Presentation regarding psychiatric emergencies in a hospital setting and how to does a late situations in certain settings.
Inclusive of serotonin syndrome, NMS, dose systems in the hospital for emergencies
3. PSYCHIATRIC EMERGENCY
âacute disturbance of behaviour, thought or mood of a patient which if untreated may lead to harm, either
to the individual or to others in the environmentâ
EPIDEMIOLOGY
Globally, 1/4 people suffer from mental illness or neurologic disorders, with depression as the number one
cause of disability worldwide (World Health Organization)
United States estimates that 1 in 5 Americans suffers from a mental, behavioral, or emotional disorder and 1 in
25 suffer from a severe mental illness (National Institute of Mental Health)
99% of emergency physicians admit at least one psychiatric patient daily
ED = safety net for patients, bridging the gap between outpatient and inpatient treatment with 1 in 8 patients
having either a substance abuse or psychiatric illness
4. Click here to add the text
REVISED AND EXTENDED TO 2030 :
overall goal is to promote mental well-being, prevent mental disorders, provide
care, enhance recovery, promote human rights and reduce the mortality,
morbidity and disability for persons with mental disorders
Build up interdisciplinary community-based mental health services for people across the
life-course, through for instance outreach services, home care and support, primary
health care, emergency care, community-based rehabilitation and supported housing.
5. GOAL & EVALUATION IN Emergency
Department
⢠The distinction between functional organic causes is crucial
⢠evaluative process for identifying primary or comorbid medical conditions is often referred
to as medical clearance
⢠Regardless of the lack of interdisciplinary consensus, the medical clearance or medical
stability assessment is critical in evaluation and treatment of patients with
psychiatric and behavioral emergencies
MEDICAL
CLEARANCE
6. Psychiatric patients have a higher incidence of medical conditions and a greater risk of injury than those
without mental health or behavioral disorders.
One study found that 34% of cases had missed severe alcohol or other drug intoxication in patients admitted to
psychiatric units
12.5% of either withdrawal or delirium tremens were missed
87.5% of prescription drug overdoses were identified
8% of patients, abnormal vital signs were not investigated further
Another study found that adults older than 55 are four times more likely to have a missed medical diagnosis
(Tucci V, Siever K, Matorin A, Moukaddam N. Down the Rabbit Hole: Emergency Department Medical Clearance of Patients with Psychiatric or Behavioral Emergencies. Emerg Med Clin
North Am 2015;33(4):721â37)
7. ASSESS FOR WEAPONS
WALK-IN / BY POLICE
ASSESS RISK, PRECAUTIONARY
HOLD, SAFE ROOM
TRIAGE
INITIAL EVALUATION, OBSERVATION,
REASSESSMENT
ASSESSMENT
ADMIT, DISCHARGE, OBSERVE
DISPOSITION
ELEMENTS OF ED
EVALUATION
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11. ⢠Accounts for 5-10% of all ED visits.
⢠large number of etiologies
⢠most emergency medicine personnel will be threatened,
and up to 50% will experience violence
⢠A 2008 survey of over 3500 US ED clinicians at 65 sites
reported that 3461 physical attacks occurred over a five-
year period and that guns or knives were brought to the ED
on a daily or weekly basis
VIOLENCE | AGITATION
12. ETIOLOGY OF VIOLENCE / AGITATION
⢠pathogenesis of violent behavior is not
well understood
⢠FIND ME mnemonics :
⢠F : functional [ie, psychiatric]
⢠I : infectious
⢠N : neurologic
⢠D : drugs
⢠M : metabolic
⢠E : endocrine
13. APPROACH TO A VIOLENCE/AGITATED PATIENT IN
EMERGENCY DEPARTMENT
14. EXPERTS RECOMMENDATION - EMDOCS/EMCRIT
1. Categorize the agitation as mild, moderate or severe
2. Employ de-escalation techniques in the mild-moderate agitated
patient and/or call a code black/grey in the moderate-severe
agitated patient
3. Physically restrain the moderate-severe agitated patient safely
with either limbs held down by security personnel or by physical
restraints
4. Administer calming medications as soon as possible
5. Treat immediate life threats and pursue the underlying diagnosis
15. 1. TREAT THEM AS A
MEDICAL EMERGENCY
+ SAFETY ASSESSMENT
2. CLASSIFY THE
AGITATION : HOW
CONTROLLABLE OF
THE PATIENT
3. THE ART OF TAKE DOWN
:
DE-ESCALATION
MEARURES
AGITATION IS A CARDINAL SYMPTOMS , NOT A DIAGNOSIS!
16. AGITATION SCALE :
Sedation Assessment Tool
Agitated Behavior Scale
Overt Aggression Scale
the Positive and Negative Syndromes Scale.
Behaviour Activity Rating Scale (BARS) : simplest scale and has
good inter-rater reliability
17.
18. EXPERTS RECOMMENDATION
Experts recommend dividing agitated patients into the
following 3 categories:
Mild : Agitated but cooperative
Moderate : Disruptive without danger
Severe : Excited delirium and/or dangerous to self
and/or staff
20. ⢠One person delegated
⢠Ensure a quiet environment
⢠Donât spend too much time
⢠Monitor your own emotional and physiologic
response so as to remain calm
⢠Maintain at least 2 armâs lengths of distance
between you and the patient with an exit door
close by and in the opposite direction of the
patient
⢠Hands should be visible and not clenched
VERBAL DE-ESCALATION
TECHNIQUE
(verbal and body language)
21. PHYSICAL RESTRAINT
Ideally, 6 trained staff with PPE - 1 for each
extremity
- 1 for the head
- 1 to give medications and help apply restraints
DOâS
- use medical grade restrainers
- cont. monitor ABC
- restraint to bedframe
DONTâS
- restraint in prone position
- restraint to bed rails
- use 2 points restraint
- tie know that difficult to undo
- put pillow under ptâs head
- restraint and walk away
24. chemical de-escalation
Benzodiazepine
â unknown cause of agitation / alcohol : prefer benzodiazepines
â options : lorazepam & midazolam
LORAZEPAM MIDAZOLAM
route : iv/im/po
short half life 10 - 20 hrs
dose : 0.5 - 2 mg ( can be given every 10 - 30 mins in severely
agitated)
route : iv/im
shorter doa : 1- 2 hrs
dose : 2.5 - 5 mg ( can be given every 3 - 5 mins)
side effect :respiratory depression, excessive somnolence, and less commonly, paradoxical disinhibition
Efficacy :
In one double-blinded, randomized trial involving 153 acutely agitated patients in the ED, midazolam (median dose 5 mg) was as
effective as droperidol (median dose 10 mg) in achieving sedation within 10 minutes
In another double-blinded, randomized trial performed in an urban ED, midazolam (5 mg IM) was found to provide more rapid
sedation of severely agitated patients than lorazepam (2 mg IM) or haloperidol (5 mg IM)
Alcohol withdrawal and
overdoses of particular drugs
may require treatment with
large cumulative doses
25. chemical de-escalation
First Generation of Antipsychotic
â include the butyrophenones and phenothiazines
â widely use : Haloperidol & dorperidol
HALOPERIDOL DROPERIDOL
Route : IV/IM/PO (IV use is not approved by the US Food and Drug
Administration (FDA)
Dose : 2.5 - 10 mg ( reduced to half in elderly)
Onset of Action : 5 - 20 mins
can give repeated doses 15 - 30 mins
analog of haloperidol with a shorter half-life
Dose : 2.5 to 5 mg
Onset of Action : 15 - 30 mins
DOA : 6 - 8 hours
Side effect : QTC prologation/cardiac dysrythmia/EPS
Efficacy :
Multiple randomized trials have demonstrated the effectiveness of droperidol in controlling acute agitation. A pharmacokinetics study of
41 patients adapted from a larger clinical trial reported that IM droperidol is rapidly absorbed, obviating the need for IV therapy.
26. chemical de-escalation
Second Generation of Antipsychotic
â widely use : Olanzapine, Zisprasidone, risperidone
â Experience using second-generation antipsychotic medications to control severe, acute agitation in the ED is limited, but growing
and preliminary studies suggest that they are effective
OLANZAPINE RISPERIDONE ZISPRASIDONE
Route : IM (IV Not FDA approved)
Dose : 5 - 10 mg (may repeat 2 h after 1st dose, then 4
h after 2nd dose) max 30 mg
Onset of Action : 15 - 45 mins
Half life : 2 - 4 hours
can give repeated doses 15 - 30 mins
Route : Im depot/ PO
Dose :1 - 6 mg (2/3 divided daily doses)
Half life : 20 hours
Route : PO/IM
Dose : 10 - 20 mg
Onset of action : 15 - 20 min
half-life : 2 - 4 hours.
Side effect : lesser degree of QTC prologation/cardiac dysrythmia/EPS
Efficacy :
In a retrospective review of 15,918 ED patients treated for acute agitation with olanzapine (median dose 10 mg IM), haloperidol (median
dose 5 mg), or droperidol (median dose 5 mg), those treated with olanzapine or droperidol were less likely to require subsequent
rescue medication . Major adverse events were uncommon and did not differ significantly among treatment groups
Risperidone : data for its use in acute agitation are limited. It has been useful in controlling agitation in the elderly and may have similar
effects to haloperidol when a benzodiazepine is added.
27. chemical de-escalation
Ketamine
â good safety profile when used for PSA, has been used for acutely agitated and violent patient, although studies have been small
and methodology has varied
KETAMINE
Dose : 1 to 2 mg/kg IV, or 4 to 6 mg/kg IM (repeat IV or IM dose using 50 % reduction in the initial dose, given after 5 - 10 mins for IV/ 10 - 25 mins.
Onset of action : 1- 2 mins IV / 4 - 5 mins IM
Duration of action : 10 to 20 minutes.
Side effect :HPT/ tachycardia/laryngospasm/reaction/vomiting/ exacerbate schizophrenia
Efficacy :
EMDOCS : Update 2021: Randomized, single institution study of 93 patients compared ketamine (4 mg/kg IM or 1mg/kg IV) and haloperidol/
lorazepam (haloperidol 5-10 mg IM/IV + lorazepam 1-2 mg IV/IM) with regards to âtime to sedationâ, and found ketamine was significantly
more effective at both 5 minutes and 15 minutes after medication administration (no statistically significant increase in adverse
effects)
EMDOCS : Update 2021: Single-centered, randomized trial of 80 patients comparing ketamine (5 mg/kg IM) and haloperidol/midazolam (5
mg for both), showing a significantly different mean âtime to sedationâ of 6 minutes for the ketamine group and 15 minutes for the
haloperidol/midazolam group (no statistical difference in serious adverse events)
UPTODATE : may be useful when initial treatments have failed, and in patients with excited delirium, but its use may be associated
with a greater need for endotracheal intubation compared to other medications depending upon the dose required to achieve
adequate sedation
28. chemical de-escalation
Combination Theraphy
â BDZ + 1st gen antipsychotic
combinations have been shown to be effective:
âMidazolam (5 mg IV or IM) and droperidol (5 mg IV or IM)
âLorazepam (2 mg IV or IM) and haloperidol (5 mg IV or IM)
(half doses to be given in elderly)
titrate midazolam every 3 to 5 minutes or lorazepam every 10 to 20 minutes as needed
Efficacy
In a multicenter, randomized, double-blind controlled trial, the combination of either droperidol (5 mg IV) and midazolam or olanzapine (5
mg IV) and midazolam provided more rapid sedation of acutely agitated ED patients (n = 336) than midazolam alone (2.5 to 5 mg IV
used for all three groups) without an increase in adverse events and with less need for rescue medication . The mean times to
sedation were 21.3 minutes for the droperidol group, 14 minutes for the olanzapine group, and 67.8 minutes for the midazolam only
(ie, control) group
29. SUMMARY
For severely violent patients :
âfirst generation (typical) antipsychotic (eg, droperidol) or
âbenzodiazepine alone (eg, midazolam) or
âcombination of a first generation antipsychotic and a benzodiazepine (eg, droperidol
and midazolam, or haloperidol and lorazepam)
agitation + drug intoxication/withdrawal : benzodiazepine.
undifferentiated agitation :
âbenzodiazepines / first-generation antipsychotics
known psychotic/ psychiatric disorder :
first generation antipsychotic agents,/ second-generation antipsychotics are a
reasonable choice
31. ALCOHOL USE DISORDER
ALCOHOL INTOXICATION
â ~4 - 40% of medical and surgical patients
experience problems related to alcohol
â >85,000 deaths a year in US are directly
attributed to alcohol use
â annual economic cost of alcohol use is
estimated to > $250 billion
â 1:10 deaths among working age adults
results from excessive drinking
32. ALCOHOL USE DISORDER
TERMINOLOGY
â Unhealthy alcohol use
â Risky use : consumption of an amount of alcohol that puts an individual at risk for health consequences
( > âstandard drinkâ)
â Binge drinking : drinking within about two hours till BAC reach 0.08g/dL
â Alcohol use disorder : dsm v
âstandard drinkâ : 14 g of ethanol
= 5 oz wine
= 12 oz of beer
= 1.5 oz of 80 proof spirits
(no / size of drinks that define risky amounts varies
internationally)
34. ALCOHOL USE DISORDER
CLINICAL FEATURES based on BAC
Signs and symptoms : vary with severity
â slurred speech
â nystagmus
â disinhibited behavior
â incoordination
â unsteady gait
â memory impairment
â stupor, or coma
â Hypotension and tachycardia
Biochemical derrangement :
â hypoglycemia
â hyperlactatemia
â hypokalemia
â hypomagnesemia
â hypocalcemia
â hypophosphatemia
35. â Supportive measures + ABC till sobreity
Resuscitation
â seek and treat life threats
â airway compromise from decreased level of consciousness
â airway opening manoeuvres and adjuncts, suction, close observation
â intubation may be required
â ventilatory support if respiratory depression or aspiration
â hypoglycaemia (due to severe ethanol intoxication)
â coexistent life-threats (e.g. GI haemorrhage, trauma)
Supportive care and monitoring
â thiamine 300mg IV
â adequate hydration
â replace electrolytes and vitamins
â manage behavioural disturbance (verbal de-escalation, chemical +/- physical restraint if indicated)
â commence an alcohol withdrawal chart
ALCOHOL USE DISORDER
TREATMENT
36. ALCOHOL USE DISORDER
DISPOSITION
â Mild to mod : ED observation until sober with screening upon discharge
â Acutely intoxicated patients should usually be observed in the emergency department until BAC
reaches 0.2 g%
â Withdrawal
â may begin at a BAL of 0.1 g% and will usually have begun before the concentration reaches zero
â Admission may be required for:
â social crisis (poor supervision or support)
â medical (high risk of withdrawal, suspected coexistent illness or complication of chronic alcohol
consumption)
â Referrals, when appropriate to:
â Emergency accommodation
â Social worker/ support services
â Drug and Alcohol service
â Child welfare services (if suspect NAI or children at risk)
37. SCREENING AND BRIEF
INTERVENTIONS FOR ALCOHOL
PROBLEMS
CAGE questions (alcohol
abuse and dependence)
â sensitivity 43â94%, specificity
70â97%
Alcohol Use Disorders
Identification Test (AUDIT)
â identifies patients with at-risk,
hazardous or harmful drinking
â sensitivity 51â97%, specificity
of 78â96%
38. ALCOHOL USE DISORDER
ALCOHOL WITHDRAWAL
global health concern, ranking 7th among
the leading causes of death and disability
2 - 7 % heavy alcohol use +
developed severe withdrawal
8 MIL
alcohol
dependent in
US alone
500K
episodes of withdrawal
requires treatment / year
39. â Alcohol : central nervous system depressant
â simultaneously enhances inhibitory tone (via modulation of gamma-
aminobutyric acid [GABA] activity)
â inhibits excitatory tone (via modulation of excitatory amino acid activity)
â alcohol dependence = preserves homeostasis through constant presence of
ethanol
â Abrupt cessation= unmasks the adaptive responses --> overactivity of the
central nervous system.
ALCOHOL WITHDRAWAL
PATHOPHYSIOLOGY
41. ALCOHOL WITHDRAWAL
DELIRIUM TREMENS (DT)
⪠~5 percent of patients who undergo withdrawal from
alcohol suffer from DT
⪠defined by hallucinations, disorientation,
tachycardia, hypertension, hyperthermia,
agitation, and diaphoresis in the setting of acute
reduction or abstinence from alcohol / meets
both criteria of alcohol withdrawal and delirium in
DSM V)
⪠begins between 48 - 96 hours after the last drink
and lasts 1-5 days
42.
43. Risk factors for the development of DT :
â history of sustained drinking
â history of alcohol withdrawal seizures
â history of DT
â Age >30
â presence of a concurrent illness
â presence of significant alcohol withdrawal in the presence of an elevated BAC
â longer period since the last drink (ie,alcohol withdrawal >2 days after their last drink are more
likely to experience DT)
44.
45.
46. â SUPPORTIVE TREATMENT
â Fluids : to maintain euvolumic state
â thiamine and multivitamins
â glucose monitoring
â vitals monitoring
â Treatment of psychomotor agitation with benzodiazepines :
â frequently use : Diazepam (Valium), lorazepam (Ativan), and chlordiazepoxide
(Librium)
â long-acting benzodiazepines with active metabolites (eg, diazepam) are preferred =
smoother clinical course with lower chance of recurrent withdrawal or seizures
â diazepam : 5 to 10 mg IV every 5 to 10 minutes
â Lorazepam, 2 to 4 mg IV every 15 to 20 minutes
TREATMENT
47. Treatment of psychomotor agitation with benzodiazepines :
1. front loading therapy
2. symptom triggered therapy
3. fixed schedule therapy
DISPOSITION
Moderate to severe withdrawal : for ICU admission
Standard monitoring includes continual assessment of vital signs, pulse oximetry, fluid
and electrolyte status, and neurologic function
51. â highly prevalenty
â 7.2 percent of individuals age 12 or over had a diagnosable SUD in the
past year, + 5.3% with an alcohol use disorder and 2.8 % with an illicit
drug use disorder
â Illicit drug use and nonmedical use of medications alone or in combination
with alcohol are associated with a substantial proportion of emergency
department visits in the United States
(2017 national survey in the United States)
SUBSTANCE USE DISORDER
54. âFundamental derangement of the mind characterized
by defective or lost contact with realityâ - Tintinalli -
âpsychotic disorders as those that include abnormalities
in one or more of five domains: hallucinations, delusions,
disorganized or abnormal motor behavior, disorganized
thinking, and negative symptomsâ - DSM V-
PSYCHOSIS
DEFINITON
56. Psychoses âapparent, often strong subjective perception of
an external object or event when no such
stimulus or situation is present.â
inferred from a patientâs speech.
( derailment or loose associations,
tangentiality, and word salad )
CLINICAL
FEATURES
HALLUCINA-
TION
DELUSION
DISORGANIZE
THINKING
NEGATIVE
SYMPTOMS âa false belief or wrong
judgment, with conviction
despite evidence to the
contrary.â
( grandiose,persecutory,
erotomanic and referential or
ideas of reference)
avolition, diminished emotional
expression, anhedonia, asociality,
and alogia.
57. Psychoses
PHYSICAL EXAMINATION
⪠no specific physical findings
⪠goal is the exclusion of coexisting medical or
traumatic conditions
⪠self inflicted injury/ environmental/restraint injury
⪠Grossly disorganized or abnormal motor behavior
i;e catatonia
59. D S M - V
Psychoses
schizophrenia spectrum and other
psychotic disorders
60. PHARMACOTHERAPY
(ANTI-PSYCHOTIC) & DISPOSITION
⢠exact mechanism of action = not known
⢠majority block the D2 receptors and 5-HT2A serotonin receptors to a varying degree
⢠classified as first-generation (typical) or second-generation (atypical) antipsychotics
⢠typical antipsychotic medications categorized as being of low, medium, or high
potency. âpotency = degree of dopamine blockadeâ
⢠High-potency drugs have higher D2 receptor blockade/ lower serotonergic and
muscarinic binding affinity = less sedating, more frequently associated with
extrapyramidal effects
⢠low potency drugs = more sedating and often more anticholinergic
symptoms.
63. Dystonic reactions
⢠Syndrome of sustained, often painful muscular spasms, producing
repetitive, twisting movements, or abnormal posture.
⢠Aetiology remains unclear
64. Acute Dystonia
⢠Occurs within 1 week of commecing/rapidly increasing dose of
antipsychotics
⢠Reducing antocholinergic medication prescribed to tread it.
⢠Insidence- 3-10% of patients exposed to all antipsychotics.
66. ⢠If severe, discontinue suspected agent.
⢠Emergency treatment with IM anticholinergic agents (e.g. procyclidine 5mg, benzatropine 2mg). Intravenous
administration is necessary only if dystonic reaction is life threatening.
⢠Continue use of anticholinergic prophylactically for 5 to 7 days in addition to antipsychotics and taper it off over 2â
3wks (long-term treatment may predispose to TD).
⢠Consider switching to antipsychotic with low propensity to cause EPSEs
⢠Alternative treatment includes use of amantadine (fewer side-effects than other agents).
⢠Oculogyric crisis that is unresponsive to anticholinergic drugs may benefit from treatment with clonazepam.
⢠If treatment is unsuccessful check serum calcium concentrations in order to exclude hypocalcaemia.
⢠Routine prophylaxis should be considered for patients with a history of previous drug-induced dystonic reaction.
⢠Tardive dystonia may respond to botulinum toxin, ECT, and deep brain stimulation
Management
67.
68. Antipsychotic Induced Parkinsonism
⢠Frequent adverse reactions
⢠Up to 20% of patients treated with antipsychotics.
⢠Characterised by tremor, rigidity and bradykinesia, similar to the
presentation of idiopathic Parkinsonâs.
⢠Generally occurs within 4 weeks of treatment, and is a major cause
of noncompliance.
69. Assesment
⢠Routine inquiry and critical examination is sufficient and should be
carried out within the first 3 months of treatment.
⢠Monitoring such effects would help optimise the minimal required
dose and majorly increase compliance to medications.
70. Treatment
Several strategies may be used, including:
⢠Dose reduction.
⢠Switching to another antipsychotic agent, e.g. clozapine/quetiapine < olanzapine/aripiprazole < risperidone
(<8mg/day).
⢠Use of anticholinergic agents (e.g. procyclidine, orphenadrine, trihexyphenidyl) or amantadine (a dopamine
agonist so beware of potential worsening of psychosis). Of note, symptoms are usually absent during sleep so
night-time dose may not be required.
⢠When treatment is by depot, there is some evidence that pipotiazine palmitate, flupentixol, or zuclopenthixol
decanoate may be better tolerated. Risperidone/paliperidone depot may be considered as another option.
78. SUICIDE
DEFINITON
⢠Across the world, the age-standardized suicide rate : 2 per 100,000
individuals
⢠>800,000 deaths from self-harm
⢠nearly 250 causes of death, suicide was the 14th leading cause of
global mortality
⢠focus on identifying risk/protective factors and acuity, collateral
his_x0002_tory, clinical synthesis, and safety management
83. SUICIDE
Management of the suicidal individual should include:
â Medical stabilization
â Reducing immediate risk and treatment planning
â Managing underlying factors and psychiatric disorders
â Monitoring and follow-up
