1. INTRODUCTION TO EMERGENCY PSYCHIATRY
Kheradmand Ali MD
Assistant Professor of Psychiatry
Shahid Beheshti Medical University

2. Definition
A psychiatric emergency is a disturbance in thoughts, feelings, or actions that requires immediate treatment.
(Kaplan and Sadock, 1996)

3. Properties
Can happen at any time either outside or during a treatment episode.
Can happen anywhere
Not confined to the Emergency Room
May happen on other services or involve other disciplines.

4. The Patient in the Emergency Setting

5. Central Principles Assessment of Acuity Assessment of Risk
Risk to self
Risk to others
Disposition to address risk factors
Documentation.

6. Acuity Acuity is often “in the eye of the beholder”
Acute conditions or symptoms may exist within the context of chronic illnesses.
Often acuity needs to be assessed within the context of available support mechanisms.
May also be resolved with appropriate support mechanisms.

7. Risk Should be viewed as existing along a continuum.
There is no black or white
Risk varies with time.
Prediction of likely behavior may be made utilizing risk assessment

8. Disposition Application of problem solving strategies.
Should address identified areas of acuity and risk.
Should encompass the “least restrictive care”doctrine.
Care should be provided in the least restrictive setting possible while still providing protection for the patient.

9. Documentation Purpose
To summarize the assessment and care of the emergency patient
To provide a roadmap which can be continued by follow up care providers.
Should follow a logical progression of thought (problem solving strategy) and logical conclusions based on assessment.
Should not include conclusions that can not be substantiated. (ie. Diagnoses, etc.)

10. The Care provider in the Emergency Setting

11. Risks Violence in the emergency setting Secondary gain issues
Generally more risk than in non-emergent settings.
Secondary gain issues
Legal exposure

12. Protection in the emergency setting
Knowledge of historical risk factors etc. prior to seeing the patient.
Careful review of the record is time well spent.
Be alert to risks of impending violence.
Careful attention to therapeutic alliance issues.
Attention to safety of physical surroundings.
Include others if needed ( ex. Police, etc.)
Confidentiality ends where there is risk of injury

13. Protection in the emergency Setting
Be aware of secondary gain issues
May help in prediction of behavior including violence.
Document, document, document
Does not refer to volume of documentation but rather quality of documentation.

14. Summary Psychiatric emergencies can occur anywhere at any time.
Important issues include protection of the patient as well as of the practitioner and staff.
Central principles guiding assessment and treatment in the emergency setting include assessment of risk and acuity, plan and disposition, and appropriate documentation.
Central principles guiding protection of practitioners in the emergency setting include appropriate knowledge, remaining alert, including others, and documentation.

15. 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.

16. 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 studies.
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 available.

17. A Run-Through of Common Presentations
Depression
With or without suicidality
Adjustment reactions
Mania
Psychosis
Intoxication
Withdrawal

18. 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.

19. A Primer on Particular Problems
Suicide
Etymology. Latin origins: (sui) self- (cide) death. Ergo, self-injurious behavior sans death-wish is not a suicide attempt.
Eighth leading cause of death in men. (Higher than homicide.)
Third leading cause of death in adolescents (15 to 24 yo).
55% of successful suicides employ a firearm.
Men succeed more often than women, but women attempt more frequently than men.
Very Difficult to Predict

20. Developing A Sense for Suicidality
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).

21. 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 potential.
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.

22. General Management of Suicidality
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 risk?
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.

23. 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)
Delirium
Dementia
Primary psychotic disorder
Intoxication or withdrawal

24. Developing A Hunch for Homicidality
Risk Factors:
History of violence; aggression
Impulsivity; intoxication
Sincere plan
Common etiologies include:
Psychosis (command AHs); affective disorders; personality vulnerabilities; substance intoxication or withdrawal

25. 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

26. 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 question.
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.

27. 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.
NEVER PLAY HERO(INE) AND TAKE THINGS INTO YOUR OWN HANDS!

28. Involuntary Admission
Pt at immediate risk for hurting self or others due to mental illness or mental retardation.
Pt is mentally ill (or mentally retarded) and unable to care for self as to acutely endanger his or her life.

29. 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

30. A Run-Down of Meds Benzos (potentiate GABA) Antipsychotics
Lorazepam (fast-acting): 1-2 mg PO/IM
Chlordiazepoxide (long-acting; preferred in EtOH withdrawal): 5-10 mg PO/IM
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.

31. 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 psychosis.
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.

32. 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.

33. Other Sundry Psychiatric Emergencies
NMS (Neuroleptic Malignant Syndrome)
A medical, as well as a psychiatric emergency
Associated with anti-psychotics and with any dopamine blocking medication
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

34. 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

35. PSYCHIATRIC EMERGENCY
Conditions need immediate interventions &any
Delay increase risk for patients and others
One of the most Pitfall in Psychiatric Emergency is NEGLECT &IGNORE of ORGANIC CAUSALITY in Emotional Disorders

36. PSYCHIATRIC EMERGENCY
SUICIDE & HOMICIDE
AGGRESSION & VIOLENCE
CATATONIA
NMS (Neuroleptic Malignant Syndrome)

37. PSYCHIATRIC EMERGENCY
Prevalence:
%20 of referrals; Suicidal
%10 of referrals; Aggressive or Violency Behavior
%40 of ALL Referrals need Hospitalization
Male= Female
Single> Married
Often Night Time

38. PSYCHIATRIC EMERGENCY
Clinical Evaluation:
FIRST : Emergency Interventions
THEN: Diagnosis & Treatment of Major Disease

39. SUICIDE Suicidal Thought Suicidal Threat Suicidal Attempt: F >M
Committed Suicide: M>F

40. SUICIDE Psychiatric Disorder: MDD, Dysthymia, BMD
Schizophrenia,Schizophreniform,Brief Psychotic Disorder
PTSD,OCD,GAD
Personality Disorders

41. SUICIDE Medical Problems:
CNS Disease (Epilepsy, MS, AIDS, Dementia, Hantington)
Endocrine (Cushing Disease, Anorexia Nervosa, Kleinfelter)
GI (Peptic Ulcer, Cirrhosis)
Immobility , Disfigurement , Persistent Chronic Pain

42. SUICIDE ETIOLOGY Biologic
Serotonergic Hypofunction, Platlet MAO decrease
,Genetic
Psychologic
Hoplessness, Depression, Impulsivity, Aggressivity
Social
Family Discord ,Divorce, Single, Lack of Support

43. SUICIDE HIGH RISK SUICIDE: Male >45 Yrs old Single & Divorce
Unemployment
Unstable Family & Interpersonal Relationship
Severe Depression, Psychosis, Personality Disorder, Substance Use (Alcohol)

44. SUICIDE HIGH RISK SUICIDE Hopelessness
Prolonged & Severe Suicidal Thought
HX of Several Attempts, with Plan, Low Rescue, Use of Fatal Methods

45. AGGRESSION & VIOLENCE AGGRESSION
Goal directed Behavior (verbal or nonverbal) for Hurt
VIOLENCE
Severe & Sudden Goal directed Behavior to Destruction of property OR Hurt OR Kill others

46. AGGRESSION & VIOLENCE BMD
Schizophrenia, Schizophreniform, Brief Psychotic Disorder
MDD
Personality Disorders

47. AGGRESSION & VIOLENCE RISK EVALUATION:
Demographic Characteristics:Male ,15-24 Yrs, Low SES &Social Support
Evaluation of Thought, Attempt, Plan for Violence, Weapons Availability
Past HX of: Violence, Antisocial Behaviors ,Impulse Control Disorder (Substance,….)
HX of Major Stressor: Loss, Family Discord…

48. AGGRESSION & VIOLENCE Impending Violence:
Verbal or Physical Threatening
Progressive Restlessness
Weapons Carrier
Substance or Alcohol Abuser
Excited Catatonia
Paranoid (Psychosis)
Personality Disorder

49. NOROLEPTIC MALIGNANT SYNDROM(NMS)
Fatal Complication due to Antipsychotics
Abrupt Discontinuation Levodopa in Parkinsonism
Anytime in Treatment Course
Prevalence:%/
Mortality Rate:%10-20
Male>Female
Young>Geriatrics

50. NOROLEPTIC MALIGNANT SYNDROM(NMS)
Major Symptoms:
Muscle Rigidity
Increase in Body Temperature
AND 2 Symptoms of:
Diaphoresis/ Tremor/ Dysphagia/ Mutism/ Urinary Incontinency/Tachycardia/Alteration in Consciousness level/Leucocytosis/HTN/ Muscle Injury (CPK)

51. NEUOROLEPTIC MALIGNANT SYNDROM(NMS)
Treatment (Conservative)
FIRST: Discontinuation of AP
Decrease Body Temperature
Monitoring of Vital Signs, Hydratation, Electrolyte, I/O
Muscle Relaxant (Bromocriptine,Amantadine, Dantrolene)
FOR 5-10 DAYS

52. NEUOROLEPTIC MALIGNANT SYNDROM(NMS)
Prevention
Use of AP in Appropriate Indications
Use of AP in Minimum Effective Dose
Use of AP with Cholinergic Properties