohol Withdrawal / Intoxication
Cannabis
Stimulants
Cocaine
Opioids
Blood Alcohol Concentration
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20-50mg/dL Decreased Fine Motor
50-100 Decreased Gross Motor
100-150 Difficulty Standing
150-250 Difficulty Sitting
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Unresponsive to voice or pain
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Respiratory Depression
Opioid Withdrawal
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Irritability / Agitation
Nausea / Vomiting / Diarrhea
Muscle Ache
Excessive Tears / Runny Nose / Yawn
Pupil Dilatation / Goose Flesh
Sweating / Fever / Insomnia