Emergency Psychiatry

1. Emergency Psychiatry E. Prost

2. Outline 1. Emergency Room Assessment 2. Behavioural Emergencies: Assessment 3. Behavioural Emergencies: Interventions

3. Excluding Physical Illness:Factors for Increased Risk • Older Age • Substance Abuse • No prior psychiatric history • Known/New physical complaints • Lower socioeconomic level Gregory et al, General Hospital Psychiatry. 2004;26:405.

4. New Psychiatric Complaints • 63% has a medical reason for behaviour • 13% had fever • 37% had tachycardia • 60% were disoriented Henneman et al, Annals of Emergency Medicine. 1994; 24:672.

5. Identifying Physical Illness • Only 4% of patients admitted to psychiatry required acute medical treatment within 24 hrs of admission. • In 83%, history and physical should have indentified the problem. Tintinalli et al, Annals of Emergency Medicine. 1994; 23: 859.

6. Question • What testing is necessary in order to determine medical stability in alert, cooperative patients with normal vital signs, a noncontributory history and physical examination, and psychiatric symptoms?

7. Answer In adult ED patients with primary psychiatric complaints, diagnostic evaluation should be directed by the history and physical examination. Routine laboratory testing of all patients is of very low yield and need not be performed as part of the ED assessment. (level B) Lukens et al, Clinical Policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Annals of Emergency Medicine. 2006;47(1):79-99.

8. Urine Toxicology Screen • Almost half of ER physicians thought urine toxicology for “medical clearance” unnecessary. • Psychiatrists use the results to determine cause of symptoms, treatment, and disposition. Lukens et al.

9. Question • Do the results of urine toxicology screens for drugs of abuse affect management in alert, cooperative patients with normal vitals, a noncontributory history and physical examination, and a psychiatric complaint?

10. Answer • Routine urine tox screens do not affect management and need not be performed as part of the ED assessment. • Tox screens obtained in the ER for use by psychiatry should not delay patient evaluation or transfer. (level C) Lukens et al.

11. Alcohol Levels 1. The patient’s cognitive abilities, rather than a specific blood alcohol level, should be the basis on which we begin the psychiatric assessment.

12. Alcohol Level However, 2. Consider using a period of observation to determine if psychiatric symptoms resolve as the episode of intoxication resolves. Lukens et al.

13. Outline • Emergency Room Assessment • Behavioural Emergencies: Assessment 3. Behavioural Emergencies: Interventions

14. Behavioural Emergencies:The Goal • To facilitate the resumption of a more typical patient-physician relationship, with an emphasis on informed consent and long-term treatment outcome. Allen et al. The Expert Consensus Guideline Series: Treatment of Behavioral Emergencies. A Postgraduate Medicine Special Report, May 2001.

15. Behavioural Emergencies:Assessment • Vitals • Medical History • Visual Examination • Urine Toxicology • MMSE • Pregnancy Test

16. Restraint vs Treatment Treatment: an intervention that follows from an assessment of the patient and a plan of care intended to improve the patient’s underlying condition.

17. Choosing an Action 1 • Verbal interventions • Offering food and beverage • Other Assistance • Voluntary medication

18. Choosing an Action 2 • Show of force

19. Choosing an Action 3 • Emergency medication • Seclusion • Physical Restraints • >80% of patients managed without the above.

20. Outline • Emergency Room Assessment • Behavioural Emergencies: Assessment • Behavioural Emergencies: Interventions

21. Choosing an Action:What’s the Cause? • General Medical Condition • Substance Intoxication • Primary Psychiatric Disorder

22. General Medical Condition • Vitals • Collateral history • Interview patient if possible • Emergency Medicine consultation • Basic bloodwork, toxicology screen

23. General Medical Condition:Behavioural Emergency • Physical Restraints • Conventional Antipsychotic, benzo, or combination. • If oral medication, use Risperidone.

24. Substance Intoxication:Medication • Benzodiazepine alone - with stimulants, risk of seizures, EPS - with hallucinogens, risk of anticholinergic effects - with alcohol • Benzodiazepine with conventional antipsychotic - D2 blockers with amphetamine abuse

25. Primary Psychiatric Diagnosis • What is the provisional diagnosis? • Oral or Parenteral? • Schizophrenia • Mania • Psychotic Depression • Personality Disorder • PTSD

26. Primary Psychiatric Diagnosis:Schizophrenia or Mania • Benzodiazepine plus conventional or atypical antipsychotic • Monotherapy with conventional or atypical antipsychotic • Benzodiazepine alone an option for mania

27. Choosing Medication • Availability of IM or liquid route • Speed of onset • History of response • Useful sedation • Side-effects • Patient preference

28. Choosing a Medication:Does “5 & 2” work? • Combinations: • More effective early in treatment • Faster onset • Reduced side-effects • Can use lower doses of components

29. Speed of Onset • IV has effect in 1 – 5 minutes • IM Haloperidol has effect in 30 – 60 minutes • Effect still increasing at 1 hour • Good for transfer and admission Clinton et al. Annals of Emergency Medicine 1987; 16(3): 319.

30. Haloperidol and Lorazepam • Some studies show equal effects in reducing agitation with lorazepam as with haloperidol. • Some show the combination is superior than either alone. Foster et al. Int Clin Psychopharmacol. 1997; 12(3): 175.

31. Droperidol? • Fewer repeat doses needed • Shorter ER stays • Much used in some states over years • But, only IM or IV Richards et al, J Emerg Med. 1998; 16: 567.; Chase and Biros, Acad Emerg Med. 2002; 9: 140.

32. Atypicals: Olanzapine • IM Olanzapine may decrease agitated behaviour more quickly than IM Haldol at 15 and 45 mins. • More acute dystonia with Haldol • More hypotension with Olanzapine Wright et al. Gen Psychiatry 2001; 158: 1149.

33. Atypicals: Olanzapine • Greater reduction in agitation in mania with Olanzapine vs Lorazepam at 2 hrs.

34. Atypicals: Risperidone • Oral Risperidone 2mg with Lorazepam 2mg comparable to IM Haldol 5mg and Lorazepam 2mg • Similar benefits over similar time period Currier et al. J Clin Psychiatry 2004; 65(3): 386; Currier et al. J Clin Psychiatry 2001; 62(3): 153.

35. Summary • What evaluation is necessary? • Use all resources in behavioural emergencies. • Use the least intrusive medications to maintain safety and restore the doctor-patient relationship.