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Psychiatric Emergencies. Evaluation and care of the Agitated Patient By Ron Larsen, MD. At the end of this session you will be able to:. Identify common Medical and Psychiatric causes of agitation Provide verbal de-escalation of the agitated patient

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Psychiatric emergencies

Psychiatric Emergencies

Evaluation and care of the Agitated Patient

By Ron Larsen, MD

At the end of this session you will be able to
At the end of this session you will be able to:

  • Identify common Medical and Psychiatric causes of agitation

  • Provide verbal de-escalation of the agitated patient

  • Provide Psychiatric evaluation of the agitated patient

  • Identify psychopharmacological treatments for the agitated patient

Agitation in emergency settings 1 7 million episodes annually in the us
Agitation in emergency settings – 1.7 million episodes annually in the US

  • Agitation is an extreme form of arousal associated with increased verbal and motor activity.

  • Agitation can lead to aggressive violent behaviors - with harm to patients, others, property - and is a leading cause of hospital staff injuries

  • Agitation can result from a myriad of origins, and its treatment is multifaceted, with pharmacology playing only one part.

Starting with a case
Starting with a case: annually in the US

  • Male brought in as a John Doe found wondering in the street by the Boise Police

  • Appears to be in mid 40s and disoriented, belligerent with the police, mildly disheveled

  • That’s all the info you have, so what could be going on with him and what do you want to do next?

Develop a broad differential
Develop a broad differential: annually in the US

  • Observe closely in a safe environment with support and obtain collateral information

  • VS including O2 Sat and BG

  • Obtain Utox, CBC, Chem panel

  • PE

  • MSE including orientation, memory, speech and fluctuations in presentation

Conditions that may cause agitation
Conditions that may cause agitation: annually in the US

  • General medical conditions:

    Head trauma


    Metabolic (hyponatremia, hypocalcemia, hypoglycemia)

    Toxic level of medications (psych, anti-seizure)

    Seizure (postictal)

    Encephalitis, meningitis or other infection

    Encephalopathy (liver or renal failure)

    Thyroid disease

    Environmental toxins

Conditions that may cause agitation1
Conditions that may cause agitation: annually in the US

  • Intoxication/withdrawal


    Recreational drugs (cocaine, ecstasy,

    ketamine, bath salts, inhalants, meth)

  • Psychiatric Disease

    Psychotic disorders


    Agitated depression

    Anxiety disorders

John doe s labs
John Doe’s labs: annually in the US

  • Utox + cocaine

  • Na: 140 K+:3.9 Mg:2.2 Creat:1.0 BUN:14 ALT:33 AST:49 ALK phos:43

  • WBC:10.8 Hct:44

  • BP:130/94 HR:108 Temp:37.1

  • PE: psychomotor agitated, paranoid appearing

  • How to manage this patient?

Acute cocaine intoxication
Acute cocaine intoxication annually in the US

  • Check EKG for evidence for MI

  • Could be an exacerbation of a primary psychotic illness such as schizophrenia

  • Tx with nothing, benzos, or antipsychotics depending on level of agitation and paranoia

  • Be aware of behavioral predictors of violence: Past hx, circumstances, substance abuse and dependence, ASP

The story evolves
The story evolves: annually in the US

  • When the RN attempts to do the ECG, the patient jumps up and screams, “Get away from me! You are trying to stop my heart!

    Get away from me!”

  • When you enter the room he is standing, looking at the door like he is getting ready to bolt

How to de escalate a patient
How to de-escalate a patient annually in the US

  • Use a calm voice

  • Sit down with the patient

  • Maintain adequate physical distance of at least 6 feet, equal distance from the door

  • Attempt to establish rapport

  • Listen to the patient’s concerns

  • Tell the patient what you want to do

When verbal de escalation is not enough
When verbal de-escalation is not enough: annually in the US

  • When there is risk of imminent harm and verbal de-escalation has been ineffective pharmacologic supports or physical restraints may be needed.

  • Substance abuse carries a 30X increase risk than the general population

  • Mental illness carries a 9X greater risk than the general population

Pharmacologic support benzodiazepines
Pharmacologic Support: Benzodiazepines annually in the US

  • Lorazepam is one of the most useful meds in an emergency. In the first 24 hours, agitation is as effectively addressed with lorazepam as with antipsychotics, even if psychosis is present

  • Usual dose is 1-2 MG IM, IV, or PO Q 1-2 hours

  • Can be additive with other agents, however, resulting in excessive sedation and respiratory depression

Pharmacologic support antipsychotics
Pharmacologic Support: Antipsychotics annually in the US

  • Antipsychotics can be quite effective in reducing agitation

  • IM Antipsychotics – Haloperidol 1-5 MG IM Q 1 hour, NTE 20-30 MG/24 hours

  • PO Antipsychotics – Risperidone 1-2 MG PO, NTE 4 MG /24 hours (also comes in rapid melting tab called Risperdal M-tab)

    - Olanzapine 10-20 MG PO, NTE 20 MG/24 hours (also comes in a rapid melting wafer called Zydis)

    - Haloperidol 1-5 MG PO Q 1-2 hours, NTE 30 MG in 24 hours

Findings that require immediate evaluation
Findings that require immediate Evaluation: annually in the US

  • Symptoms

    Loss of memory, disorientation

    Severe headache

    Extreme muscle stiffness or weakness

    Heat intolerance

    Psychosis (new onset)

    Difficulty breathing

Findings continued
Findings continued: annually in the US

  • Signs

    Abnormal vital signs: pulse, BP, or Temp

    Overt trauma

    One pupil larger than the other

    Slurred speech




Psychiatric evaluation of the agitated patient
Psychiatric Evaluation of the annually in the USAgitated patient

  • Make visual observations before a direct patient interview, with attention to verbal and nonverbal interaction with the examiner

  • Obtain collateral information while de-escalation is in process

  • Once it is determined that the patient does not have an acute medical problem, the first question if whether the patient has a delirium

Psychiatric evaluation first r o delirium
Psychiatric Evaluation, annually in the USFirst r/o delirium:

  • Examine for disorientation, altered level of awareness, and problems directing, focusing, or sustaining attention.

  • Observe for evidence of visual hallucinations

  • Check for signs of language impairment, problems naming, or other cognitive deficits

  • Also consider evidence for a chronic cognitive impairment that may be a contributing factor (hx of a brain injury, developmental disability or dementia)

Psychiatric evaluation next r o intoxication or withdrawal
Psychiatric Evaluation, Next annually in the USr/o intoxication or withdrawal

  • Cocaine intoxication with pupillary dilation, perspiration, vomiting, confusion, dyskinesias, dystonias, and seizures

  • Opiate intoxication with pupillary constriction and slurred speech

  • Alcohol withdrawal associated with increased BP and pulse, sweating, hand tremor, anxiety, and transient visual or tactile hallucinations

Psychiatric evaluation then consider psychosis
Psychiatric Evaluation, annually in the USThen consider Psychosis

  • Agitation due to a known Psychiatric disorder can best be assessed with the help of collateral information

  • Schizophrenia is usually first diagnosed in the late teens and early twenties

  • Mania and Agitated Depression have an episodic course

  • Anxiety disorders also have a life-long course starting in the late teens and early twenties

As a last resort guidelines for the use of restraints
As a last resort – annually in the USGuidelines for the use of restraints

  • The use of restraints puts patients at risk for physical injury and death and can be traumatic even without physical injury.

  • Unless the patient is actively violent, verbal de-escalation should be tried first.

  • Medications should be offered and an effort made to involve the patient in decisions about medications

Restraint guidelines
Restraint guidelines annually in the US

  • If the patient is an immediate danger to self or others, restraints are indicated

  • If the restrained patient will engage in a reasonable dialog, verbal de-escalation efforts should continue, including getting the patients input on medication.

  • Medication should be administered to calm a patient who has been placed in restraints.

Restraints continued
Restraints continued annually in the US

  • All patients in restraints should be monitored to assess response to interventions and to prevent complications from this interventions.

  • Treatment should be directed toward minimizing time in restraints and allowing the patient to regain control

  • Adhere to CMS and TJC standards for seclusion and restraints

Management of agitation summary
Management of agitation - Summary annually in the US

  • Obtain a brief hx and VS (with O2 Sat and BG)

  • Consider findings that require immediate evaluation and treatment

  • Balance evaluation and management of the patient simultaneously

  • Whenever possible de-escalate to calmness with a verbal approach alone

  • Establish a working diagnosis before instituting appropriate pharmacologic intervention

  • Avoid the restraint process if at all possible