Behavioral Emergencies 2015
Three patients to see . . .A. 24 year old female with multiple superficial lacerations to left arm.
Boyfriend called police, apparently was in an argument and locked herself in the
bathroom threatening suicide. Brought by police. The triage nurse has known her
for years.VS 78, 130/70, 22, O2 sat 97% pain
15/10. GCS=15.
B. 43 year old male fell off a ladder and had a brief period of unresponsiveness. Awoke with moderate headache and walked into
the kitchen. 20 minutes later his wife noted he seemed a bit confused and staggered a
bit walking to the living room. When he didn’t seem to know where he was, she
called the ambulance. He is now insistent that he be allowed to go home, gets up off the stretcher and pushes away the nurse.
VS 68, 140/105, RR 12, O2 sat 94%, GCS=14.
C. A 36 year old male presents with his wife, who says that they are having difficulty at
home. He is demanding and argumentative, and his wife is worried
especially over money he has spent lately. He has run out of medications and his
family doctor is away for two weeks. He hasn’t been sleeping more than 1 or 2
hours per night. He has plans to sell his business and start a new one. One night he
was out driving his car all night. VS 110, 145/90, 20, O2 sat 97%, GCS=15.
Objectives
1. Discuss the approach to the agitated
psychiatric patient.
2. Discuss the approach to the agitated
medical/ surgical patient.
3. Display knowledge of the appropriate therapeutic
choices for various scenarios.
4. Discuss the concept of “medical clearance”.
5. Display knowledge of suicide risk stratification.
6. Discuss the indications and contraindications for
emergency psychiatric consultation.
7. Display knowledge of involuntary commitment and the
legal aspects of this act.
8. Discuss the approach to and treatment of the anxious patient.
9. Knowledge of the differential diagnosis for confusion in the elderly.
Acute Agitation:PsychosisOrganicBehavioral
Managing Violent Patients
Emergency Psychiatric Assessment Steps
Safety and stabilization
Identification of homicidal, suicidal, or other dangerous behavior
Medical evaluation
Psychiatric diagnosis and severity assessment
Psychiatric consultation
What are potential causes of agitation or violent behavior?
Organic - deriving from medical disorders, including substance abuse and other toxidromes.
Drug/etoh withdrawal Toxidromes Endocrinopathies Metabolic derangements Substance abuse Infections Neurologic illness
Psychotic – schizophrenic, manic, delusional.
Non- organic, non-psychotic – personality disorders, impulse control disorders.
Risk Factors for Violence
Previous history of violenceIntoxicationParanoid delusions Drug/etoh withdrawal Personality Disorder
List some risk factors for violence:
Taylor—psychosis vs violenceThe risk of being violent is raised by psychosis:
what is the likelihood that a violent episode is due to psychosis? 95% to 99% of society’s violence must be explained
otherwise. When violence is a problem, who is most at risk?
immediate social circle of a patient with psychosis are most at risk.
What are the 2 main routes by which psychosis is related to violence?1. Individuals unremarkable before the onset of illness
and their violence is driven by psychotic symptoms; 2. conduct, emotional difficulties and/or childhood abuse
preceded the psychosis; lifestyle and substance misuse may be more prominent factors in the violence.
De-escalation PrinciplesPerceived threat is a major driverAct as an advocate, not an adversaryMake patient comfortableCreate a therapeutic alliance
Recognize AgitationEarly EscalatingTensionHostilityUncooperativenessExcitementPoor impulse control
AngryPacing/restlessnessClenched fistsLoud speech/shouting
Prevention See them fastDisarm patientPrivate but not isolated bedSafe room= no weaponsKeep door openSecurity nearbyYou and patient equidistant to doorSafe you = no weapons
De-escalation Principles: CANITC=Containment & SafetyA=AssessmentN=Nonviolent De-
escalation TechniquesI=InterventionT=Takedown & Control
De-escalation 10 TechniquesRespect personal
spaceDon’t provoke pt.Establish verbal
contactBe conciseIdentify
wants/feelingsListen closely
Agree or agree to disagree
Set clear limitsOffer choices and
optimismDebrief patient
and staff
PO Drugs
Offers patient choice and controlStrengthens the therapeutic alliancePreferred by patientsFast actingBenzos & Antipsychotics
Physical RestraintSystematic, consistent, protocol-driven
and practiced techniques are best.Preserve the physician- patient
therapeutic alliance where possible. Restraint team – at least 5 trained
members and an experienced leader.team should enter the room in unison.Leader moves to the head and other
members each take a limb.
Restraint DocumentationTime limited order Patient’s presentation and reason for
restraint, including the potential danger to patients or others.
The plan of care.Assess decision making capacity. Nursing notes:
injuries frequent assessmentvital signs, medical and behavioural status; readiness for discontinuation of restraint.
Really Agitatedbenzos still preferred, PO if possibleLorazepam
0.5 – 2 IM/PO mg q 30 min. reliable IM absorption, no metabolites
Consider midazolam quicker onset IM, lasts 45 mins.5 mg IM q 15 min
haloperidol 5 mg + lorazepam 2 mg IMMore rapid sedation
Alternative:Olanzepine 10 mg IM
84 year old femaleBrought in by daughter because she has
is more sleepy in the daytime than usual, not getting out of bed as much, appetite is markedly decreased
Says she feels quite well, but has a coughDaughter says she seems slightly
confused off and on in last three days.
Compare dementia & deliriumDementia—
chronic impaired cognitive functioning in several areas,
including memory, abstract thinking, judgment, personality, and other higher cortical functions such as language
Delirium ==acute
impairment in cognitive function & clouding of consciousness, a reduction in the awareness
of the external environment (manifest as difficulty sustaining attention), varying degrees of alertness ranging from drowsiness to stupor, and sensory misperception
Delirium is Common!up to 70% of cases missed11%-42% of medical inpatients have delirium
Increased mortality, readmission,
complications, falls, institutionalization,
length of stay, aggression
drugs are most common reversible cause of
delirium especially anticholinergics, benzodiazepines and
narcotics
diphenhydramine (Benadryl) associated with cognitive decline
and urinary retention in hospitalized elderly (also
dimenhydrinate)
Two Types of Delirium25 % --Agitated
usually identifiedMost: Hypoactive
often missedhigher mortality
Delirium Risk FactorsAdmission Characteristic vs Odds Ratio (95%
Confidence Interval) Fracture 6.6 (2.2-19.3)Cognitive impairment 6.3 (2.9-13.7)Age >80 5.2 (2.6-10.4)Severe illness 3.5 (1.5-8.2)Age >65 3.0 (1.2-7.7)Infection 3.0 (1.4-6.1)Vision impairment 1.7 (1.0-2.8)
Neurohospitalist. 2013 October; 3(4): 194–202.
AEIOU M&M TIPSMnemonic for Delirium EtiologyE - epilepsy (especially post-ictal)I - infectionO - oxygen (hypoxia)U - uremiaM - myocardial infarction& - anesthesiaM - metabolicT - trauma/fractureI - InsulinP - polypharmacyS - stroke
All cases of Delirium require investigation for underlying organic cause
Mental Status and Mini-Mental State Examinations
MMSE: Cognitive testing the MMSE consists of a series of tasks that assess
orientation, immediate and short-term memory, attention, calculation, language, visual construction.
A score of 23 or less (out of a maximum possible of 30) = cognitive impairment.
Behavior What is the patient doing?
Affect What feelings is the patient displaying?
Orientation Does the patient know what is happening, where, and when?
Language Is the patient understanding and being understood?
Memory Can the patient recall historical details, recent and remote?
Thought content Is the patient reporting beliefs that make little sense?
Perceptual abnormalities Is the patient experiencing unusual sensory phenomena?
Judgment Is the patient able to make rational decisions?
Preventionnonpharmacological intervention may
prevent delirium in hospitalized older patients
education of family members about delirium, presence of clock, calendar, familiar objects, glasses in patient's room, reorientation of patient by family members, and extended visitation timesReduced delirium (NNT 13), falls
Age Ageing 2012 Sep;41(5):629
Delirium in Elderly DementiaTraining, environmental intervention by
guideline decreases use of restraints,
increases family & patient satisfaction.
Antipsychotic use increases mortality
No clear benefit to any medication
interventionsGeri-EM Education Program
Delirium RxSupport:Quiet room, low lights, familiar people/
objects, re- orientation. Avoid physical restraints.Low dose haldol or risperidone . Treat
pain, cause.Caution re: drugs in elderly dementia—
risk vs benefitIncreased mortality with antipsychoticsBenzos and anticholinergics can worsen
sx.No evidence cholinergics work
Two patients to see . . .Case 1. Police bring in a 43-year-old male to
the ED after he threatened to kill his wife and then shoot himself. He insists that he just “lost his cool” but now feels better and wants to leave. He lost his job and has been drinking more heavily in the past couple months leading to arguments.
Case 3: 23 year old female complains of chest pains, palpitations, dizziness, nervousness and tremors over the past several months. Says family doctor not listening to her.
Clinical Assessment in the ED Clinical Assessment of the Patient with Suicide Risk1. Medical history 2. Psychiatric history3. Suicidal behavior history (previous attempts)4. Substance use history5. Psychosocial history --life stressors, impulsivity, aggression, relationships6. Family psychiatric history to include history of suicide7. Physical examination8. Mental status examination (MSE)9. Relevant laboratory tests10.Drug inventory, including over-the-counter (OTC) drugs and supplements
AnxietyShearer SL. Recent Advances in the Understanding and Treatment of Anxiety Disorders. Prim Care Clin Office Pract 34(2007) 475.
• most common mental health disorders, • more prevalent than both affective and substance abuse disorders. • 1-year prevalence 16% • lifetime prevalence is 28.8% • median age of onset among mood disorders (age 30), • median age of onset among anxiety disorders is much younger (age
11).
Anxiety disorders can adversely affect quality of life, mobility, education,employment, social functioning, health care, and physical well being.• a primary anxiety disorder often contributes to secondary
depression or substance abuse. • comorbidity with physical conditions associated with poor quality
of life and disability.• Anxiety disorders impose a societal economic burden
comparable with the cost of depression
Generalized Anxiety DisorderGAD is the anxiety disorder linked to the
highest frequency (35.6%) of self-medication with alcohol and drugs, associated with greater comorbidity and
suicidalityin one sample, 87% of primary care
patients with GAD did not present with the complaint of anxiety or worry; most had nonspecific somatic complaints
(eg, insomnia, head/muscle aches, fatigue, GI Sx)
Panic Disorder/ Agoraphobia TreatmentPatient Education important!
Feelings vs cognitionCognitive Behavioral Therapy
True remission of panic disorder with high functioning occurs in 50% to 70% of patients who receive CBTSSRIs, SNRI’s
highly effective compared with placebohigh rate of discontinuation syndrome
Benzodiazepines are considered second-line or adjunctive treatment • failure to address frequent comorbid depression,• tolerance or abuse potential, • effects on driving, and • possible deleterious effects on cognitive–behavioral treatment
(CBT), especially with as-needed use
Switch: nonresponder to CBT, SSRI trial may work, & vice versa
Acute interventionAnxiety—avoidance—relief cycleFace fears—cognitive reframing &
educationNormalize feelings vs cognitionTeach patience & ability to delay and
reflect vs react“Wagon wheel in a rut”
Positive messages need repetitive reinforcement & support
Major Depressive DisorderInsomnia/ sleep disturbanceAnhedoniaDepressed moodSuicidal thoughts
BHP 9 toolTime(SAD PERSONS mnemonic)
Comorbid—Medical Illness
Cafarella, et al Treatments for anxiety and depression in patients with chronic obstructive pulmonary disease: A literature review. Respirology 2012. 17: 627.
• to bear oneself toward : use <treat a horse cruelly>
• to care for or deal with medically or surgically <treat a disease>
Treat:
Hollon S. et al Effect of Cognitive Therapy With Antidepressant Medications vs Antidepressants Alone on the Rate of Recovery in Major Depressive Disorder A Randomized Clinical Trial JAMA Psychiatry. doi:10.1001/jamapsychiatry.2014.1054 online Aug 20, 2014
Cuijpers P Combined pharmacotherapy and psychotherapy in the treatment of mild to moderate major depression? JAMA Psychiatry 2014;71(7):747-8
Spirito A. Cognitive-Behavioral Therapy for Adolescent Depression and Suicidality Child Adolesc Psychiatric Clin N Am 20 (2011) 191–204
NNT=4
Management: DepressionCBT—as effective as Psychopharm
Start in mild to moderateMay need reduction of symptoms first in
severe depressionPsychopharmaceutical
SSRI: first line (caution in Bipolar illness)SNRICaution re benzodiazepines
Simkin D, Black N. Meditation and Mindfulness in Clinical Practice Child Adolesc Psychiatric Clin N Am 23 (2014) 487–534Miller. Neuroanatomical Correlates of Religiosity and Spirituality. JAMA Psychiatry, 2013; 1 DOI: 10.1001/jamapsychiatry.2013.306Rasic, D et al. Longitudinal relationships of religious worship attendance and spirituality with major depression, anxiety disorders, and suicidal ideation and attempts: Findings from the Baltimore epidemiologic catchment area study J Psych Research Vol. 45, 848-854 (2011)
Williams N et al. Interventional psychiatry: how should psychiatric educators incorporate neuromodulation into training? Acad Psychiatry. 2014 Apr;38(2):168-76.
Nyer M What is the Role of AlternativeTreatments in Late-lifeDepression?Psychiatr Clin N Am 36 (2013) 577–596
Yinger, el al. Music Therapy and Music Medicine for Children and Adolescents Child Adolesc Psychiatric Clin N Am 23 (2014) 535–553
XPopper CW. Single-Micronutrient and Broad-Spectrum Micro- nutrient Approaches for Treating Mood Disorders in Youth and Adults Child Adolesc Psychiatric Clin N Am 23 (2014) 591–672
Gow R, Hibbeln J.
Omega-3 Fatty Acid and Nutrient Deficits in Adverse Neurodevelopment and Childhood Behaviors Child Adolesc Psychiatric Clin N Am 23 (2014) 555–590
Diamond, P et al. Ketamine infusions for treatment resistant depression: a series of 28 patients treated weekly or twice weekly in an ECT clinic J Psychopharmacol June 2014 28: 536-544
Price R et al Effects of ketamine on explicit and implicit suicidal cognition: a randomized controlled trial in treatment-resistant depression. Depression and Anxiety 31:335–343, 2014
Ketamine had a rapid antidepressant effect in some patients with severe depression
http://www.scientificamerican.com/article/is-ketamine-next-big-depression-drug/
https://itunes.apple.com/us/app/safety-plan/id695122998?mt=8
http://www.therapistaid.com/therapy-worksheet/safety-plan/suicide/none
Mental Health & SuicideOver 90% of suicide victims have a mental
health and/or substance use disorder50-75% receive inadequate treatmentRisk increased in Mood Disorders, Anxiety
Disorders, PTSD, and comorbid states with medical illness
Highest in elderly3rd most common cause of mortality in young
adultsIndependent of diagnosis, targeting and
treating suicidal ideation and behaviors may have benefit.
Suicidal ContinuumBest identified before any suicidal behavior occurs. Early identification of suicidal ideation presents the
greatest opportunity to reduce the risk of suicide attempt and death. Continuum begins with suicidal thoughts, evolving into a wish to die, consolidated into an intention to act, resulting in a methodology or plan formulated to end
one’s life. The evolution of these steps can occur over minutes
or years. Each step along the continuum presents an
opportunity to intervene and prevent the act of suicidal self-directed violence.
Treatment TargetsBrent D et al. The Treatment of Adolescent Suicide
Attempters Study (TASA): Predictors of Suicidal Events in an Open Treatment Trial J. Am. Acad. Child Adolesc. Psychiatry, 2009;48(10):987-996suicidal ideation, family cohesion, sequelae of previous abuse.
“40% of events occurred with 4 weeks of intake: an emphasis on safety planning and increased therapeutic contact early in treatment may be warranted”
Wren et al: concept of multiple risk intervention
Safety Box concept IFEM Hong Kong
Direct Warning SignsThree signs with highest likelihood of suicidal
behaviors in the near future:Suicidal communication - writing or talking about suicide, wish to die, or
death (threatening to hurt or kill self))
• Seeking access or recent use of lethal means: such as weapons,
medications, or other lethal means
• Preparations for suicide - evidence or expression of suicide intent, and/or
taking steps towards implementation of a plan. Makes arrangements to divest
responsibility for dependent others (children, pets, elders), or making other
preparations such as updating wills, making financial arrangements for paying
bills, saying goodbye to loved ones, etc.
Worse with a history of previous or multiple attempts
Suicide Risk Assessment & Action
† Modifiers that increase the level of risk for suicide of any defined level :• Acute state of Substance Use: Alcohol or substance abuse history is associated with impaired judgment and may increase the severity of the suicidality and risk for suicide act• Access to means :(firearms, medications) may increase the risk for suicide act• Existence of multiple risk factors or warning signs or lack of protective factors†† Evidence of suicidal behavior warning signs in the context of denial of ideation should call for concern (e.g., contemplation of plan with denial of thoughts or ideation)
1. Ideation QuestionsExample of Questions on Ideation:• “With everything that has been going on, have you been
experiencing any thoughts of killing yourself?”• When did you begin having suicidal thoughts?• Did any event (stressor) precipitate the thoughts?• How often do you have thoughts of suicide?• How long do they last?• How strong are the thoughts of suicide?• What is the worst they have ever been?• What do you do when you have these (suicidal) thoughts?• What did you do when they were the strongest ever?• Do thoughts occur or intensify when you drink or use drugs?
2. Intent QuestionsExample of Questions on Intent:• Do you wish you were dead?• Do you intend to try to kill yourself?• Do you have a plan regarding how you might kill yourself?• Have you taken any actions towards putting that plan in place?• How likely do you think it is that you will carry out your plans?
3. Preparatory Behavior Questions (may need collateral hx)
Examples of Questions on Preparation:• Do you have a plan or have you been planning to kill yourself?If so, how would you do it? Where would you do it?• Do you have the (drugs, gun, rope) that you would use? Where is it right now?• Do you have a timeline in mind for killing yourself?• Is there something (an event) that would trigger acting on the plan?• How confident are you that your plan will end your life?• What have you done to begin to carry out the plan?• Have you made other preparations (e.g., updated life insurance, made arrangements for pets)?
Safety PlanComponent of Safety Plan:The Safety Plan should consist of a written, prioritized list of coping strategies and sources of support that patients can use to alleviate a suicidal crisis.Patients are instructed first to recognize when they are in crisis (Step 1) and then to utilize Steps 2 through 5 as needed to reduce the level of suicide risk:
1. Recognizing warning signs of an impending suicidal crisis2. Employing internal coping strategies3. Utilizing social contacts and social settings as a means of distraction from suicidal thoughts4. Utilizing family members or friends to help resolve the crisis5. Contacting mental health professionals or agencies6. Restricting access to lethal means.
Suicide Focused Therapy
Suicide-focused psychotherapies that have been shown to be effective in reducing risk for repeated self-directed violence should be included in the treatment plan of patients at high risk for suicide, if the risk for suicide is not adequately addressed by psychotherapy specific to the underlying condition.
Goals of Consultation& Hospitalization
Diagnostic ClarificationTreatment initiationMaintenance of SafetyNote Risk vs Benefit: regression,
damage to therapeutic alliance
Benzodiazepines in Suicidal Risk• Use caution when prescribing benzodiazepines
to patients at risk for suicide. • It is important to pay attention to the risk of
disinhibition from the medication, and
respiratory depression (particularly when
combined with other depressants) by limiting the
amount of benzodiazepines dispensed.• Avoid benzodiazepines with a short half-life and
the long-term use of any benzodiazepine to
minimize the risk of addiction and depressogenic
effects.
Depression and Suicide in Children and AdolescentsCan send home if:
The patient is not imminently suicidal.
The patient is in medically stable condition.
The patient and the parents agree to return to the ED if suicidal intent recurs.
The patient is not intoxicated, delirious, or demented.
Potentially lethal means of self-harm have been removed.
Treatment of underlying psychiatric diagnoses has been arranged.
Acute precipitants to the crisis have been addressed and attempts have been undertaken to resolve them.
The physician believes that the patient and family will follow through on treatment recommendations.
The patient's caregivers and social supports are in agreement with the discharge plans.
Borderline PDmood instability, impulsivity, aggressivity
and prone to intense anger.Tendency toward self injury.
Major risk factor for suicide.Associated with as many as 55 % of
attempted suicides.More likely to make repeated attempts
than actually complete one.
Anorexia nervosa Refusal to maintain weight within a
normal range for height and age (>15% below ideal body weight)
Fear of weight gain Severe body image disturbance in which
body image is the predominant measure of self worth with denial of the seriousness of the illness
In females, secondary amenorrhea for greater than three cycles or primary amenorrhea
Eating Disorder Questions--SCOFF1. Do you make yourself Sick because you
feel uncomfortably full? 2. Do you worry you have lost Control over
how much you eat? 3. Have you recently lost more than One
stone (6.4 kg or 14 lb) in a 3-mo period?
4. Do you believe yourself to be Fat when others say you are too thin?
5. Would you say that Food dominates your life?
Eating Disorders ComplicationsCachexia Impaired cell-mediated immunity
Loss of subcutaneous fat Neurologic complications
Muscle wasting Peripheral neuropathy
Hypothermia Seizures
Pitting edema Wernicke encephalopathy
Dehydration Cortical atrophy
Starvation ketosis Euthyroid sick syndrome
Growth retardation Dermatologic complications
Osteopenia and fractures Dry, brittle hair and nails
Primary or secondary amenorrhea Lanugo
Cardiac complications GI complications
Bradycardia Delayed gastric emptying
Orthostatic hypotension Fatty liver infiltration
Arrhythmia Metabolic complications
Prolonged QTc interval
Electrolyte abnormalities
Conduction abnormalities Ketonuria
Mitral valve prolapse Impaired glucose control
Pericardial effusion
Bone marrow suppression
Anemia
Leukopenia
Thrombocytopenia
Suicide is one of the leading causes of death for patients with anorexia.
Involuntary AdmissionInvoluntary hospitalization is considered
when: The patients words or behaviours suggest
that they are at imminent risk of harm to themselves or others,
There is a mental health illnessSpecific guidelines are governed by
individual provinces/ states. Is not a determination of competency