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:
Would be better treated in a medical setting (e.g., infection requiring IV antibiotics)
Will cause the acute decompensation in the next few hours requiring a higher level of care (e.g., severe alcohol withdrawal)
Causing behavioral symptoms but should be treated by something other than psychiatric medications (e.g., delirium due to an underlying infection)
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
Detect or rule out presence of condition that has treatment consequences
Determine the relative safety and appropriate dose of potential alternative treatments
Provide baseline measurements before instituting treatment
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 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

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: = mild, 13-24= moderate,
25-36= moderately severe, >36= severe

50. Opioid withdrawal treatment
Drug
Dose
Withdrawal Symptoms
Clonidine
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
mg p.r.n. t.i.d.
myalgia
Immodium
2 mg p.r.n. max 6 tabs/day
diarrhea
Trazodone
mg q.h.s. p.r.n.
insomnia
Benzodiazepines
p.r.n.
anxiety
CPSO MMT Guidelines-2011

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 intoxication

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:
When a specific medication is asked for
Stating that prescription was “lost” and provider not immediately available
Claims allergy to alternate medications
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: