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

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Presentation on theme: "Medical stability & Substance related emergencies M. Nadeem Mazhar MBBS, MRCPsych, FRCPC, DABPN."— Presentation transcript:

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

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

3 “MEDICAL CLEARANCE”

4 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)

5 Medical stability Making 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)

6 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)

7 Physical examination Specific 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)

8 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

9 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

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

11 Chest Rales- congestive heart failure Rhonchi- pneumonia

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

13 Abdomen Hepatomegaly- undiagnosed liver disease Acute tenderness- acute pathology that needs to be addressed in ED

14 Extremities Any deficits, limps or pain

15 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

16 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)

17 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

18 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

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

20 Laboratory tests TSH: Elevated- hypothyroidism leading to depression, cognitive changes Low- hyperthyroidism leading to manic like symptoms, agitation

21 Laboratory tests Vitamin B12 & Folate: Low B12- neurological changes, memory problems Low folate- evidence of general malnutrition, association with depression

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

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

24 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

25 Agitation- medical causes Hypogylcemia: Altered mental status Sweating Tachycardia Weakness

26 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

27 Agitation- medical causes Structural brain abnormality: Varies by lesion Altered mental status Headache Meningeal signs Focal neurological deficit or progressive neurological deterioration

28 Agitation- medical causes Toxicologic emergency: Varies by substance Mental status changes Pupillary changes Vital sign changes Sweating

29 SUBSTANCE RELATED PSYCHIATRIC EMERGENCIES

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

31 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

32 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 mmol/L – mmol/L)

33 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 mg/dl per hour In case of persistent alteration in consciousness→ exclude other causes e.g., other toxins, metabolic dysfunction or subdural hematoma

34 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

35 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

36 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

37 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

38 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

39 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

40 Agitated, aggressive & psychotic patient Agitated 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

41 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 hours, about 5% of patients in alcohol withdrawal, develop DTs- hallucinations (usually visual), delirium and severe autonomic instability

42 Alcohol withdrawal & CIWA 1) Nausea and vomiting: 0-7 score 2) Tremor: 0-7 3) Paroxysmal sweats: 0-7 4) Anxiety: 0-7 5) Agitation: 0-7 6) Tactile disturbances: 0-7 7) Auditory disturbances: 0-7 8) Visual disturbances: 0-7 9) Headache: ) Orientation: 0-4

43 CIWA & Medication Cumulative ScoreMedication Requirement 0-8No medication 9-14Medication optional 15-20Medication treatment >20Strong risk of DT 67Maximum possible cumulative score

44 Structured medication regimens 1 ) Chlordiazepoxide: 50 mg Q6H X 4 Followed by 25 mg Q6H X 8 2) Diazepam: 10 mg Q6H X 4 Followed by 5 mg Q6H X 8 3) Lorazepam: 2 mg Q6h X 4 Followed by 1 mg Q6H X 8 4) Carbamazepine: 400 mg BID on day 1 Tapering down to 200 mg as a single dose on day 5

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

46 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

47 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)

48 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

49 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

50 Opioid withdrawal treatment CPSO MMT Guidelines-2011 DrugDoseWithdrawal Symptoms Clonidine mg P.r.n. b.i.d.- q.i.d. Agitation, diapohresis Dimenhydrinate50 mg p.o. or p.r. p.r.n. nausea Ibuprofen mg p.r.n. t.i.d. myalgia Immodium2 mg p.r.n. max 6 tabs/day diarrhea Trazodone mg q.h.s. p.r.n. insomnia Benzodiazepinesp.r.n.anxiety

51 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

52 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 intoxica tion

53 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

54 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 for 2.Stating that prescription was “lost” and provider not immediately available 3.Claims allergy to alternate medications 4.Threaten to be suicidal unless get prescription for specific medication

55 SUBSTANCE RELATED PSYCHIATRIC EMERGENCIES- CASE DISCUSSION

56 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

57 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)

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

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

60 DSM-IV Sedative/Hypnotic Withdrawal Two 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

61 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

62 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:


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