Behavioral Emergencies

1. Behavioral Emergencies PARAMEDIC PROGRAM P. Andrews Summer 07

2. Strange But True A 28-year old male was brought into the ER after an attempted suicide. The man had swallowed several nitroglycerin pills and a fifth of vodka. When asked about the bruises about his head and chest, he said that they were from him ramming himself into the wall in an attempt to make the nitroglycerin explode.

3. What’s this all about? • Is it normal or abnormal? • Prevalence? • Pathophysiology of behavioral and psychiatric disorders • Factors that alter behavior or emotional status • Medical legal considerations • Overt behaviors associated with behavioral and psychiatric disorders

4. Verbal techniques useful in mgmt of the emotionally disturbed pt. • Appropriate safety measures • When should family, etc be removed from premises? • Techniques for physical assessment • When are you expected to transport a patient against his/her will? • To restrain or not?

5. Affect Anger Anxiety Confusion Depression Fear Mental status Open-ended questions Posture Post-traumatic stress syndrome Psychogenic amnesia Schizophrenia Bereavement Biological/organic Bipolar disorder Catatonia Delirium Delusions Dementia Flat affect Manic Multiple personality disorder Phobia Positional asphyxia Terms

6. Behavioral and Psychiatric Emergencies • Not clear cut • They require a complete history, exam, and careful/skilled approach • Most of what you do will depend on your people skills • Behavioral emergency • Behavior is so unusual, bizarre, threatening or dangerous – possibly life-threatening to self or others

7. What is normal, anyway??? • Determined by • Culture • Ethnic groups • Socioeconomic class • Personal interpretation, opinion • Does it • Interfere with core life functions? • Pose a threat to the life or well-being of the patient or others? • Significantly deviate from society’s expectations? • Normal ? Behavior that is readily acceptable in a society!

8. Pathophysiology • ~ 20% of population has some type of mental health problem • 1 in 7 will require treatment • Anxiety • Depression • Eating disorders • Mild personality disorders • Behavioral and psychiatric disorders incapacitate more people than all other health problems combined!

9. True/not true? • All mental patients are unstable and dangerous • Their conditions are incurable

10. Biological causes • Alcohol • Drugs (including OTC, Rx) • Infection • Tumors

11. Potential Organic Causes Frontal atrophy from Alzheimer’s disease Brain neoplasm

12. Psychosocial • Personality style • Dynamics of unresolved conflict • Crisis management methods • Environment • Traumatic childhood incidents

13. Sociocultural • Situational • Relationships • Support systems • Social isolation • Rape/assault • Witnessing acts of violence • Loss of a job • Ongoing prejudice or discrimination

14. Assessment of behavioral patients • The same as for all other patients • Scene size-up – look for hazards • Initial assessment – watch posture & body language • Focused history • Physical examination • You begin your care at the same time – good interpersonal skills, remember?

15. More about the H & E • Listen – open-ended questions • Pay attention • Spend time • Be assured • Do not threaten • Let there be silence • Place yourself at their level • Keep a safe & proper distance • Appear comfortable • Don’t judge • Never lie

16. Mental status examination • General appearance • Behavioral observations – verbal and non-verbal behavior • Orientation • Memory • Sensorium – is pt. Focused, paying attention? • Perceptual processes – thought patterns ordered? • Mood and affect • Intelligence • Thought processes • Insight • Judgment • psychomotor

17. Form a general impression

18. Dementia • 25 – 50% over 85 y/o have dementia • Alzheimer’s most common • Mini-strokes • Affected person sometimes recognizes first signs • Keys? • Lost while driving, etc • Common tasks • Difficulty with words • Time between first symptoms & death – 7 – 10 years

19. Gradual impairment of memory and cognitive functions Forgetfulness Failure to recognize objects or stimuli Orientation Excellent recall of past history May not remember current events Affect Normal or flat, depending on stage of condition Aphasia Impaired communication Apraxia Impaired motor activities Agnosia Failure to recognize objects Disturbance in executive functioning Impaired ability to plan, organize or sequence Dementia

20. Causes: • Alzheimer’s disease • AIDS • Parkinson’s disease • Vascular disease • Head trauma • Substance abuse

21. Dementia and Delirium • Delirium may occur in dementia patients • Delirium Presentation • Rapid onset (hours or days) • Inattention, disorientation, memory impairment and visual hallucinations • Causes of delirium are usually reversible • Rule out acute medical problems, medication changes

22. Treatment • Supportive • Meds • Aricept • Cognex

23. Schizophrenia • Gross distortions of reality • Preoccupation with inner fantasies • Withdrawal from social interaction • Disorganization of thoughts, perceptions, and emotions • Behavior linked with medication noncompliance • Chronic substance abuse in teenage years linked to development of the disease

24. Schizophrenia Symptoms • Disorganized behavior/dress • Flat affect • Disorganized speech • Incoherent or frequently veers off track • Delusions • Hallucinations • Often auditory; sometimes visual • Motor Movements • May act upon hallucinations

25. Profiles of Schizophrenic Behavior • Delusional: • A man who wraps his house in tin foil to divert the rays from FBI satellites. • Paranoid: • The man introduces himself as Jesus Christ and tells you that the city council is out to crucify him.

26. Profiles of Schizophrenic Behavior • Disorganized (interview with a physician): • “S____t on you all who rip into my internals! The grudgerometer will take care of you all! I am the Queen, see my magic, I shall turn you all into sidgelings forever!”

27. Profiles of Schizophrenic Behavior • Undifferentiated: • Magical thinking • Creates new words or cryptic language • Cannot reason abstractly

28. Diagnosis of Schizophrenia • Two or more symptoms must each be present for a significant portion of each month over the course of 6 months. • Sx must cause a social or occupational dysfunction • Most schizophrenics are diagnosed in early adulthood

29. Approach to a schizophrenic pt. • Be supportive • Be nonjudgmental • Don’t reinforce the patient’s hallucinations – but know that he considers them real • Speak openly and honestly • Be encouraging and realistic • Be alert for aggressive behavior • Restrain pt if necessary

30. Anxiety Disorders • Panic Attacks • Acute, unprovoked episodes • Last approximately 1 hour • Symptoms: • Cardiac chest pain, nausea • Dyspnea or a sense of feeling “smothered” • Fear of going crazy • Paresthesia, dizziness • Trembling, shaking

31. Mood Disorders: Mania • Sudden onset with rapid progression of symptoms (days) • Presentation: • Progressive inflation of self-esteem • Distracted, racing thoughts • Delusions may occur • Very talkative with rapid speech • Excessive involvement in high pleasure/high risk activities

32. Management for anxiety disorder • Simple, supportive • Be empathetic • Assess medical complaints & tx prn • Consider sedative • Valium • Versed • Ativan • Benadryl

33. Bipolar disorder • One or more manic episodes with or without depression, lasting at least one week • Not common • Episodes often begin suddenly and escalate rapidly • Disorder usually develops in adolescence or early adulthood

34. Mild “On top of the world” Egocentric Decreased need for sleep Severe elation Rapid speech Illogical associations Delusions of grandeur Excessive involvement in pleasurable activities with high potential for consequences The Stages of Mania

35. Mood Disorders: Depression • Situational v. persistent • Lack of interest in daily activities • Altered mood impairs daily functioning • May be present with other disorders • Bipolar disease • Substance abuse

36. Presentation of Depression • Bizarre behavior usually not seen in depression • Inability to see beyond the person’s immediate situation • Lethargy, slow thought process and speech • Stooped posture • Poor appearance

37. General Management Considerations • Behavioral crisis development and management are viewed as a “spectrum” • Patients do not suddenly develop anger or passivity • Use the scene dynamics wisely to effect patient cooperation • Never leave depressed or suicidal patient alone

38. Assess situation • Protect self and others • Summon law enforcement if necessary • If no evidence of immediate danger, then one EMT responsible for assessing, treating and communicating with patient • Transport with consent (when possible) without sirens

39. The Spectrum

40. When is it time for patient restraint?

41. Use only when necessary • ·          Patient is a danger to themselves or others • ·          Look for all possible causes for the behavior • ·          Restraints must allow for adequate monitoring of vital signs • ·          Restraints applied by law enforcement must allow sufficient “slack” • ·         

42. Patient must be able to straighten the abdomen and chest and take full breaths • The officer must accompany the patient in the ambulance • Approved equipment for prehospital personnel • Padded leather • Soft restraints (posey, velcro, seatbelts)

43. Unapproved methods of restraint for prehospital personnel • Hard plastic ties or device that requires a key to remove • Backboard, scoop, or flat used to sandwich the patient • “Hog - tied” (hands and feet behind the patient) • Methods or material that could cause neurovascular compromise • Evaluate and document the condition of the restrained extremity (neurovascular check) every 15 minutes.

44. Documentation of Restraint Application • Reason the restraints were needed·          • Which agency applied the restraints·          • Information and data regarding the monitoring of circulation to the restrained extremity·          • Information and data regarding the monitoring of respiratory status while restrained

45. Somatoform disorders • Somatization disorder • Pt is preoccupied with physical symptoms • Conversion disorder • Loss of function (blindness, paralysis) • Hypochondriasis • Exaggerated interpretation of physical symptoms

46. Neurotransmitters and Behavior

47. Neurotransmitters: Norepi • Promotes awakening and enhances dreams • Elevates mood • CNS locations: cortex, medulla, hypothalamus, limbic system, cerebellum • NE locations outside the CNS • Mania and delusions with overstimulation • Depression with low levels

48. Neurotransmitters: Dopamine • Stimulates emotional responses • Controls subconscious skeletal movement • CNS locations: cerebral cortex, hypothalamus and limbic system • Schizophrenia and schizoid symptoms from amphetamines

49. Neurotransmitters: Serotonin • Controls sleep, sensory perception, mood control • Thermal regulation • CNS locations: hypothalamus, limbic system and cerebellum • Hallucinations with LSD and overstimulation • Depression and anxiety with low levels

50. Neurotransmitters: GABA • Gamma aminobutyric acid • Depresses mood and emotion • CNS locations: everywhere! • Enhanced by benzodiazepines • Anxiety from low levels of GABA