ADOLESCENT EMERGENCIES

1. ADOLESCENT EMERGENCIES ANITA ROBINSON, M.D.

2. ADOLESCENTEMERGENCIES • Suicide • Drug Intoxication • Pregnancy • rape

3. Suicide Background • Third leading cause of death for teens and young adults • Persons more likely to commit suicide -Older adolescents • -Males (4x more than females) • Persons more likely to attempt suicide -females

4. Etiology and Pathogenesis • Normal stresses of adolescence -Biological -Psychological • -Social/environmental • Society’s view of adolescence • Role of socioeconomic factors

5. Etiology of Suicide Attempt Predisposing Vulnerable Suicide factors = Adolescent = Attempt ^ Acute Stressors

6. Predisposing Factors • Abuse – Physical/Sexual • Chronic Diseases • Chronic substance abuse, teen/parent • Family disorganization • Poor school performance • Family hx of suicide • Age/ firearm in the house

7. Predisposing Factors (cont.) • Recent behavioral changes • Feeling of….HALERS • Psychiatric illness ADHD Affective Disorder Conduct/ Anxiety Disorder Depression

8. Acute Stressors • Early/Late psychological maturation • Sexuality Anxiety about beginning sex homosexuality • pregnancy • Death of someone close • Recent loss (person/relationship)

9. Acute Stressors (cont.) • Changes in school performance • Victimization, assault,rape • Substance use experimentation • Major changes in social environment • Onset of psychiatric disorder • Media

10. Vulnerable Adolescent • Late adolescent • Depression • Low self esteem coupled with multiple failures • Not fitting in, no friends

11. Signs of suicide • Changes eating/sleeping habits • Withdrawal • Chronic drug use • Frequent somatic complaints • Giving away favorite possessions • Feelings of hopelessness,guilt,poor concentration,boredom,school grade drop

12. Case Jessie is a 17 y.o. female who you are seeing in the ER at 4PM on a Saturday afternoon. She presents with a known Tylenol overdose earlier that day. She ‘s somewhat drowsy, but is coming to and able to answer basic questions. She is medically stable. Her mother comes with the Tylenol bottle and states that it was recently brought and that

13. Case (cont.) 10 pills were missing (325mg each). After 4 hours, Tylenol levels are in a safe zone, and you have to determine her disposition. What specific points from the hx are important to ask Jessie? What criteria should you use to hospitalize?

14. Risk Assessment Factors • Low • Moderate • High

15. Factor PRECIPATATING EVENT • LOW, argument with friend, teacher • MODERATE, fight with close friend,school failure,difficult home situation • HIGH, break-up important relationship,thrown out of home,pregnancy discovery,death close relationship,thinking disorder,hallucinations

16. FACTOR INTENDED PURPOSE • LOW, unknown, impulsive • MODERATE, attention seeking, to punish,escape,cannot face shame or failure • HIGH,to be dead, no purpose in living, to join deceased one

17. FACTOR PLAN - PERCEIVED LETHALITY • LOW, small amount of pills, perceived low toxicity • MODERATE,small amount of pills,perceived as toxic, slash wrist • HIGH, violent method, large amount of pills, perceived toxic

18. FACTOR PLAN – REAL LEATHALITY • LOW, relative innocuous • MODERATE.moderately harmful but perceived recovery • HIGH, significant potential for death

19. FACTOR PLAN – SPECIFICITY • LOW,no solid plan • MODERATE, specific plan, not rehearsed,several plans, method readily available • HIGH, one method chosen and steps in place, may have rehearsed plan

20. FACTOR PLAN - DISCOVERY POTENTIAL • LOW,announces intent, someone at home • MODERATE, someone expected at home, calls someone, location highly visible • HIGH, isolated location or situation,tells no one

21. FACTOR LIFE STRESSORS – CURRENT • LOW, none • MODERATE, environmental changes, physical changes, failure to achieve • HIGH, death of close individual, thrown out of home, rejection by boyfriend

22. FACTOR MOOD - AFFECT – BEHAVIOR • LOW, optimistic, able to verbalize • MODERATE, depressed,but mood lightens,few friends • HIGH, flat, distant affect, no friends, no change in mood after talking

23. FACTOR PAST COPING AND MENTAL HEALTH • LQW, good coping and support, no mental health issues • MODERATE, distorts reality, impulsive, uses peers for support, some depression,mood swings • HIGH. loose reality,victim of fate,depressed

24. FACTOR FAMILY STRUCTURE – FUTURE PLANS • LOW, supportive, good coping.,definite future goals • MODERATE, overburden family but tries to be supportive,wants to be somebody but no plans • HIGH, overburden family,no coping,no plans, alienated

25. SUMMARY • PRECIPITATING EVENT • INTENDED PURPOSE • PLAN METHOD-PRECEIVED LETHALITY REAL LETHALITY SPECIFICITY DISCOVERY POTENTIAL

26. SUMMARY (cont.) • LFE STRESSORS – CURRENT • MOOD – AFFECT – BEHAVIOR • PAST COPING AND MENTAL HEALTH • FAMILY STRUCTURE/FUTURE PLANS

27. DRUG EFFECTS • THERAPEUTIC • INTOXICATION • OVERDOSE • WITHDRAWAL

28. DRUGS OF ABUSE • Illicit and nonillicit • Combination of both • Alcohol, #1 followed by smoking cigarettes and marijuana • Rise in stimulant use • Inhalant use popular with early adolescents • Cocaine, opiate, and othe drug use stable

29. CLASSES OF DRUGS • Opioids – Depressants type 1 • Stimulants • Sedatives,hypnotics –Depressants type2 • Inhalants – Depressants type 3 • Hallucinogens • Marijuana • Phencyclidine - PCP

30. CASE Ann is a 17 y.o. who present in your clinic with a 2 day hx of cough, rhinorhea, sore throat, and generalized muscle aches. She also has had abdominal pain with vomiting and diarrhea. Her temp is normal and pulse slightly elevated. She appears agitated. Her P.E. is normal except for dilated pupils.

31. OPIOID CLASS • Morphine • Heroin • Codeine • Oxycodone and hydromorphone • Merperedine and methodone • Talwin, darvon, ultram • Nsaids

32. OPIOID SYMPTOMS • V.S. – depressed • Mental Status – euphoria, stupor • Physical – miosis, decreased reflexes, analgesia,amnesia, constipation, pulmonary edema, respiratory depression and coma

33. OPIOID WITHDRAWAL • V>S> - rapid pulse • Mental status – anxious, paranoid • Physical – mydriasis, flu like symptoms, abdominal pain, increased reflexes

34. STIMULANT/ANTICHOLINERGIC SYMPTOMS • V>S> - increased • Mental status – euphoria, anxious • Physical – mydriasis,reflexes increased, arrythmia,increased muscle tone, seizures, pulmonary edema, coma

35. STIMULANT CLASS • Cocaine • Amphetamines (designer drugs) • Ritalin • Caffeine, nicotine

36. STIMULANT WITHDRAWAL • V.S. – depressed • Mental status – severe depression and paranoid state, suicide high • Physical – decreased reflexes, marked fatigue,difficult to awake,constipation

37. SEDATIVE/HYPNOTIC • Alcohol • Benzodiazepine • Barbiturates • SSRI • Tricyclic antidepressants • Anticonvulsants

38. SEDATIVE/HYPNOTIC SYMPTOMS • V.S. – decreased • Mental status – euphoria, stupor • Physical – marked respiratory depression, slurred speech, staggering gait, decreased reflexes,nystagmus, seizures, arrythmis. coma

39. FLUMAZENIL • Benzodiazepine antidote • Use with caution • May cause vomiting • May not totally reverse respiratory depress. • Seizures in physical dependence and mixed overdoses • Arrythmia with tricyclics and mixed overdoses

40. INHALANTS • Aromatic and aliphatic types • Benzene, moth balls kerosene, gasoline • Airplane glue, correction fluid • Amyl nitrate, butyl nitrate, nitrous oxide • Feon

41. INHALANT SYMPTOMS • V.S. – decreased • Mental status – euphoria, stupor • Physical – respiratory depression, hypoxia,,arrythmia, renal and muscle damage, coma

42. HALLUCINOGENS • Lsd • Mescaline • Pilocybin,, peyote cactus • Mushrooms • Nutmeg • Ergots

43. HALLUCINOGEN SYMPTOMS • V.S. – increased • Mental status – euphoria with hallucinations • Physical – impaired senses,synesthesia, sweating, dilated pupils,palpitations,tremors and poor coordination

44. PHENYCYCLIDINE • PCP • V.S. – may be normal, increased B.P. ,temp, • Mental status – confusion, anxiety, amnesia • Physical – vertical nystgmus,and may see horizontal or rotary, muscle rigidity. Catatonia,ataxia,sweating, extreme muscle strength, seizures

45. PREGNANCY - DIAGNOSIS • LABORATORY Urine HCG- + 7-10 days after conception severe renal damage interferes Serum HCG- + 6-12 days after ovulation peaks 10-12 weeks

46. PREGNANCY-PHYSICAL EXAM • Always perform pelvic exam,including GC/CHL • Bimanual exam Less than 12 weeks enlarged globularr uterus below the symphysis pubis 16 weeks midway umbilicus/pubic bone 20 weeks umbilicus

47. PREGNANCY - PSYCHOSOCIAL • Concrete vs. abstract thinking • Sexual history • Parental knowledge • Ability to communicate with parents • Partner awareness and what pt. Wants to do • Pregnancy outcome options • Support status and safety to go home

48. RAPE • Under age 18 and less than 72 hours – rape kit,, family advocacy, commanding officer,Dr. Craig’s group • Over age 18 and less than 72 hours,above but refer to SAVI, Cindy Stewart, 202 685-1171,for navy family advocacy other branches

49. RAPE • Under age 18 and greater than 72 hours,do standard STD work up,HEADDS, family advocacy – central contact Jackie Richardson, 202 685-1182 or county rape crisis center • Over age 18 and greater than 72 hours, work up as above but refer to SAVI, contact Cindy Stewart 202 685-1171

50. STATUTORY RAPE • DC law, sexual acts or sexual contact between a child under 16 and any person four or more years older. • Maryland, Sexual contact with another person who is under 14 and the person performing the sexual contact is four or more years older than the victim or.