1. Psychiatric emergencies frank ferrucci,pa-c anna jacques hospital frank ferrucci,pa-c anna jacques hospital

2. overview topics disorders legal issues state dependent

3. Cases 38 y.o. female brought in by EMS for suicidal thoughts 15 y.o. male found in basement 44 y.o. pregnant female

4. Why are most psych emergencies sent to the ED ? medical clearance evaluation by crisis services (who are they and what do they do?) medications safety placement no beds/services

5. what kinds of psych emergencies do you see Depressed Manic Out of control Suicidal Psychotic Detox placement

6. What happens when one of these comes to the ED? medical clearance stabilize keep patient safe evaluation by crisis disposition

7. general priniciples of psych emergencies in the ed keep yourself and the patient safe level any drugs that you are able to always keep a high index of suspicion for organic causes whenever possible use psych specific rooms direct observation

8. what are the disposition options in the ed? d/c home outpatient follow up CSU bed partial hospitalization full inpatient hospitalization

9. review of common disorders depression suicidal/homicidal ideations bipolar schizophrenia behavioral disorders medical conditions that mimic psych conditions

10. Depression Unipolar depression typically low energy, low self esteem, loss of interest in enjoyable activities, anxiety, insomnia etc serotonin (5-HT) overall incidence in US= 20/12%

11. Depression A. At least 5 of the following, during the same 2-week period, representing a change from previous functioning; must include either (a) or (b): (a) Depressed mood (b) Diminished interest or pleasure (c) Significant weight loss or gain (d) Insomnia or hypersomnia (e) Psychomotor agitation or retardation (f) Fatigue or loss of energy (g) Feelings of worthlessness (h) Diminished ability to think or concentrate; indecisiveness (i) Recurrent thoughts of death, suicidal ideation, suicide attempt, or specific plan for suicide B. Symptoms do not meet criteria for a mixed episode (ie, meets criteria for both manic and depressive episode). C. Symptoms cause clinically significant distress or impairment of functioning.D. Symptoms are not due to the direct physiologic effects of a substance or a general medical condition.E. Symptoms are not better accounted for by bereavement, ie, the symptoms persist for longer than 2 months

12. Depression disposition depends on acquity “Hospital level of care” insurance psych meds out of the ED??

13. suicide 11th leading cause of death in US Definitions: suicide attempt suicide gesture suicide gamble suicide equivalent

14. Suicide men more effective, women more determined age distribution?? professions US dentists police season

15. Suicide prisoners recent discharge from pysch hospital socioeconomic issue abuse

18. suicide activities associated w/suicide will, unexpected visits to family,buying a gun, VISIT TO PCP characteristics preoccupation with death,few social contacts, isolation/withdrawal, focused on the past, hopeless, no goals, thoughts of enjoyable future

19. suicide recent life experiences relationships, job, family past life experiences family hx of suicide high school abuse

20. suicide mental illness bipolar major depression (especially when?) schizophrenia A/V hallucinations worst if they have insight anxiety disorders substance abuse SI generally worsening when under the influence chronic substance abuse=chronic losses

21. suicide delirium and dementia loss of memory, disorientation, hallucinations, delusions, poor judgment may occasionally have insight

22. suicide mental status review Appearance: In addition to the dress and hygiene notes in people who are depressed (eg, disheveled, unkempt and unclean clothing), the following should be noted Affect: One specific emotion of concern is where the patient exhibits a flat affect when describing their thoughts and plans of suicide and self-destructive behavior. Thoughts: 1) command hallucinations 2) delusions 3) obsession with their suicide Homicidal thoughts Judgment

23. Suicide Insight : suicide is final answer to temporary problem Intellect: does the person understand the consequences of the behavior? Orientation and memory: is the patient delirious or demented?

25. suicide Pt is felt to be high risk...now what? 1:1 watch remove everything (esp shoes/socks) section 12 (in mass) evaluation by crisis admission

26. suicide medico-legal aspects responsibility legalities of sec 12 minors what if you disagree with crisis??

27. Bipolar disorder deep depression alternating with excessive highs decreased sleep, pressured speech, reckless behavior, grandiosity between highs+lows= general high functioning bipolar I vs II

28. bipolar 25-50% will attempt suicide equal between sexes often diagnosis of young people diagnostic criteria

29. bipolar mania at least 1 week of profound mood disturbance 3 or more of: grandiosity, decr sleep, pressured speech, racing thoughts, incr goal focused activity, excessive pleasurable activities causes impairment of work or danger to patient mood is NOT the result of substance abuse or medical condition

30. bipolar major depressive episodes: over 2 weeks...5 or more of the following: depressed mood, loss of interest in activities, weight loss/gain, hypersomnia or insomnia, loss of energy or fatigue, indecisiveness, preoccupation with death symptoms cause significant impairment and distress mood is NOT the result of substance abuse or medical condition

31. bipolar physical exam depressed episode= unkempt, unclean, poor hygiene, poor eye contact, flat affect, monotone voice manic episode: hyperactive, restless, energized, clothes often garish, euphoric,grandiosity, clothes disorganized,VERY impaired judgement

32. Bipolar indications for inpatient hospitalization danger to self/others inability to function out of control

33. bipolar drugs for manic phase geodon, zyprexa, seroquel, risperdal drugs for depression seroquel drugs for maintenance lamictal, lithium, abilify

34. bipolar medicolegal pitfalls

37. schizophrenia disorder marked by changes in thinking, behavior and perception positive sxs: delusions, hallucinations negative sxs: flat affect, social withdrawal, limited vocabulary

38. dsm-IV defintiion sxs for at least 6 mos, with at least 1 mos of active sxs much of the time, and must result in significant impairment of occupational and social functioning

39. ED concerns NEVER diagnose someone with schizophrenia in the ED always on guard for organically based delirium this is the reason for medical screening exams

40. demographics equal between sexes average age of onset 18-25 completed suicide rate=10% science editorial

41. history insidious onset (loss of functioning in home, society, occupation) years ahead of diagnosis abrupt onset of hallucinations/delusion/disorganized thoughts

42. diagnosis two or more of the following: delusions, hallucinations, disorganized speech, catatonic behavior, poor affect, social withdrawal etc loss of occupation, social and self care functioning since onset of illness organic causes ruled out

43. NMS fever, rigidity, ams, tachycardia often days after starting neuroleptics watch for rhabdo lytes, ck, urine myoglobin, tox, inr tx= fluids, sedatives, restraints, antipyretics, amantidine

44. TD involuntary movements of tongue, lips,truch and extremities long term use of antipsychotics must differentiate from other movement disorders video

45. ss similiar to NMS anticholinergic toxidrome usually from SSRI OD fluids, benzos, watch for rhabdo

46. physical can range from catatonic to wildly combative and everything in between paranoid schizophrenics can be extremely dangerous exam tailored to rule out organic cause of delirium examples of organic based delirium??

47. schizophrenia if you suspect this as a new diagnosis level of drugs you can tox screen FSBS lytes imaging

48. detox requests very frequent cause of ED visits substance of abuse is important which withdrawals are dangerous? which active drug use is dangerous? beds hard to find (esp fri-mon) often will d/c home with list

49. managing withdrawal ciwa protocol benzos, benzos, benzos clonidine tough it out big boy...

52. physical+chemical restraint give patient the option can often talk pts down safety in numbers don’t half-ass it document, document, document watch the mouth get police involved

53. chemical restraint exact combination depends on circumstances 5-2-1 droperidol zyprexa and zyprexa zydis

54. psych patients holding in the ed beds harder and harder to find boredom, agitation, worsening psychosis section 12s, restraint orders have to be renewed=documented reevaluations dealing with daily medications

55. medicolegal pitfalls of psych care in ed missing the actively suicidal patient allowing an intoxicated pt to leave documentation, documentation missing organic causes of symptoms side effects of medications

56. medicolegal videos