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The Evaluation and Treatment of the Emergency Psychiatric Patient W. Scott Griffies, M.D. LSUNO Department of Psychiatry.

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Presentation on theme: "The Evaluation and Treatment of the Emergency Psychiatric Patient W. Scott Griffies, M.D. LSUNO Department of Psychiatry."— Presentation transcript:

1 The Evaluation and Treatment of the Emergency Psychiatric Patient W. Scott Griffies, M.D. LSUNO Department of Psychiatry

2 An ER Behavioral Healthcare Infrastructure ER physician assessment includes mental status exam. Crisis Assessment S.W., P.N.P., or P.R. include complete psychosocial assessment. Psychiatric Consultant rounds bi-daily. (possible telepsychiatry) Social Service (S.W.) Discharge Plan/Resources.

3 CIU/BHETU Stabilization Units In Conjunction with ER 5-30% have medical illness

4 Disposition Evaluation Nature and duration of Illness Relationship to baseline Adequacy of self-care Level of social supports Risk of homicide/suicide

5 Differential Diagnosis Delirium Psychotic Disorders Mood Disorders Developmentally Disabled – have above diagnoses, but, since they are often nonverbal, diagnoses will be primarily based on behavioral observations and descriptions.

6 Medical Delirium Acute Onset Fluctuating, Altered Sensorium Abnormal MMSE

7 Life-Threatening - - WWHHIMP Drug withdrawal Wernicke encephalopathy Cerebral hypoxemia Hypoglycemia Hypertensive encephalopathy Intracranial bleeding Meningitis/encephalitis Poisoning

8 An Option for Outpatient Psychosocial Planning of Substance Dependence Call AA/NA and have sponsor visit patient in ER Prescribe daily or bidaily NA/AA Group meetings for first 2 weeks post discharge. Follow-up with addiction disorder clinic. Register for Rehab Program.

9 Psychotic Disorders Clear sensorium Delusions Hallucinations Disorganized speech and behavior Flat or inappropriate affect

10 Psychosis Differential Substance – induced Due to medical condition Schizophrenia Mood Disorder (BMD/MDE) Dementia with delusions

11 Psychosis Differential (cont.) Brief Psychotic Episode Schizophreniform Delusional Disorder

12 Mood Disorders – BMD and MDE +/- Psychotic Features, Severe Agitation Mania - - Decreased need for sleep, increased energy, agitation, irritability, liability, projects, missions, hypertalkative, pressured, racing. R/o organic etiology, especially if acute.

13 Treatment of Acute Psychotic/Severe Agitation Haldol 5 mg, Benadryl 50 mg, Ativan 2 mg IM. (B 52 ) Repeat Haldol 5mg IM +/- Ativan 1-2 mg q1-2h IM as needed until calm.

14 Other Guidelines Use 25-50% for elderly Monitor ECG when possible Most calm after 1-2 injections

15 Treatment of Acute Agitation Other Options Zyprexa 10 mg q 2 h X 1, then q 4 h not to exceed 30 mg/24 h. Do not give concomitant Benzos. Geodon 10 mg q 2 h or 20 mg q 4 h, not to exceed 40 mg/24 h. Use 25-50% for elderly/medically compromised. Not indicated for dementia-related psychosis.

16 Switching to Oral Antipsychotics for Schizophrenia, BMD, MDE with Psychoses While Awaiting Admission. Haldol 2-5 mg po q daily --BID Zydis (melts in mouth): 10-15 mg po q daily initially. Seroquel 50 po BID. Increase by 100 mg/day to 600 mg/day in divided doses - - more at night.

17 Switching to Oral Antipsychotics for Schizophrenia, BMD, MDE with Psychoses While Awaiting Admission. (Cont.) Risperidol 1 mg po BID. 1 st day, 2 mg BID 2 nd day, 3 mg 3 rd day. Geodon 40 mg po BID (usually 2 nd line) Abilify 10-15mg Use 25-50% for elderly/medically compromised.

18 Second Generation Antipsychotics: Long term Side Effects Zyprexa, -- most weight gain, metabolic syndrome (Relative cotraindication in D.M. Obesity,  Cholesterol) Risperidol, Seroquel – Second-most metabolic syndrome issues. Geodon, Abilify – least weight gain and metabolic syndrome.

19 Second Generation Antipsychotics: Side Effects Risperidol – hyperprolactenemia Geodon – Relative QTC prolongation Relative contraindication in patients with CVS history. If CVS history, perform EKG. Seroquel – most antihistaminic, sedating

20 Anxiety Adjustment d/o with anxious mood GAD Panic OCD Social Phobia

21 ER Treatment of Anxiety Ativan 1-2 mg po q 4-6 h Klonipin 0.5 – 1 mg po BID – TID Use SSRI long term.

22 Borderline P.D. Impulsivity Parasuicidal behavior Abandonment anxiety Labile affect

23 Agitation in Borderline P.D. Benzodiazepines may disinhibit Seroquel 50 po nightly/BID

24 Suicide Level of intent Level of lethality Prior attempts Late life white divorced male Living alone Lack of sleep/agitation

25 Major Depressive Episode (MDE) Depressed mood or loss of interest/pleasure x 2 weeks. Five/nine symptoms – depressed mood,  interest/pleasure,  or  weight, insomnia/hypersomnia, psychomotor agitation/retardation, fatigue/  energy,  selfworth,  concentration, SI

26 Choice of Antidepressant – General Issues Needs weekly f/u x 4 weeks with new antidepressant Start low, go slow, especially in anxious, somatisizing patients. Early side effects usually diminish in 10-14 days. If tolerable, hang in there.

27 Choice of Antidepressant – General Issues Activating agent may need sleeping agent – Trazodone (Priapism), Ambien, Lunesta Don’t give if mania hx

28 Antidepressant Choices– Selective Variables Wellbutrin (150 mg) - norepinephrine/dopamine – activating,  energy,  concentration, no sexual SE’s. Effexor (75 mg) - combination serotonin, norepinephine – monitor BP, especially at higher dose – good for GAD also.

29 Antidepressant Choices– Selective Variables Cymbalta (30 mg) – combination norepinephrine/ serotonin – pain syndromes, start 30 mg for 7-14 days to mitigate nausea. Remeron (15 mg) – po q nightly – combination serotonin, norephinephrine, sedating

30 Antidepressant Choices – Selective Variables Prozac (10-20 mg) – in some, more activating, give in am, start 10 mg in panic/anxiety. Paxil (10-20 mg) – in some more sedating, more wt gain.

31 Antidepressant Choices – Selective Variables Zoloft (25-50 mg) – activating or sedating, can be nicely calming Celexa/Lexapro (10-20 mg) – most serotonin - receptor selective.

32 ER Physician R/O underlying medical causes for presenting delirium, psychosis, or mood disorder. PEC if S/H or G.D.

33 Mental Status Exam: ARTT SMAJIC Appearance – well dressed/disheveled Rapport – good/eye contact Thought Process – linear, goal directed, looseness of associations (LOA), tangential, disorganized Thought Content – S/HI, A/VH Speech – N/R/R/V/T

34 Mental Status Exam: ARTT SMAJIC (Cont.) Mood – upset, angry, sad Affect – blunted, full range, depressed Judgment – good, poor Insight – good, poor Cognition – see MMSE

35 “MINI-MENTAL STATE EXAM” Maxi- mum Score Score Orientation 5 ( ) What is the (year) (season) (date) (day) (month)? 5 ( ) Where are we? (state) (country) (town) (hospital) (floor).

36 MMSE (Cont.) Maxi- mum Score ScoreRegistration 3 ( )Name 3 objects: 1 second to say each. Then ask the patient all after you have said them. Give 1 point for each correct answer. Then repeat them until he learns all 3. Count trials and record. Trials_________

37 MMSE (Cont.) Maxi- mum Score ScoreAttention and Calculation 5 ( )Serial 7’s 1 point for each correct. Stop after 5 answers. Alternatively spell “world” backwards. Recall 3 ( ) Ask for the 3 objects repeated above. Give 1 point for each correct.

38 MMSE (Cont.) Maxi- mum Score ScoreLanguage 9 ( )Name a pencil, and watch (2 pts) Repeat the following “No ifs, ands or buts.” (1 point) Follow a 3-stage command: “Take a paper in your right hand, fold it in half, and put it on the floor” (3 points) Read and obey the following:

39 MMSE (Cont.) Maxi- mum Score ScoreClose your eyes ( 1point) 5 ( )Write a sentence ( 1 point) Copy design (1 point) Total Score________________ FIG 6-1. From Folstein MF, Folstein SE, McHugh PR: J. Psychiatr Res 1975, 12:189-198

40 Structured Diagnostic Interview with Psychosocial Assessment S.W./Psychiatric Nurse Practitioner/Psychiatric Resident - HPI, DSM IV symptoms - Past psychiatric history - Family psychiatric history - Past medical history - Social history with current social supports and resources. - MSE

41 Psychiatrist Consultant Confirm diagnosis Medication recommendations

42 Disposition and Treatment Recommendations Inpatient Outpatient ER medications

43 Withdrawal Delirium (alcohol, benzodiazepine, barbiturates) Fixed with symptom triggered schedule. Ativan 1-2 mg PO, IM or IV, Q 4-6 h; Ativan 1-2 mg PO, IM, IV; Q 1-2 h prn P>100, BP> 150/100; hold for sedation Or, give symptom – triggered alone, if more appropriate.

44 Alcoholism Thiamine 100 mg po q daily Folate 1 mg po q daily MVI 1 taken po q daily

45 Opiate Withdrawal Evaluation Positive Opiate UDS Positive history Dilated pupils, piloerection, muscle cramps

46 Opiate Withdrawal Treatment Clonidine 1 mg po TID – QID with 1 mg po q 2 h for BP > 150/100, p > 100 Bentyl 20 mg po QID prn abdominal cramps. Pepto-Bismol, Imodium, Maalox, Mylanta Robaxin - muscle spasm.

47 Substance Dependence Disposition Medical admission for detoxification if unstable. Psychiatric admission if suicidal. Outpatient addiction follow-up and rehab.

48 Outpatient Detoxification Option Patients w/o history of prior seizures or withdrawal delirium. Valium 10 mg po TID-QID with 2-3 prn for agitation/tremulousness Taper over 5-7 days MVI

49 Ativan Outpatient Detoxification Option If patient has increased LFT’s Ativan 1-2 mg po q 4-6 h with 2-3 prn’s Taper over 10-14 days by dose, while preferentially maintaining frequency.

50 MEDICAL DELIRIUM TREATMENT ISSUES CBC, electrolytes, BUN, Cr, LFT’s, UDS, possible CT scan. Admit for medical stabilization of underlying causes.

51 Psychosis Due to Medical Condition Drugs and Toxins Intracranial masses (tumor, abscess, subdural) Anoxia Normal Pressure Hydrocephalous

52 Psychosis Due to Medical Condition (cont.) Neurodegenerative diseases Infection Nutritional (B 12, Folate) Metabolic/Endocrine Inflammatory/autoimmune

53 Mood Disorder Due to a Medical Condition Carcinoid Pancreatic Cancer Collagen-vascular disease Endocrinopatheses (Cushings, Addison’s hypoglycemia, hyper/hypocalcaemia, hyper/hypothyroid) Lymphoma Viral illness (mono, hepatitis, flu)

54 Depressed Mood Due to a Pharmacologic Agent Clonidine Propanolol Corticosteroids Ibuprofen Indomethacin Ampicillin Teracycline Cimetidine

55 Mania Due to Pharmacologic Agent Baclofen Cimetidine Corticosteroids Disulfiram Isonazid Levodopa


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