1. Psychosis, Substance Abuse Suicide/Homicide Self-Directed Learning Assessment Nikki Waller, MD 2009-2010

2. Objectives Discuss recognition, initial stabilization, and department management of Discuss recognition, initial stabilization, and department management of –Acute psychosis –Substance abuse –Suicide/homicide

3. Psychosis Abnormal thought patterns, with intact cognition Abnormal thought patterns, with intact cognition Usually due to mental disorders, but can be from acute drug intoxication or chronic abuse Usually due to mental disorders, but can be from acute drug intoxication or chronic abuse Most important are schizophrenia, mania, and depression in the setting of the ED Most important are schizophrenia, mania, and depression in the setting of the ED

4. Schizophrenia Delusions and hallucinations Delusions and hallucinations Most common of the psychoses Most common of the psychoses Mood is usually unaffected and flat Mood is usually unaffected and flat May present quiet and withdrawn or violent, paranoid and suspicious May present quiet and withdrawn or violent, paranoid and suspicious Neuroleptics are the mainstay of treatment chronically and acutely Neuroleptics are the mainstay of treatment chronically and acutely Often present because they have stopped taking meds Often present because they have stopped taking meds

5. Mania Often associated with bipolar disorder Often associated with bipolar disorder Elevated mood and energy Elevated mood and energy Acute mania: fast and pressured speech, agitation, grandiose delusions, and insomnia Acute mania: fast and pressured speech, agitation, grandiose delusions, and insomnia Can be violent Can be violent sedating neuroleptics are often needed sedating neuroleptics are often needed Lithium for chronic use, but not in the acute setting Lithium for chronic use, but not in the acute setting

6. Depression Rare to present with psychotic features Rare to present with psychotic features Usually not violent or agitated Usually not violent or agitated

7. Evaluation Should be a plan in the ED to deal with violent or abusive patients Should be a plan in the ED to deal with violent or abusive patients Obtain as much info as possible from patient, family, paramedics etc. Obtain as much info as possible from patient, family, paramedics etc. Try to obtain history prior to restraints or sedatives Try to obtain history prior to restraints or sedatives May not be able to obtain any reliable history May not be able to obtain any reliable history May need to interview with security present if patient is violent/agitated May need to interview with security present if patient is violent/agitated Workup should be guided by h and p. Workup should be guided by h and p. If known psychiatric disorders may require basic labs, drug levels, tox/etoh screens, lytes If known psychiatric disorders may require basic labs, drug levels, tox/etoh screens, lytes If new or worsened presentation, would need exclusion of organic causes (uti, drug ingestion, head injury etc) If new or worsened presentation, would need exclusion of organic causes (uti, drug ingestion, head injury etc)

8. Therapy Ensure patient and healthcare worker safety first. Ensure patient and healthcare worker safety first. Glucose, o2, thiamine, narcan, and possibly flumazenil first for acutely delusional patient may improve status Glucose, o2, thiamine, narcan, and possibly flumazenil first for acutely delusional patient may improve status Restraint options: Restraint options: –Seclusion (must be watched) –Physical restraints (if necessary, but also must be watched) –Drugs: droperidol, haldol, ativan, geodon –Start with small doses and watch for sedative effects.

9. Disposition Consult psych, frequent documentation of status if restrained. Consult psych, frequent documentation of status if restrained. Involuntary commitment if necessary Involuntary commitment if necessary Must rule out drug/etoh intoxication or other reversible cause before they are “cleared from a medical standpoint” to be considered only psych. Must rule out drug/etoh intoxication or other reversible cause before they are “cleared from a medical standpoint” to be considered only psych.

10. Depression and Suicide Depression Depression –most common psychiatric disorder (2- 3%) –Persistent dysphoric mood or loss of interest in activities for at least 2 weeks Suicide Suicide –2 nd leading cause of death among teens/young adults –Women attempt more often, –Men more likely successful

11. Clinical Features Guilt and hopelessness Guilt and hopelessness Thoughts of death or suicide Thoughts of death or suicide Change in appetite/weight Change in appetite/weight Insomnia/excessive sleep Insomnia/excessive sleep Fatigue Fatigue Difficulty concentrating Difficulty concentrating Can be situational Can be situational Can be medical causes (hypothyroidism) Can be medical causes (hypothyroidism) Need Pmhx, psychiatric problems, meds hx Need Pmhx, psychiatric problems, meds hx Risk assessment is KEY: Risk assessment is KEY: Ask about homicide, suicide, specific plan, and what their access is to those plans. Ask about homicide, suicide, specific plan, and what their access is to those plans. Take away medication, weapons etc in the department. Take away medication, weapons etc in the department.

12. Suicide Risks High risk High risk –Older –Males –Living alone –Physically ill –Depressed –Schizophrenic –h/o substance abuse –Prior attempts Low risk Low risk –Younger –Females –No clear/active plan –Gesturing behavior –Strong social support and follow up

13. Rate of suicide in the US is about 1% (31,000 deaths/yr) Rate of suicide in the US is about 1% (31,000 deaths/yr) Drug overdose most common form of attempt Drug overdose most common form of attempt

14. Suicide Attempts Get as much history as possible from all sources Get as much history as possible from all sources Immediate ABC’s if patient is unstable Immediate ABC’s if patient is unstable Remove any items patient may have on them that could be a threat (lighter, pills, knife etc) Remove any items patient may have on them that could be a threat (lighter, pills, knife etc) For overdose: get time of ingestion, quantity, strength of substance, what substance(s), any other available substances that are unaccounted for, how much was initially available, when was patient last seen and normal For overdose: get time of ingestion, quantity, strength of substance, what substance(s), any other available substances that are unaccounted for, how much was initially available, when was patient last seen and normal Patient needs a sitter Patient needs a sitter Work up as appropriate, but should include cbc, chem 10, urine tox, pregnancy, etoh screen (gets all alcohols), acetaminophen and salicylate level Work up as appropriate, but should include cbc, chem 10, urine tox, pregnancy, etoh screen (gets all alcohols), acetaminophen and salicylate level CXR to look for pill fragments CXR to look for pill fragments EKG to document normal QRS, no arrhythmias or prolonged QT EKG to document normal QRS, no arrhythmias or prolonged QT If “found in the garage with car on”, consider Carbon monoxide levels If “found in the garage with car on”, consider Carbon monoxide levels Anything else that may be deemed necessary based on injuries etc. Anything else that may be deemed necessary based on injuries etc.

15. Disposition Should be carefully documented and determined with help their mental health provider Should be carefully documented and determined with help their mental health provider –Contract for safety –Document careful follow up plan –Adequate social support –Admit those with: Active plan Active plan Cannot contract Cannot contract High risk factors High risk factors Acute psychosis Acute psychosis High risk attempt (gunshot, hanging, significant ingestion with lethal substance (tricyclics etc) High risk attempt (gunshot, hanging, significant ingestion with lethal substance (tricyclics etc) Danger to themselves or others (manic, wreckless, severe suicide risk) Danger to themselves or others (manic, wreckless, severe suicide risk)

16. Substance Abuse Huge problem in the country, and problem for EM Huge problem in the country, and problem for EM Commonly see “want to stop drinking, or stop using drugs”, Commonly see “want to stop drinking, or stop using drugs”, But patient may present as an “found altered and unknown toxin suspected” But patient may present as an “found altered and unknown toxin suspected”

17. “Wants detox” For UNC the information you need to know is: For UNC the information you need to know is: Substances used, and on average how much and for how long Substances used, and on average how much and for how long Last use Last use History of withdrawal (DT’s etc) History of withdrawal (DT’s etc) Other current medical problems that would need attention (i.e cocaine use, but now having chest pain) Other current medical problems that would need attention (i.e cocaine use, but now having chest pain) Psychiatric history including suicidality Psychiatric history including suicidality Are they currently in withdrawal, or getting ready to go into withdrawal Are they currently in withdrawal, or getting ready to go into withdrawal Can I clear them from a medical standpoint? Can I clear them from a medical standpoint?

18. Detox Once you have cleared them, you can either call freedom house (UNC specific), or if they are full, then psych can help dispo (once they are clear from a medical standpoint) Once you have cleared them, you can either call freedom house (UNC specific), or if they are full, then psych can help dispo (once they are clear from a medical standpoint) May need admission for r/o mi (if active cp and cocaine), or if history of withdrawal seizures from etoh etc. May need admission for r/o mi (if active cp and cocaine), or if history of withdrawal seizures from etoh etc.

19. Acute Presentation of Substance Abuse ABC’s: check for gag, determine gcs, ?need for immediate intubation ABC’s: check for gag, determine gcs, ?need for immediate intubation History (as with suicide attempts) History (as with suicide attempts) Vitals and neurologic status, expecially pupil size, diaphoresis, heart rate Vitals and neurologic status, expecially pupil size, diaphoresis, heart rate EKG EKG Look for toxidrome pattern Look for toxidrome pattern

20. Approach to patient Toxidromes: common patterns of findings with specific ingestions (more in the tox lecture) Toxidromes: common patterns of findings with specific ingestions (more in the tox lecture) IV/o2/monitor IV/o2/monitor Coma Cocktail: Coma Cocktail: Thiamine (100mg iv): alcoholics are predisposed to thiamine deficiency and may have wernicke-korsakoff’s. Thiamine (100mg iv): alcoholics are predisposed to thiamine deficiency and may have wernicke-korsakoff’s. Dextrose (1amp d50): for any pt with altered mental status, check glucose Dextrose (1amp d50): for any pt with altered mental status, check glucose Narcan (0.01mg/kg iv): give to suspected narcotic toxidrome, or severe altered mental status Narcan (0.01mg/kg iv): give to suspected narcotic toxidrome, or severe altered mental status Flumazenil: benzo antagonist, but MANY contraindications and we don’t normally give in the acute setting. Flumazenil: benzo antagonist, but MANY contraindications and we don’t normally give in the acute setting.

21. Differential Diagnosis Organophosphate poisoning Organophosphate poisoning Pontine hemorrhage Pontine hemorrhage Clonidine overdose Clonidine overdose

22. Work up Basic and tox labs Basic and tox labs Drug levels (depakote, lithium) if appropriate Drug levels (depakote, lithium) if appropriate CXR CXR EKG EKG Possible head ct/neck ct if trauma is suspected or if not a clear “tox” history Possible head ct/neck ct if trauma is suspected or if not a clear “tox” history Urine tox/pregnancy Urine tox/pregnancy Cardiac labs if cocaine and chest pain, or if you cannot determine chest pain Cardiac labs if cocaine and chest pain, or if you cannot determine chest pain

23. Opiates/Narcotics (heroin/fentanyl) Death from respiratory depression Death from respiratory depression Sx: depressed mental status Sx: depressed mental status PE: PE: –Lethargy –Pinpoint pupils –Decreased respiratory drive Evaluation: ***responds to Narcan (can give every 2-3 minutes, little bit at the time until max of 10 mg or mental status returns Evaluation: ***responds to Narcan (can give every 2-3 minutes, little bit at the time until max of 10 mg or mental status returns Admit: persistently altered, or drugs with long half life (methadone) Admit: persistently altered, or drugs with long half life (methadone)

24. Amphetamines/Cocaine Death from: mi, arrhythmias, cva, hyperthermia, renal failure Death from: mi, arrhythmias, cva, hyperthermia, renal failure All sympathomimetics All sympathomimetics Sx: euphoric, anxious, agitated, paranoid, “chest pain” Sx: euphoric, anxious, agitated, paranoid, “chest pain” Neuro findings: Neuro findings: –Seizure –Focal findings (weakness) –“wash-out”- decreased ms, lethargy, drowsiness with chronic use, or after prolonged binging

25. Cardiopulmonary Findings Dysrhythymias, hypo or hypertension, signs of MI Dysrhythymias, hypo or hypertension, signs of MI Asthma or reactive airway disease Asthma or reactive airway disease Hyperthermia (> 105.0) Hyperthermia (> 105.0) Can get pneumomediastinum from smoking Can get pneumomediastinum from smoking

26. pneumomediastinum Air in soft tissues And around the Neck. Can also sometimes See air around the heart Border (not in this one)

27. Differential Diagnosis CNS infection CNS infection Pheochromocytoma Pheochromocytoma Thyroid storm Thyroid storm Vasculitis Vasculitis hypoglycemia hypoglycemia

28. Workup and treatment Abc’s, full labs and cxr, ekg, head ct (if needed) Abc’s, full labs and cxr, ekg, head ct (if needed) Benzos (ativan etc) for agitation, chest pain Benzos (ativan etc) for agitation, chest pain If evidence of MI: give nitrates, heparin, ptca if needed If evidence of MI: give nitrates, heparin, ptca if needed DO NOT GIVE B-BLOCKERS DO NOT GIVE B-BLOCKERS Treat hypothermia Treat hypothermia If asymptomatic and no end organ damage, then can d/c, but otherwise admit as appropriate If asymptomatic and no end organ damage, then can d/c, but otherwise admit as appropriate

29. Hallucinogens (LSD, MDA, PCP, psilocybin) Exact mech. Of action unknown, but thought to interact with serotonin and dopamine mechanisms in the CNS. Exact mech. Of action unknown, but thought to interact with serotonin and dopamine mechanisms in the CNS. Death: from activities associated with concurrent use (driving etc) Death: from activities associated with concurrent use (driving etc) Sx: Sx: –Euphoria, hallucinations –Bad trip: paranoia, anxiety, unusual thought process –Most have “sense of self” except with PCP

30. Signs of Hallucinogens Hyperthermia (associated with some) Hyperthermia (associated with some) Anticholinergic effects Anticholinergic effects –Dry mouth –Dialated pupils –Tachycardia –Flushing –delirum

31. Differential Diagnosis Acute psychosis Acute psychosis Conversion disorder Conversion disorder Encephalitis Encephalitis Neurosyphillis Neurosyphillis Dementia Dementia

32. Evaluation/therapy/dispo Often don’t show up on utox Often don’t show up on utox Standard labs, check CK if suspect possible rhabdomyolisis Standard labs, check CK if suspect possible rhabdomyolisis Reassurance and Benzos for agitation prn Reassurance and Benzos for agitation prn d/c if asymptomatic at 4-6 hours d/c if asymptomatic at 4-6 hours

33. Toxic alcohols Will discuss in tox lecture Will discuss in tox lecture

34. THE END