Medical stability & Substance related emergencies

1. Medical stability & Substance related emergencies M. NadeemMazhar MBBS, MRCPsych, FRCPC, DABPN

2. Objectives • Review issues regarding “medical clearence” in ED • Assess common medical causes of agitation • Evaluate assessment substance related emergencies

3. “Medical clearance”

4. Medical clearance “There is no way to rule out every possible medical illness a patient may have prior to admission to a psychiatric unit” (Zun 2005)

5. Medical stability Making a reasonable investigation to exclude the possibility of patient having an illness that: • Would be better treated in a medical setting (e.g., infection requiring IV antibiotics) • Will cause the acute decompensation in the next few hours requiring a higher level of care (e.g., severe alcohol withdrawal) • Causing behavioral symptoms but should be treated by something other than psychiatric medications (e.g., delirium due to an underlying infection) • Worsening the psychiatric process (e.g., untreated pain that is causing the agitation) (Clinical Manual of Emergency Psychiatry)

6. Physical examination • Evaluation of patient’s general medical status necessitates that a physical examination be performed • Physical examination may be performed by the psychiatrist, another physician, or a medically trained clinician • Particular caution in examination of patients with histories of sexual abuse- “All but limited examination of such patients should be chaperoned” (APA Practice Guidelines for Psychiatric Evaluation of Adults- second edition, 2006)

7. Physical examination Specific elements may include the following: • General appearance, height, weight, BMI & nutritional status • Vital signs • Head and neck, heart, lungs, abdomen, and extremities • Neurological status, including cranial nerves, motor and sensory function, gait, coordination, muscle tone, reflexes, and involuntary movements • Skin e.g., stigmata of self injury or drug use • Any body area or organ system specifically mentioned in the HPI or ROS (APA Practice Guidelines for Psychiatric Evaluation of Adults- second edition, 2006)

8. General appearance • Cachexia- suspicion of cancer, HIV, TB, malnutrition • Obvious respiratory distress • Obvious physical distress or agitation • Grossly dishevelled or malodorous patient • Rashes- allergic or infectious diseases

9. HEENT • Dry mucous membranes- dehydration • Pupils and eye movements- focal neurological deficits, evidence of drug intoxication/withdrawal • Scleral icterus- jaundice • Proptosis- hyperthyroidism • Bruises, lacerations- evidence of head/facial trauma • Poor dentition- nutritional status

10. Neck • Thyromegaly- goiter, hyperthyroidism • Neck rigidity- meningitis, encaphalitis

11. Chest • Rales- congestive heart failure • Rhonchi- pneumonia

12. Cardiovascular • Rate, rhythm, regularity of heartbeat • Vascular disease- any absent peripheral pulses

13. Abdomen • Hepatomegaly- undiagnosed liver disease • Acute tenderness- acute pathology that needs to be addressed in ED

14. Extremities • Any deficits, limps or pain

15. Neurological • Any focal deficits indicating stroke • Festinating gait, rigidity- parkinsonism • Tremors- EPSE, Parkinson’s disease • Broad based gait- hydrocephalus, tertiary syphilis • Evidence of tardive dyskinesia

16. Diagnostic tests in Psychiatry • Detect or rule out presence of condition that has treatment consequences • Determine the relative safety and appropriate dose of potential alternative treatments • Provide baseline measurements before instituting treatment • Monitor blood levels of medication when indicated (APA Practice Guidelines for Psychiatric Evaluation of Adults- second edition, 2006)

17. Laboratory tests CBC: • Macrocytic anemia- vitamin B12/folate deficiency, alcohol abuse • Microcytic anemia- iron deficiency • Normocytic anemia- acute bleeding or chronic inflammatory disease • Leukocytosis- acute infection • Leukopenia- advanced HIV disease, leukemia, carbamazepine • Low platelets- Valproate, ITP

18. Laboratory tests Electrolytes & Creatinine: • Elevated creatinine- renal failure • Hyponatremia- SSRI’s • Hypernatremia- dehydration, renal failure • Hypokalemia- risk for arrhythmia, bulimia, diuretic use • Hyperkalemia- risk for arrhythmia, renal failure • Low bicarbonate- acidosis, aspirin ingestion

19. Laboratory tests Liver enzymes: • Elevated AST: ALT ratio- alcohol abuse • Elevated ALT & AST: liver failure due to multiple causes e.g., acetaminophen ingestion, hepatitis

20. Laboratory tests TSH: • Elevated- hypothyroidism leading to depression, cognitive changes • Low- hyperthyroidism leading to manic like symptoms, agitation

21. Laboratory tests Vitamin B12 & Folate: • Low B12- neurological changes, memory problems • Low folate- evidence of general malnutrition, association with depression

22. Laboratory tests • Syphilis serology/HIV testing • Medication levels • Blood alcohol levels • Fasting blood glucose or hemoglobin A1c • Pregnancy test • Urinalysis • Urine drug screen

23. Other investigations Chest X-ray: Considered for all homeless people, any patients with suspicion of TB, and elderly patients Head CT: In patients with altered mental status or new-onset psychosis- to rule out SOL or bleeding EEG: Evidence of metabolic encephalopathy (delirium), nonconvulsive status epilepticus ECG: Medications that may influence cardiac function Lumbar puncture: Any patient with new mental status changes, fever, and/or meningeal signs- to rule out meningitis, encephalitis, bleeding, cryptococcal infection

24. Agitation- medical causes Delirium: • Waxing and waning level of consciousness • Fluctuation in vital signs • Confusion • Can be irritable or passive and detached • More common in elderly

25. Agitation- medical causes Hypogylcemia: • Altered mental status • Sweating • Tachycardia • Weakness

26. Agitation- medical causes Post-ictal states: • Altered level of consciousness • Confusion • Ataxia • Todd paralysis • Neurological signs such as slurred speech • Evidence of tongue biting or incontinence

27. Agitation- medical causes Structural brain abnormality: • Varies by lesion • Altered mental status • Headache • Meningeal signs • Focal neurological deficit or progressive neurological deterioration

28. Agitation- medical causes Toxicologic emergency: • Varies by substance • Mental status changes • Pupillary changes • Vital sign changes • Sweating

29. Substance Related psychiatric emergencies

30. Initial evaluation • Thorough history using available resources • MSE • Physical examination • Laboratory tests • Imaging studies • Urine drug detection- ELISA, gas chromatography- mass spectrometry

31. The depressed patient MSE suggestive of depression or psychomotor slowing: • Alcohol intoxication • Sedative-hypnotic toxicity • Opioid toxicity • OTC cough & cold medication • Inhalant intoxication • CNS stimulants withdrawal

32. Alcohol intoxication • Most common cause of substance related emergencies • Studies showing up to 40% of ED patients having alcohol detected in their blood • CNS depressant effect by increasing responsivity of GABA type A receptors to GABA and inhibiting effects of glutamate at its receptors • Disinhibition at onset resulting agitation, combativeness and rarely psychosis • Dose-dependent CNS depression: Diminished coordination→ slurred speech/ataxia→ respiratory depression/coma • Legal limit: 0.05%- 0.08% (50mg/dl – 80mg/dl or 10.85 mmol/L – 17.36 mmol/L)

33. Alcohol intoxication • Treatment of alcohol intoxication- supportive • Gastric lavage not useful due to rapid absorption of alcohol from gastrointestinal tract • Serial monitoring of toxic blood alcohol levels for expected gradual drop • Chronic alcoholics metabolize ETOH at a rate of 15-20 mg/dl per hour • In case of persistent alteration in consciousness→ exclude other causes e.g., other toxins, metabolic dysfunction or subdural hematoma

34. Sedative-hypnotic toxicity • Can occur in acute overdoses, patients exceeding scheduled doses or with concomitant administration of other CNS depressants • Accumulation can also result in liver disease, advanced age and pharmacokinetic drug interactions • Temazepam, oxazepam, lorazepam & alprazolam metabolized primarily by conjugation- less likely to accumulate in liver impairment • Dose dependent effects on coordination, cognition and consciousness • Paradoxical agitation/excitement can also result from drug induced disinhibition

35. Sedative-hypnotic toxicity • Vomiting, diarrhea and urinary retention can occur in BZD toxicity • Flumazenil ≤ 1mg reverses BZD effects- may precipitate seizures in dependent individuals • BZD’s rarely lethal by themselves • Synergism with other CNS depressants e.g., alcohol & opioids • Can worsen ventilation in patients with preexisting cardio-respiratory conditions e.g., OSA, COPD & CHF • High index of suspicion in patients with history of ETOH abuse • BZD misuse also likely in patients on opioids & cocaine users

36. Opioid toxicity • Miosis + CNS & respiratory depression • Slow, shallow respiration, absent GI sounds & urinary retention • Toxicity can also result from acetaminophen or NSAIDs frequently combined with prescription opioids • Naloxone is a specific antidote→ can precipitate opioid withdrawal • Repeated doses may be required due to naloxone’s short half life

37. OTC cold & cough medications • Frequently abused by adolescents to get “high” • May contain mixtures of various antihistamines, sympathomimetics with or without dextromethorphan • Difficult to detect in urine→ pseudoephedrine may screen positive for amphetamine

38. Inhalant intoxication • Include a variety of hydrocarbons including toxic solvents • Initial stage of disinhibition, excitement, or a sense of drunkenness→ restlessness, ↓consciousness, ataxia, respiratory depression, coma and death with ↑inhaled concentrations • Risk of arrhythmias, possible hepatic injury and long-term effects on cognition

39. CNS stimulant withdrawal • The cocaine “crash” • Dysphoria that may be accompanied by suicidal ideation, sleep disturbance and cravings • Increased appetite as a rebound to appetite-suppressant effects of stimulants

40. Agitated, aggressive & psychotic patient Agitated behavior ranging from belligerence to physical aggression to full blown psychosis: • Alcohol withdrawal • Sedative-hypnotic withdrawal • Opioid withdrawal • CNS stimulant intoxication • Hallucinogen intoxication • Marijuana intoxication

41. Alcohol withdrawal • Combativeness and aggression could be seen in both alcohol intoxication and withdrawal • BAL at which withdrawal occurs varies from patient to patient • Can begin in as little as 6 hours from the last drink • Autonomic instability: ↑BP, tachycardia & sweating • GI symptoms: Nausea, vomiting & diarrhea • CNS activation: Anxiety & tremor • Serious withdrawal: Hallucinations & seizures • Delirium tremens: After 48-72 hours, about 5% of patients in alcohol withdrawal, develop DTs- hallucinations (usually visual), delirium and severe autonomic instability

42. Alcohol withdrawal & CIWA 1) Nausea and vomiting: 0-7 score 2) Tremor: 0-7 3) Paroxysmal sweats: 0-7 4) Anxiety: 0-7 5) Agitation: 0-7 6) Tactile disturbances: 0-7 7) Auditory disturbances: 0-7 8) Visual disturbances: 0-7 9) Headache: 0-7 10) Orientation: 0-4

43. CIWA & Medication

44. Structured medication regimens 1) Chlordiazepoxide: • 50 mg Q6H X 4 • Followed by 25 mg Q6H X 8 2) Diazepam: • 10 mg Q6H X 4 • Followed by 5 mg Q6H X 8 3) Lorazepam: • 2 mg Q6h X 4 • Followed by 1 mg Q6H X 8 4) Carbamazepine: • 400 mg BID on day 1 • Tapering down to 200 mg as a single dose on day 5

45. Pharmacological treatment of alcohol withdrawal • Benzodiazepines • Anticonvulsants • Beta- blocking agents • Alpha-adrenergic agonists • Thiamine • Neuroleptic agents

46. Sedative-hypnotic withdrawal • Occurs within the first few hours to days after discontinuation following a period of regular use • Similar to alcohol withdrawal except: extended over days to weeks (instead of hours to days) • Anxious prodrome→ tremor, tachycardia, hypertension, diaphoresis, GI upset, mydriasis, sleep disturbance & nightmares, tinnitus, ↑sensitivity to sound, light & tactile stimuli • Confusion, delirium, hyperthermia & GTCS can occur in severe withdrawal • Significant anxiety, sleep disturbance and mild autonomic symptoms may persist for many months

47. Sedative-hypnotic withdrawal • Switch to longer acting agent & gradually taper (10%/week) • Carbamazepine 200 mg t.i.d. for 7-10 days (gabapentin and divalproex are alternatives)

48. Opioid withdrawal • Heralded by anxiety, craving/preoccupation & vague discomfort (hyperalgesia) • Pupillary dilatation, lacrimation, rhinorrhea, diaphoresis, piloerection, arthralgia/myalgia, diarrhea, yawning & sneezing • Rarely causes change in mental status except for ↑anxiety • Onset: 6-72 hours after last use/dose • Peak: 2-4 days • Resolution: 7-10 days • Not life threatening in otherwise healthy patient • Miscarriage in pregnancy

49. Clinical Opiate Withdrawal Scale (COWS) • Resting pulse rate (0-4 score) • Sweating (0-4 score) • Restlessness (0-5 score) • Pupil size (0-5 score) • Bone or Joint aches (0-4 score) • Runny nose or tearing (0-4 score) • GI upset (0-5 score) • Tremor (0-4 score) • Yawning (0-4 score) • Anxiety or irritability (0-4 score) • Gooseflesh skin (0-5 score) • Severity of withdrawal: 5-12= mild, 13-24= moderate, 25-36= moderately severe, >36= severe

50. Opioid withdrawal treatment CPSO MMT Guidelines-2011