Page 236 - TNFlipTest

ER56 Emergency Medicine
Psychiatric Emergencies Toronto Notes 2019 Psychiatric Emergencies
Approach to Common Psychiatric Presentations
• seePsychiatry,PS2
• beforeseeingpatient,ensureyourownsafety;havesecurity/policeavailableifnecessary
History
• safety
■ assess suicidality: suicidal ideation (SI), intent, plan, lethal means, past attempts, protective factors
■ assess homicidality: homicidal ideation (HI), access to weapons, intended victim, and history of
violence
■ driving and children
■ command hallucinations
• identifycurrentstressorsandcopingstrategies
• moodsymptoms:manic,depressive
• anxiety:panicattacks,generalizedanxiety,phobias,obsessive-compulsivedisorder,post-traumatic
stress disorder
• psychoticsymptoms:delusions,hallucinations,disorganizedspeech,disorganizedorcatatonic
behaviour, negative symptoms (affective flattening, alogia, avolition)
• substanceusehistory:mostrecentuse,amount,previouswithdrawalreactions
• pastpsychiatrichistory,medications,adherencewithmedications
• medicalhistory:obtaincollateralifavailable
Physical Exam
• completephysicalexamfocusingon:vitals,neurologicalexam,signsofheadtrauma,signsofdrug toxicity, signs of metabolic disorder
• mental status exam: general appearance, behaviour, cooperation, speech, mood and affect, thought content and form, perceptual disturbances, cognition (including MMSE if indicated), judgment, insight, reliability
Investigations
• investigations vary with age, established psychiatric diagnosis vs. first presentation, history and physical suggestive of organic cause
• asindicated:bloodglucose,urineandserumtoxicologyscreen,pregnancytest,electrolytes,TSH,AST/ ALT, bilirubin, serum Cr, BUN, and osmolality
• bloodlevelsofpsychiatricmedications • CTheadifsuspectneurologicaletiology • LPifindicated
Acute Psychosis
Differential Diagnosis
• primarypsychoticdisorder(e.g.schizophrenia)
• secondarytomedicalcondition(e.g.delirium)
• drugs:substanceintoxicationorwithdrawal,medications(e.g.steroids,anticholinergics) • infectious(CNS)
• metabolic(hypoglycemic,hepatic,renal,thyroid)
• structural(hemorrhage,neoplasm)
Management
• violenceprevention
■ remain calm, empathic, and reassuring
■ ensure safety of staff and patients, have extra staff and/or security on hand
■ patients demonstrating escalating agitation or overt violent behaviour may require physical restraint
and/or chemical restraint
• treatagitation:wheneverpossible,offermedicationtopatientsasopposedtoadministeringwithforce
(helps calm and engage patient)
■ benzodiazepines: lorazepam 2 mg PO/IM/SL
■ antipsychotics: olanzapine 5 mg PO, haloperidol 5 mg PO/IM
• treatunderlyingmedicalcondition
• psychiatryorCrisisInterventionTeamconsult
Key Functions of Emergency Psychiatric Assessment
• Is the patient medically stable?
• Rule out medical cause
• Is psychiatric consult needed?
• Are there safety issues (SI, HI)?
• Is patient certifiable? (must demonstrate
risk [present/past test] and apparent mental illness [future test])
Psychiatric Review of Systems
MOAPS Mood Organic Anxiety Psychosis Safety intoxication