1. TRANSITION SERIES Topics for the Advanced EMT CHAPTER Psychiatric Disorders 22

2. Objectives Review the frequency of psychiatric disorders. Understand the basic pathophysiology of psychiatric disorders. Discuss assessment and strategies for managing a patient with a psychiatric disorder.

3. Introduction Mental disorders affect cognition, emotion, mood, or behavior. A wide display of symptoms or behaviors can be seen with psych patients. Generally, these patients need extra time and care regarding communication.

4. Epidemiology Mental disorders affect an estimated 1 in 4 adults a year. Leading cause of disability in 15-44 age bracket. Responsible for more than 6% of emergency department visits.

5. Pathophysiology No real known cause for psych problems –Thought to be interaction of multiple factors. –First task is to rule out any non-psych reason for the change in behavior.  Medical conditions  Traumatic injuries

6. Pathophysiology No real known cause for psych problems –Treatment commonly a combination of drugs, counseling, and group therapies.

7. Pathophysiology (cont’d) Types of psychiatric disorders –Psychosis and schizophrenia –Mood disorders –Anxiety disorders –Somatoform disorders

8. Pathophysiology (cont’d) Types of psychiatric disorders (continued) –Factitious disorders –Dissociative disorders –Sexual and gender identity disorders –Eating disorders

9. Pathophysiology (cont’d) Types of psychiatric disorders (continued) –Impulse control disorders –Personality disorders –Attention deficit hyperactivity disorders –Autism spectrum disorders –Substance related disorders –Alzheimer’s disease –Suicide

10. Assessment Be sure to rule out medical/traumatic causes for alterations. Signs and symptoms will vary for each individual and each situation.

11. The patient with a mental disorder will require additional communication skills, patience, and compassion. Touch may be comforting to some patients, but do not touch a patient without the patient’s consent.

12. Assessment (cont’d) Consider the following approach with psych patients: –Gain consent for treatment.  Determine mental status first. –Assess mental status of the patient.  Note mood, posture, dress, grooming, etc.

13. Assessment (cont’d) Consider the following approach with psych patients: –Conduct the verbal interview.  Note suicidal or homicidal ideations, hallucinations, delusions, phobias, etc.

14. Restraint and Patient Safety Core principle is to do no harm. EMS should not be in direct contact with a violent patient. In many systems the police are responsible for providing restraint. When assisting with restraint, follow proper application principles.

15. Agitated Delirium Condition that leads to the death of a patient with an apparent psychiatric emergency. Patients often present with psychosis, hallucinations, and “superhuman strength.” Behavior ceases rapidly with the onset of respiratory/cardiac arrest.

16. Emergency Medical Care Safety of the provider is paramount. Assess the patient for trauma or medical conditions (treat if found). Use restraints based on protocol. Provide supportive environment for the patient to receive care. Transport the patient to an appropriate facility.

17. Case Study Your EMS unit is dispatched for a patient with a psychological problem. The address is for a local group home in your community. Upon your arrival, you see a patient standing in the corner of the porch, his hands covering his face. He is surrounded by others you assume to also live at the home.

18. Case Study (cont’d) Scene Size-Up –Standard precautions taken. –Group of people standing around the assumed patient. –You hear some yelling as you start to approach.

19. Case Study (cont’d) Scene Size-Up (continued) –The unconfirmed NOI is for a psych emergency. –Entry and egress from porch will be easy once the small crowd disperses. What are some concerns you have based on the scene size-up?

20. Case Study (cont’d) Primary Assessment Findings –Scene is secured by PD. –The patient is still standing, muttering something you can't understand. –Airway, breathing, and circulation seem intact based on the patient's ability to stand and vocalize. –As you approach the patient for examination, he starts yelling at you.

21. Case Study (cont’d) Is this patient a high or low priority? Why? What are the life threats to this patient? What emergency care should you provide based on the primary assessment findings?

22. Case Study (cont’d) After a brief while, the patient finally trusts you enough to allow you to approach him. Although you ask him specific questions about how he feels, he just keeps repeating, “The ants are crawling all over me,” despite the fact that there are no ants anywhere to be seen.

23. Case Study (cont’d) Medical History –Unknown Medications –Unknown Allergies –Unknown

24. Case Study (cont’d) Pertinent Secondary Assessment Findings –Pupils midsize and midposition. –Airway clear and breathing normal. –Membranes pink and hydrated. –Breath sounds equal bilaterally. –Patient does not express any areas of pain on his body.

25. Case Study (cont’d) Pertinent Secondary Assessment Findings (continued) –Vitals are within normal limits. –Patient still insists there are ants crawling all over him. –BGL 102 mg/dL, pulse ox is 99% on room air.

26. Case Study (cont’d) What is your field impression at this time? What would be the next steps in management you would provide to the patient?

27. Case Study (cont’d) Care provided: –Patient placed on the cot in semi-Fowler position. –Pulse ox maintained en route (99%- 100%). –Patient verbally reassured and reassessed en route to ED. –As a precaution, your partner calls ahead to the ED to have security standing by.