Medical stability & Substance related emergencies M. Nadeem Mazhar MBBS, MRCPsych, FRCPC, DABPN.

Medical stability & Substance related emergencies M. Nadeem MazharMBBS, MRCPsych, FRCPC, DABPN

Objectives

• Review issues regarding “medical clearence” in ED• Assess common medical causes of agitation• Evaluate assessment substance related emergencies

“MEDICAL CLEARANCE”

Medical clearance

“There is no way to rule out every possible medical illness a patient may have prior to admission to a psychiatric unit”

(Zun 2005)

Medical stabilityMaking a reasonable investigation to exclude the possibility of patient having an illness that:1. Would be better treated in a medical setting (e.g.,

infection requiring IV antibiotics)2. Will cause the acute decompensation in the next few

hours requiring a higher level of care (e.g., severe alcohol withdrawal)

3. Causing behavioral symptoms but should be treated by something other than psychiatric medications (e.g., delirium due to an underlying infection)

4. Worsening the psychiatric process (e.g., untreated pain that is causing the agitation)

(Clinical Manual of Emergency Psychiatry)

Physical examination

• Evaluation of patient’s general medical status necessitates that a physical examination be performed

• Physical examination may be performed by the psychiatrist, another physician, or a medically trained clinician

• Particular caution in examination of patients with histories of sexual abuse- “All but limited examination of such patients should be chaperoned”

(APA Practice Guidelines for Psychiatric Evaluation of Adults- second edition, 2006)

Physical examinationSpecific elements may include the following:• General appearance, height, weight, BMI & nutritional

status• Vital signs• Head and neck, heart, lungs, abdomen, and extremities• Neurological status, including cranial nerves, motor and

sensory function, gait, coordination, muscle tone, reflexes, and involuntary movements

• Skin e.g., stigmata of self injury or drug use• Any body area or organ system specifically mentioned in

the HPI or ROS(APA Practice Guidelines for Psychiatric Evaluation of Adults- second edition, 2006)

General appearance

• Cachexia- suspicion of cancer, HIV, TB, malnutrition• Obvious respiratory distress• Obvious physical distress or agitation• Grossly dishevelled or malodorous patient• Rashes- allergic or infectious diseases

HEENT

• Dry mucous membranes- dehydration• Pupils and eye movements- focal neurological deficits,

evidence of drug intoxication/withdrawal• Scleral icterus- jaundice• Proptosis- hyperthyroidism• Bruises, lacerations- evidence of head/facial trauma• Poor dentition- nutritional status

Neck

• Thyromegaly- goiter, hyperthyroidism• Neck rigidity- meningitis, encaphalitis

Chest

• Rales- congestive heart failure• Rhonchi- pneumonia

Cardiovascular

• Rate, rhythm, regularity of heartbeat• Vascular disease- any absent peripheral pulses

Abdomen

• Hepatomegaly- undiagnosed liver disease• Acute tenderness- acute pathology that needs to be

addressed in ED

Extremities

• Any deficits, limps or pain

Neurological

• Any focal deficits indicating stroke• Festinating gait, rigidity- parkinsonism• Tremors- EPSE, Parkinson’s disease• Broad based gait- hydrocephalus, tertiary syphilis• Evidence of tardive dyskinesia

Diagnostic tests in Psychiatry

1. Detect or rule out presence of condition that has treatment consequences

2. Determine the relative safety and appropriate dose of potential alternative treatments

3. Provide baseline measurements before instituting treatment

4. Monitor blood levels of medication when indicated

(APA Practice Guidelines for Psychiatric Evaluation of Adults- second edition, 2006)

Laboratory tests

CBC:• Macrocytic anemia- vitamin B12/folate deficiency,

alcohol abuse• Microcytic anemia- iron deficiency• Normocytic anemia- acute bleeding or chronic

inflammatory disease• Leukocytosis- acute infection• Leukopenia- advanced HIV disease, leukemia,

carbamazepine• Low platelets- Valproate, ITP

Laboratory tests

Electrolytes & Creatinine:• Elevated creatinine- renal failure• Hyponatremia- SSRI’s• Hypernatremia- dehydration, renal failure• Hypokalemia- risk for arrhythmia, bulimia, diuretic use• Hyperkalemia- risk for arrhythmia, renal failure• Low bicarbonate- acidosis, aspirin ingestion

Laboratory tests

Liver enzymes:•Elevated AST: ALT ratio- alcohol abuse•Elevated ALT & AST: liver failure due to multiple causes e.g., acetaminophen ingestion, hepatitis

Laboratory tests

TSH:• Elevated- hypothyroidism leading to depression,

cognitive changes• Low- hyperthyroidism leading to manic like symptoms,

agitation

Laboratory tests

Vitamin B12 & Folate:• Low B12- neurological changes, memory problems• Low folate- evidence of general malnutrition, association

with depression

Laboratory tests

• Syphilis serology/HIV testing• Medication levels• Blood alcohol levels• Fasting blood glucose or hemoglobin A1c• Pregnancy test• Urinalysis• Urine drug screen

Other investigations

Chest X-ray: Considered for all homeless people, any patients with suspicion of TB, and elderly patientsHead CT: In patients with altered mental status or new-onset psychosis- to rule out SOL or bleedingEEG: Evidence of metabolic encephalopathy (delirium), nonconvulsive status epilepticusECG: Medications that may influence cardiac functionLumbar puncture: Any patient with new mental status changes, fever, and/or meningeal signs- to rule out meningitis, encephalitis, bleeding, cryptococcal infection

Agitation- medical causes

Delirium:• Waxing and waning level of consciousness• Fluctuation in vital signs• Confusion• Can be irritable or passive and detached• More common in elderly

Agitation- medical causes

Hypogylcemia:• Altered mental status• Sweating• Tachycardia• Weakness

Agitation- medical causes

Post-ictal states:• Altered level of consciousness• Confusion• Ataxia• Todd paralysis• Neurological signs such as slurred speech• Evidence of tongue biting or incontinence

Agitation- medical causes

Structural brain abnormality:• Varies by lesion• Altered mental status• Headache• Meningeal signs• Focal neurological deficit or progressive neurological

deterioration

Agitation- medical causes

Toxicologic emergency:• Varies by substance• Mental status changes• Pupillary changes• Vital sign changes• Sweating

SUBSTANCE RELATED PSYCHIATRIC EMERGENCIES

Initial evaluation

• Thorough history using available resources• MSE• Physical examination• Laboratory tests• Imaging studies• Urine drug detection- ELISA, gas chromatography- mass

spectrometry

The depressed patient

MSE suggestive of depression or psychomotor slowing:

• Alcohol intoxication• Sedative-hypnotic toxicity• Opioid toxicity• OTC cough & cold medication• Inhalant intoxication• CNS stimulants withdrawal

Alcohol intoxication

• Most common cause of substance related emergencies• Studies showing up to 40% of ED patients having alcohol

detected in their blood• CNS depressant effect by increasing responsivity of GABA

type A receptors to GABA and inhibiting effects of glutamate at its receptors

• Disinhibition at onset resulting agitation, combativeness and rarely psychosis

• Dose-dependent CNS depression: Diminished coordination→ slurred speech/ataxia→ respiratory depression/coma

• Legal limit: 0.05%- 0.08% (50mg/dl – 80mg/dl or 10.85 mmol/L – 17.36 mmol/L)

Alcohol intoxication

• Treatment of alcohol intoxication- supportive• Gastric lavage not useful due to rapid absorption of

alcohol from gastrointestinal tract• Serial monitoring of toxic blood alcohol levels for

expected gradual drop• Chronic alcoholics metabolize ETOH at a rate of 15-20

mg/dl per hour• In case of persistent alteration in consciousness→

exclude other causes e.g., other toxins, metabolic dysfunction or subdural hematoma

Sedative-hypnotic toxicity

• Can occur in acute overdoses, patients exceeding scheduled doses or with concomitant administration of other CNS depressants• Accumulation can also result in liver disease, advanced

age and pharmacokinetic drug interactions• Temazepam, oxazepam, lorazepam & alprazolam

metabolized primarily by conjugation- less likely to accumulate in liver impairment• Dose dependent effects on coordination, cognition and

consciousness• Paradoxical agitation/excitement can also result from

drug induced disinhibition

Sedative-hypnotic toxicity• Vomiting, diarrhea and urinary retention can occur in

BZD toxicity• Flumazenil ≤ 1mg reverses BZD effects- may precipitate

seizures in dependent individuals• BZD’s rarely lethal by themselves• Synergism with other CNS depressants e.g., alcohol &

opioids• Can worsen ventilation in patients with preexisting

cardio-respiratory conditions e.g., OSA, COPD & CHF• High index of suspicion in patients with history of ETOH

abuse• BZD misuse also likely in patients on opioids & cocaine

users

Opioid toxicity

• Miosis + CNS & respiratory depression• Slow, shallow respiration, absent GI sounds & urinary

retention • Toxicity can also result from acetaminophen or NSAIDs

frequently combined with prescription opioids• Naloxone is a specific antidote→ can precipitate opioid

withdrawal• Repeated doses may be required due to naloxone’s short

half life

OTC cold & cough medications

• Frequently abused by adolescents to get “high”• May contain mixtures of various antihistamines,

sympathomimetics with or without dextromethorphan• Difficult to detect in urine→ pseudoephedrine may

screen positive for amphetamine

Inhalant intoxication

• Include a variety of hydrocarbons including toxic solvents• Initial stage of disinhibition, excitement, or a sense of

drunkenness→ restlessness, ↓consciousness, ataxia, respiratory depression, coma and death with ↑inhaled concentrations• Risk of arrhythmias, possible hepatic injury and long-

term effects on cognition

CNS stimulant withdrawal

• The cocaine “crash”• Dysphoria that may be accompanied by suicidal ideation,

sleep disturbance and cravings• Increased appetite as a rebound to appetite-suppressant

effects of stimulants

Agitated, aggressive & psychotic patientAgitated behavior ranging from belligerence to physical aggression to full blown psychosis:• Alcohol withdrawal• Sedative-hypnotic withdrawal• Opioid withdrawal• CNS stimulant intoxication• Hallucinogen intoxication• Marijuana intoxication

Alcohol withdrawal• Combativeness and aggression could be seen in both

alcohol intoxication and withdrawal• BAL at which withdrawal occurs varies from patient to

patient• Can begin in as little as 6 hours from the last drink• Autonomic instability: ↑BP, tachycardia & sweating• GI symptoms: Nausea, vomiting & diarrhea• CNS activation: Anxiety & tremor• Serious withdrawal: Hallucinations & seizures• Delirium tremens: After 48-72 hours, about 5% of

patients in alcohol withdrawal, develop DTs- hallucinations (usually visual), delirium and severe autonomic instability

Alcohol withdrawal & CIWA

1) Nausea and vomiting: 0-7 score2) Tremor: 0-73) Paroxysmal sweats: 0-74) Anxiety: 0-75) Agitation: 0-76) Tactile disturbances: 0-77) Auditory disturbances: 0-78) Visual disturbances: 0-79) Headache: 0-710) Orientation: 0-4

CIWA & MedicationCumulative Score Medication Requirement

0-8 No medication

9-14 Medication optional

15-20 Medication treatment

>20 Strong risk of DT

67 Maximum possible cumulative score

Structured medication regimens1) Chlordiazepoxide: • 50 mg Q6H X 4• Followed by 25 mg Q6H X 82) Diazepam:• 10 mg Q6H X 4• Followed by 5 mg Q6H X 83) Lorazepam:• 2 mg Q6h X 4• Followed by 1 mg Q6H X 84) Carbamazepine:• 400 mg BID on day 1• Tapering down to 200 mg as a single dose on day 5

Pharmacological treatment of alcohol withdrawal• Benzodiazepines• Anticonvulsants• Beta- blocking agents• Alpha-adrenergic agonists• Thiamine• Neuroleptic agents

Sedative-hypnotic withdrawal• Occurs within the first few hours to days after

discontinuation following a period of regular use• Similar to alcohol withdrawal except: extended over days

to weeks (instead of hours to days)• Anxious prodrome→ tremor, tachycardia, hypertension,

diaphoresis, GI upset, mydriasis, sleep disturbance & nightmares, tinnitus, ↑sensitivity to sound, light & tactile stimuli• Confusion, delirium, hyperthermia & GTCS can occur in

severe withdrawal• Significant anxiety, sleep disturbance and mild

autonomic symptoms may persist for many months

Sedative-hypnotic withdrawal

• Switch to longer acting agent & gradually taper (10%/week)• Carbamazepine 200 mg t.i.d. for 7-10 days (gabapentin

and divalproex are alternatives)

Opioid withdrawal• Heralded by anxiety, craving/preoccupation & vague

discomfort (hyperalgesia)• Pupillary dilatation, lacrimation, rhinorrhea, diaphoresis,

piloerection, arthralgia/myalgia, diarrhea, yawning & sneezing• Rarely causes change in mental status except for

↑anxiety• Onset: 6-72 hours after last use/dose• Peak: 2-4 days• Resolution: 7-10 days• Not life threatening in otherwise healthy patient• Miscarriage in pregnancy

Clinical Opiate Withdrawal Scale (COWS)• Resting pulse rate (0-4 score)• Sweating (0-4 score)• Restlessness (0-5 score)• Pupil size (0-5 score)• Bone or Joint aches (0-4 score)• Runny nose or tearing (0-4 score)• GI upset (0-5 score)• Tremor (0-4 score)• Yawning (0-4 score)• Anxiety or irritability (0-4 score)• Gooseflesh skin (0-5 score)• Severity of withdrawal: 5-12= mild, 13-24= moderate, 25-36= moderately severe, >36= severe

Opioid withdrawal treatment

CPSO MMT Guidelines-2011

Drug Dose Withdrawal Symptoms

Clonidine 0.1-0.2 mg P.r.n. b.i.d.- q.i.d.

Agitation, diapohresis

Dimenhydrinate 50 mg p.o. or p.r. p.r.n.

nausea

Ibuprofen 200-400 mg p.r.n. t.i.d.

myalgia

Immodium 2 mg p.r.n. max 6 tabs/day

diarrhea

Trazodone 50-100 mg q.h.s. p.r.n.

insomnia

Benzodiazepines p.r.n. anxiety

CNS stimulant intoxication• Amphetamines, cocaine & MDMA• Physical signs: tachycardia, tachypnea, hypertension,

mydriasis, myoclonus, hyperreflexia, tremor, vomiting, hyperthermia & possible seizures• Psychosis: paranoid delusions, tactile or visual

hallucinations. Rarely FTD or bizarre delusions. Appear abruptly & resolve quickly (i.e., within days). More likely to have insight• Stimulant toxicity fatal in severe cases, often from

cardiovascular or cerbrovascular causes• Treatment: minimization of stimulation, sedation with

BZD, caution with neuroleptics due to the potential for lowering seizure threshold and avoiding physical restraints if possible

Hallucinogen intoxication

• Physical symptoms: hyperthermia & seizures• Psychological symptoms: prominent anxiety symptoms

with “bad trips” including panicky feelings & fear of losing one’s mind. Psychosis is typically accompanied with relatively preserved insight• Treatment: Similar to management of stimulant

intoxication

Marijuana intoxication

• Common presentation in chronic high-dose marijuana users is the experience of hypervigilance, depersonalization& derealization• Physical symptoms/signs: conjunctival injection,

orthostatic hypotension, dry mouth & tachycardia

Drug seeking patient

• BZD’s for anxiety• Opioids for the treatment of pain (often out of

proportion to objective findings)• Suspect drug seeking behavior:1. When a specific medication is asked for2. Stating that prescription was “lost” and provider not

immediately available3. Claims allergy to alternate medications4. Threaten to be suicidal unless get prescription for

specific medication

SUBSTANCE RELATED PSYCHIATRIC EMERGENCIES- CASE DISCUSSION

History• 35 years old with diagnoses of GAD, panic disorder with

agoraphobia and antisocial personality traits presents to ER with worsening anxiety (thinks his chest and head are going to explode), diffuse muscle aches, diarrhea, nausea and sweating

Medications• Effexor XR 75 mg QD• Epival 500 mg BID• Risperidone 0.5 mg BID• Clonazepam 1 mg TID + 1 mg PRN daily (concerns about

abusing)

Physical examination• Temp 36.7• Pulse 101• Resp 20• BP 145/97• Oxygen sats 98%• Dilated pupils

Diagnosis & Treatment• Most likely substance related diagnosis?• Pharmacological treatment options?

DSM-IV Sedative/Hypnotic WithdrawalTwo or more of the following:

• Autonomic hyperactivity (sweating or pulse rate greater than 100)

• Increased hand tremor• Insomnia• Nausea or vomiting• Transient visual, tactile or auditory hallucinations or illusions• Psychomotor agitation• Anxiety• Grand mal seizures

DSM-IV Opioid Withdrawal

Three or more of the following:

• Dysphoric moods• Nausea or vomiting• Muscle aches• Lacrimation or rhinorrhea• Pupillary dilatation, piloerection or sweating• Diarrhea• Yawning• Fever• Insomnia

Reference• APA Practice Guidelines for Psychiatric Evaluation of Adults- second

edition (2006).• Riba M., Ravindranath D. (2010). Clinical Manual of Emergency Psychiatry. Washington DC: American Psychiatric Publishing Inc.• Zun LS. Evidence-based evaluation of psychiatric patients. J Emerg Med 2005; 28: 35-39.