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BEHAVIORAL EMERGENCIES. DAN MUSE, MD. BEHAVIORAL EMERGENCIES DEFINITION.
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BEHAVIORAL EMERGENCIES DAN MUSE, MD
BEHAVIORAL EMERGENCIESDEFINITION • Walter Payton`s father, Edward, died at 54 in 1979 under circumstances that are not clear. Arrested by a young, white policeman for driving while intoxicated, he was put in Columbia`s jail to ``dry out`` and was found dead a few hours later.
BEHAVIORAL EMERGENCIESDEFINITION • The coroner found no traces of alcohol or drugs and said he died of a cerebral hemorrhage. A court-ordered autopsy cleared local officials of wrongdoing.
BEHAVIORAL EMERGENCIESDEFINITION BEHAVIORAL EMERGENCY: a temporary change in behavior or exacerbation of a chronic underlying behavioral disorder that results in a threat to the patient or others.
BEHAVIORAL EMERGENCIES BEHAVIORAL EMERGENCIES are a specific subset of altered mental status.
AMS ALTERED MENTAL STATUS IS A SYMPTOM AND NOT THE DIAGNOSIS CAUSES • INFECTION: Meningitis, Sepsis • STRUCTURAL: Stroke, Trauma, Seizure • METABOLIC: Hypoglycemia, Hyponatremia • INGESTIONS: Narcotics, Alcohol, PCP…… • PSYCHIATRIC: Psychosis, Bipolar….... • CONGENITAL/GENETIC
AMSPNEUMONIC • A – Alcohol • E – Epilepsy • I -Insulin • O – Opioids /Drugs • U- Uremia • T– Trauma, Temperature • I– Infection • P– Poisonings • P– Psychiatric • S– Stroke, Shock
BEHAVIORAL EMERGENCIESALCOHOL • Results in behavioral changes by itself • In the inebriated state we oftentimes see personality changes….
BEHAVIORAL EMERGENCIESALCOHOL • The drunk asshole • We all know him and some of us have been him. • There is usually a sense of importance. • They are argumentative and believe they are always right • They can become destructive and violent.
BEHAVIORAL EMERGENCIESALCOHOL EXCEPT FOR THE VIOLENT BEHAVIOR, THEY ACT LIKE…….
BEHAVIORAL EMERGENCIESALCOHOL • The drunk asshole is a temporary but oftentimes a recurring condition.
BEHAVIORAL EMERGENCIESALCOHOL • Drops in alcohol may result in seizures and delirium in chronic alcoholics • Either a seizure and a post-ictal state or delirium can result in behavioral changes which may cause the patient to be a threat to himself.
BEHAVIORAL EMERGENCIESEPILEPSY (SEIZURE) • INTRINSIC SEIZURES • STRUCTURAL: Space occupying; tumor, bleed, edema. • HYPOXIA. • POISONINGS: INH • METABOLIC: Hypoglycemia, Hyponatremia • INFECTION: Meningitis; Febrile Seizures • PSYCHIATRIC: Pseudo-seizures
TYPES OF SEIZURESEPILEPSY FOUNDATION • Absence Seizures • Atypical Absence Seizures • Atonic Seizures • Clonic Seizures • Myoclonic Seizures • Tonic Seizures • Tonic-Clonic Seizures • Simple Partial Seizures • Complex Partial Seizures • Secondarily Generalized Seizures • Febrile Seizures • Nonepileptic Seizures • Refractory Seizures • New Terms and Concepts for Seizures and Epilepsy • Gelastic and Dacrystic Seizures
ABSENCE SEIZURE • Absence seizures are lapses of awareness, sometimes with staring. • They begin and end abruptly, lasting only a few seconds. • More common in children. • Absence seizures can be so brief that they sometimes are not detected for months.
ABSENCE SEIZURE • Simple absence seizures: During a simple absence seizure, a person usually just stares into space for less than 10 seconds. Because they happen so quickly, it’s very easy not to notice simple absence seizures — or to confuse them with daydreaming or not paying attention.
ABSENCE SEIZURE • Complex absence seizures: During a complex absence seizure, a person will make some kind of movement in addition to staring into space. Movements may include blinking, chewing, or hand gestures. A complex absence seizure can last up to 20 seconds.
SIMPLE PARTIAL SEIZURES • Simple partial seizures can be motor seizures that cause change in muscle activity. • These seizures can be sensory seizures that cause changes in any one of the senses. • These seizures can be autonomic seizures that cause changes in the part of the nervous system that automatically controls bodily functions. • These seizures can be psychic seizures that change how people think, feel, or experience things.
COMPLEX PARTIAL SEIZURE • Complex partial seizures last 1 to 2 minutes. • These seizures may have an aura (or warning). • Complex Partial Seizures include automatisms (such as lip smacking, picking at clothes, fumbling), unaware of surroundings or may wander.
AMSDIABETES • Hypoglycemia • Results in cognitive impairment. • Behavior can be dull, somnolent, and confused. • It can also result in confusion and agitation.
AMSDIABETES • Checking for a low blood sugar is always part of the AMS evaluation
DRUGS • Drug abusers oftentimes have underlying psychologic issues. • The combination can result in behavioral changes that can result in potential harm to themselves and/or others.
DRUGSNARCOTICS • Use of narcotics result in a sedative state. • Withdrawals or use of naloxone result in agitation • This in turn can cause aggressive behavior.
COCAINE • A stimulant • Causes elevated heart rate and blood pressure • Can become agitated • May develop psychosis • Can result in vascular events; head bleed, heart attack
COCAINE • CNS effect depends on amount used and to some extent the personality of the person • Manic behavior and euphoria may occur • Psychosis with delusions, paranoia and hallucinations are possible.
DISSOCIATIVE AGENTS • Drugs such as PCP (phencyclidine) and ketamine, were initially developed as general anesthetics for surgery • Distort perceptions of sight and sound and produce feelings of detachment (dissociation) from the environment and self.
DISSOCIATIVE AGENTS • These mind-altering effects are not hallucinations. • Pcp and ketamine are therefore more properly known as "dissociative anesthetics."
DEXTROMETHORPHAN • Dextromethorphan, a widely available cough suppressant, when taken in high doses can produce effects similar to those of pcp and ketamine.
PCPPHENCYCLIDINE • PCP is a synthetic hallucinogen. • Used for recreational purposes • Has the ability to cause the user to feel invulnerable and exceptionally strong • Is sometimes mixed in marijuana
PCPPHENCYCLIDINE • The drug also cause analgesia and extremity numbness. • Combined with the hallucinations and sense of superhuman strength, these patients are cause for major trauma to themselves and those trying to restrain them.
HALLUCINOGENS • Hallucinogens are natural and synthetic drugs that create a distortion of ones senses. • A person may see, hear feel things that are not real. • How they react to these hallucinations dictates what they may do to themselves and others
HALLUCINOGENS • Lysergic acid diethylamide (LSD) and psilocybin mushrooms are two examples of synthetic and natural hallucinogens. • Indian tribes use the mushrooms for religious practices.
PREVALENCE OF STUDENTS WHO HAVE USED HALLUCINOGENS AND PCP Source: Monitoring the Future Survey, 2000 Note: Data not available for PCP Prevalence for 8th and 10th graders
METHAMPHETAMINE • Synthetic drug that is easily made on the streets. • Highly addictive and leads to long term health and psychiatric issues.