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 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 Meds Alcohol Illicit Drugs Other Informants / Family Recent History

Evaluation BA Drug Screen BP – P Pulse Ox X-Ray / CT

CS2 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 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 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 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 Safety Plan De-escalation Procedures Code Drill Practice, Practice, Practice

Aggression Risk Factors Intoxication Hopelessness Irritability Disorganized Thought Disheveled Appearance Psychomotor Agitation Verbal Agitation Behavioral Agitation

Suicide Assessment Risk Factors Protective Factors

Interventions 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 TRUMP METHOD AceMedical Disorder JokerSubstance Induced KingMood Disorder w/ Psychosis QueenSchizophrenia JackPersonality Disorder

ACE Delirium –Attention –Concentration –MMSE

Mend A Mind Metabolic Electrical Nutrition Drugs / Toxins Arterial Mechanical Infectious Neoplastic Degenerative

Joker Increased Risk of Suicide Alcohol Withdrawal / Intoxication Cannabis Stimulants Cocaine Opioids

Blood Alcohol Concentration mg/dL Decreased Fine Motor Decreased Gross Motor Difficulty Standing Difficulty Sitting 300 Unresponsive to voice or pain 400 Respiratory Depression

Opioid Withdrawal Irritability / Agitation Nausea / Vomiting / Diarrhea Muscle Ache Excessive Tears / Runny Nose / Yawn Pupil Dilatation / Goose Flesh Sweating / Fever / Insomnia