Behavioral & Behavioral & Psychiatric Psychiatric Problems Problems Scott Marquis, MD Scott Marquis, MD
Feb 24, 2016
Behavioral & Behavioral & Psychiatric Psychiatric ProblemsProblems
Scott Marquis, MDScott Marquis, MD
What is a behavioral What is a behavioral emergency?emergency?
An unanticipated behavioral An unanticipated behavioral episodeepisode
Behavior that is threatening to Behavior that is threatening to patient or otherspatient or others
Requires immediate intervention Requires immediate intervention by emergency respondersby emergency responders
Abnormal BehaviorAbnormal Behavior No clear definition, but is No clear definition, but is
maladaptivemaladaptive Deviates from societies norms and Deviates from societies norms and
expectationsexpectations Interferes with individual well-Interferes with individual well-
being and ability to functionbeing and ability to function Harmful to self or othersHarmful to self or others
Behavioral ChangeBehavioral Change NeverNever assume a patient has a assume a patient has a
psychiatric illness until all possible psychiatric illness until all possible physical causes have been ruled physical causes have been ruled outout
‘‘Clues’Clues’Underlying Physical IllnessUnderlying Physical Illness
Sudden onsetSudden onset Visual, but not auditory, hallucinationsVisual, but not auditory, hallucinations Memory loss or impairmentMemory loss or impairment Altered pupil size, asymmetry, or Altered pupil size, asymmetry, or
impaired reactivityimpaired reactivity Excessive salivation or incontinenceExcessive salivation or incontinence Unusual breath odorsUnusual breath odors
Behavioral ChangeBehavioral ChangePossible CausesPossible Causes
Low blood sugarLow blood sugar HypoxiaHypoxia Inadequate cerebral blood flowInadequate cerebral blood flow Head traumaHead trauma Drugs, alcoholDrugs, alcohol Excessive heat or coldExcessive heat or cold CNS infectionsCNS infections
Behavioral Change Behavioral Change PathophysiologyPathophysiology
Biological or organicBiological or organic PsychosocialPsychosocial Socio-culturalSocio-cultural
Organic CausesOrganic Causes DiseaseDisease
Metabolic disorders, infection, Metabolic disorders, infection, endocrine disorders, neoplastic endocrine disorders, neoplastic disease, cardiovascular disease, or disease, cardiovascular disease, or degenerative diseasedegenerative disease
Physical injuryPhysical injury Head traumaHead trauma
More Organic CausesMore Organic Causes ToxinsToxins
Drug abuse, medication reactions, Drug abuse, medication reactions, carbon monoxidecarbon monoxide
Disturbance in cognitive Disturbance in cognitive functioningfunctioning Delirium, dementiaDelirium, dementia
Psychiatric DisordersPsychiatric Disorders
EpidemiologyEpidemiology Mental health problems affect as Mental health problems affect as
much as 20% of general populationmuch as 20% of general population More than all other health problems More than all other health problems
combined!combined! An estimated 1 in 7 persons will An estimated 1 in 7 persons will
need treatment for an emotional need treatment for an emotional disturbance at some time in their disturbance at some time in their liveslives
Anxiety DisordersAnxiety Disorders Most common psychiatric problem Most common psychiatric problem
encountered in outpatients encountered in outpatients Painful uneasiness, a reaction to Painful uneasiness, a reaction to
difficult situations or past/present difficult situations or past/present life stressorslife stressors
Interferes with effective functioningInterferes with effective functioning Agitation or restlessness quite often Agitation or restlessness quite often
confused as something elseconfused as something else
Anxiety DisordersAnxiety Disorders Anxiety, generalizedAnxiety, generalized Panic disordersPanic disorders PhobiasPhobias Obsessive-compulsive disorderObsessive-compulsive disorder Post-traumatic syndromesPost-traumatic syndromes
Mood DisordersMood Disorders Patient mood ranges from Patient mood ranges from
extremely low to euphoric behaviorextremely low to euphoric behavior May often be more subtle, a loss of May often be more subtle, a loss of
interest or enjoyment in any of interest or enjoyment in any of his/her normal pleasureshis/her normal pleasures
Physical complaints are commonPhysical complaints are common
DepressionDepression Hopelessness, worthlessness, Hopelessness, worthlessness,
sleep or eating disturbances, sleep or eating disturbances, unable to concentrate, slowed unable to concentrate, slowed reaction timereaction time
AlwaysAlways ask about suicide! ask about suicide! A factor in 50% of suicidesA factor in 50% of suicides
Bipolar DisorderBipolar Disorder Manic-depressive cyclesManic-depressive cycles Manic – euphoric, grandiose, Manic – euphoric, grandiose,
pressured, may claim to have pressured, may claim to have special powersspecial powers
Depressed – sad, hopeless, Depressed – sad, hopeless, suicidal, “crash” after maniasuicidal, “crash” after mania
May be delusional in either phaseMay be delusional in either phase
Psychotic DisordersPsychotic Disorders ““A break from reality”A break from reality” Not always a psychiatric cause; Not always a psychiatric cause;
consider alcohol, drugs, and consider alcohol, drugs, and medication reactionsmedication reactions
One percent of general population One percent of general population will be diagnosed with will be diagnosed with schizophreniaschizophrenia
SchizophreniaSchizophrenia Debilitating distortions of speech Debilitating distortions of speech
and thoughtand thought Bizarre hallucinations, delusions, Bizarre hallucinations, delusions,
or behavioror behavior Social withdrawalSocial withdrawal Lack of emotional expressiveness, Lack of emotional expressiveness,
“flat”“flat”
SchizophreniaSchizophrenia ParanoidParanoid CatatonicCatatonic DisorganizedDisorganized UndifferentiatedUndifferentiated
Substance-Related Substance-Related DisordersDisorders
IntoxicationIntoxication DependenceDependence WithdrawalWithdrawal
A close friend of psychiatric illnessA close friend of psychiatric illness Particularly tight links to Particularly tight links to
depression and suicidal behavior!depression and suicidal behavior!
Violent PatientsViolent Patients
SuicideSuicide NeverNever dismiss any suicidal threat, no dismiss any suicidal threat, no
matter how well you know the patientmatter how well you know the patient
Suicide rate in your prehospital Suicide rate in your prehospital population is 10 times that of the population is 10 times that of the general population!general population!
Women attempt suicide more oftenWomen attempt suicide more often Men Men succeedsucceed more often more often
Who is at greatest risk?Who is at greatest risk? White men over 40White men over 40 Living alone, divorced, or widowedLiving alone, divorced, or widowed Substance abuse problemsSubstance abuse problems Severe depressionSevere depression Past suicide attemptsPast suicide attempts Highly lethal planHighly lethal plan
SuicideSuicide Asking about a specific suicide Asking about a specific suicide
plan will plan will notnot make suicide more make suicide more likely!likely!
Having a detailed plan does put Having a detailed plan does put your patient at higher riskyour patient at higher risk
Suicide Suicide Additional Risk FactorsAdditional Risk Factors
Means are available, low likelihood of Means are available, low likelihood of rescuerescue
Poor physical health; chronic disease Poor physical health; chronic disease or pain syndromeor pain syndrome
Recent loss of a loved one, anniversaryRecent loss of a loved one, anniversary Sudden life changes; unemployment, Sudden life changes; unemployment,
bankruptcy, imprisonmentbankruptcy, imprisonment Family history of suicide, especially a Family history of suicide, especially a
parentparent
Managing Behavioral Managing Behavioral EmergenciesEmergencies
Guiding PrinciplesGuiding Principles Respect the dignity of the patientRespect the dignity of the patient Assure your own as well as the Assure your own as well as the
patient’s and others safetypatient’s and others safety Diagnose and treat organic causes Diagnose and treat organic causes
of behavioral disordersof behavioral disorders Work with law enforcement to Work with law enforcement to
improve patient care outcomesimprove patient care outcomes
Scene Size-UpScene Size-Up Pay careful attention to dispatch Pay careful attention to dispatch
information for indications of information for indications of potential violencepotential violence
Never enter potentially violent Never enter potentially violent situations without police supportsituations without police support
If personal safety is uncertain, If personal safety is uncertain, stand by for policestand by for police
Scene Size-UpScene Size-Up In suicide cases, be alert for In suicide cases, be alert for
hazardshazards Automobile running in closed garageAutomobile running in closed garage Gas stove pilot light blown outGas stove pilot light blown out Electrical devices in waterElectrical devices in water Toxins on or around the patientToxins on or around the patient
Scene Size-UpScene Size-Up Quickly locate the patientQuickly locate the patient Stay between patient and doorStay between patient and door Scan quickly for any dangerous Scan quickly for any dangerous
articlesarticles If patient has a weapon, ask him/her If patient has a weapon, ask him/her
to put it downto put it down If he/she won’t, back out and wait for If he/she won’t, back out and wait for
the policethe police
Scene Size-UpScene Size-Up Look for…Look for…
Signs of possible underlying medical Signs of possible underlying medical problemsproblems
Methods or means of committing Methods or means of committing suicidesuicide
Multiple patientsMultiple patients
General ApproachGeneral Approach Do not argue or shout Do not argue or shout Remove disturbing persons or Remove disturbing persons or
objectsobjects Provide emotional supportProvide emotional support Explain all procedures carefully to Explain all procedures carefully to
anxious or confused patientsanxious or confused patients
Initial AssessmentInitial Assessment Rapid assessment of ABC’sRapid assessment of ABC’s Identify and treat potentially life-Identify and treat potentially life-
threatening illness and injuriesthreatening illness and injuries Observe patient’s outward Observe patient’s outward
behavior and body languagebehavior and body language
Interview ApproachInterview Approach Communicate in a calm and non-Communicate in a calm and non-
threatening, nonjudgmental waythreatening, nonjudgmental way Identify yourself and offer the Identify yourself and offer the
patient assistancepatient assistance Seek the patient’s cooperationSeek the patient’s cooperation Encourage patient to talk; show Encourage patient to talk; show
you are listeningyou are listening
Interview ApproachInterview Approach Be supportive and limit Be supportive and limit
interruptionsinterruptions Respect patient’s space, limit Respect patient’s space, limit
touching unless given permissiontouching unless given permission Be direct and always tell the truthBe direct and always tell the truth Involve trusted family, friendsInvolve trusted family, friends
Focused HistoryFocused History Ask for and acknowledge patient’s Ask for and acknowledge patient’s
complaintscomplaints Determine onset of behavioral eventDetermine onset of behavioral event Ask about precipitating factors; Ask about precipitating factors;
remove patient from these, if possibleremove patient from these, if possible Existing life situationExisting life situation Previous psychiatric as well as Previous psychiatric as well as
medical historymedical history
Focused HistoryFocused History Mental status, affect, and behaviorMental status, affect, and behavior Current medications and alcohol or Current medications and alcohol or
illicit drug useillicit drug use Evaluate potential for suicide!Evaluate potential for suicide!
AssessmentAssessmentSuicidal PatientsSuicidal Patients
Do not trust “rapid recoveries”Do not trust “rapid recoveries” Do something tangible for the Do something tangible for the
patientpatient Do not try to deny that a suicide Do not try to deny that a suicide
attempt occurredattempt occurred NeverNever challenge a patient to go challenge a patient to go
ahead, do itahead, do it
AssessmentAssessmentViolent PatientsViolent Patients
Find out if patient has threatened or Find out if patient has threatened or has history of violence, aggression, has history of violence, aggression, combativenesscombativeness
Assess body language for clues to Assess body language for clues to potential violencepotential violence
Listen for clues to violence in Listen for clues to violence in patient’s speechpatient’s speech
Monitor movements, physical activityMonitor movements, physical activity Be firm, clearBe firm, clear
Physical ExamPhysical Exam Vital signs and general appearanceVital signs and general appearance Skin examSkin exam Mental statusMental status Evidence for medical problem, Evidence for medical problem,
recent trauma, or an overdoserecent trauma, or an overdose Threat to self or othersThreat to self or others Patient able to provide for needsPatient able to provide for needs
Management PrinciplesManagement Principles Treat life-threatening medical Treat life-threatening medical
problems or traumatic injury first problems or traumatic injury first and foremostand foremost
Hypoxic? Hypoperfused? Hypoxic? Hypoperfused? Temperature extreme? Temperature extreme? Hypoglycemic? Overdose? Hypoglycemic? Overdose? Trauma? Infection?Trauma? Infection?
Management PrinciplesManagement Principles Maintain scene safety; control any Maintain scene safety; control any
violent situationsviolent situations NeverNever leave the patient alone leave the patient alone Transport patient against his/her Transport patient against his/her
will, if indicatedwill, if indicated Restrain the patient only as last Restrain the patient only as last
resortresort
Restraining PatientsRestraining Patients A patient may be restrained if you A patient may be restrained if you
have good reason to believe have good reason to believe he/she is a danger to:he/she is a danger to: YouYou Himself/herselfHimself/herself OthersOthers
Restraining PatientsRestraining Patients Have sufficient manpowerHave sufficient manpower Have a plan; know who will do whatHave a plan; know who will do what Use only as much force as needed; Use only as much force as needed;
don’t be punitivedon’t be punitive When the time comes, act quickly; When the time comes, act quickly;
take the patient by surprisetake the patient by surprise Use at least four rescuers, one for Use at least four rescuers, one for
each extremityeach extremity
Restraining PatientsRestraining Patients Use humane restraints (soft Use humane restraints (soft
leather, cloth) on limbsleather, cloth) on limbs Secure patient to stretcher with Secure patient to stretcher with
straps at chest, waist, thighsstraps at chest, waist, thighs If patient spits, cover his/her face If patient spits, cover his/her face
with surgical maskwith surgical mask Once restraints are applied, never Once restraints are applied, never
remove them!remove them!
Chemical RestraintsChemical Restraints When physical restraints alone are When physical restraints alone are
not enoughnot enough Establish on-line medical controlEstablish on-line medical control Haloperidol (Haldol), 5-10 mg IV or IMHaloperidol (Haldol), 5-10 mg IV or IM Lorazepam (Ativan), 1-2 mg IV or IMLorazepam (Ativan), 1-2 mg IV or IM Diphenhydramine (Benadryl), 25-50 Diphenhydramine (Benadryl), 25-50
mg IV or IM or hydroxyzine, 50-100 mg IV or IM or hydroxyzine, 50-100 mg IMmg IM
Chemical RestraintsChemical Restraints Haldol and movement disorders do Haldol and movement disorders do
not mix wellnot mix well Worsens extrapyramidal effectsWorsens extrapyramidal effects Minimal anticholinergic and Minimal anticholinergic and
cardiovascular effectscardiovascular effects Ativan ideal for agitation due to Ativan ideal for agitation due to
withdrawalwithdrawal Beware of additive CNS depressant effectBeware of additive CNS depressant effect
Chemical RestraintsChemical Restraints Antihistamines Antihistamines
Hydroxyzine useful in drug abusers, Hydroxyzine useful in drug abusers, little habituationlittle habituation
Benadryl can worsen asthma Benadryl can worsen asthma symptoms and lower seizure symptoms and lower seizure thresholds at higher dosesthresholds at higher doses
Behavioral EmergenciesBehavioral EmergenciesPearlsPearls
Look carefully for physical causes Look carefully for physical causes to explain behavioral emergenciesto explain behavioral emergencies
Pay special attention to your own Pay special attention to your own and others safetyand others safety
Ask about suicide or past violent Ask about suicide or past violent behaviorbehavior
Treat patients fairly and with as Treat patients fairly and with as much dignity as possiblemuch dignity as possible