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The Case

Neuropsychiatric Emergencies Andy Jagoda, MD, FACEP Professor of Emergency Medicine Mount Sinai School of Medicine New York, New York. The Case. 26 year old female presents to the ED with a chief complaint of “acting strange”

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The Case

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  1. Neuropsychiatric Emergencies Andy Jagoda, MD, FACEPProfessor of Emergency MedicineMount Sinai School of MedicineNew York, New York

  2. The Case 26 year old female presents to the ED with a chief complaint of “acting strange” According to her husband, for the past 24 hours she has been having periods of fear and paranoia PMH none Tob none Medications none ETOH none Drugs none LNMP s/p abortion 2 day prior

  3. The Case Vital Signs: 150/90 110 18 100% Blood Sugar 120 mg / dL Patient is extremely agitated, fearful, and uncooperative Pupils equal and reactive to light Moving all four extremities Patient was triaged to the Psychiatric Emergency Department

  4. The Questions • What per cent of patients triaged to the psychiatric ED have an underlying medical condition causing their acute complaint? • What constitutes “medical clearance”? • What is delirium? • What strategies are available to manage the agitated / violent patient?

  5. Psychiatrists should be able to medically evaluate their own patients by performing a complete history and physical examination?True False

  6. Emergency physicians should be able to competently evaluate the psychiatric and neurologic mental status of their patientsTrue False

  7. Background • 105 million ED visits a year in the USA • 2% to 12% of patients presenting to the ED have a psychiatric complaint • 25% to 50% of patients with psychiatric illness also have a medical disorder that can contribute to acute disturbances in thought, behavior, mood, or social relationships • 4% to 12% of psych inpatients have a medical condition identified as precipitating the admission Tintinalli et al. Ann Emerg Med 1994; 23:859 Dolan et al. Arch Intern Med 1985; 145: 2085

  8. Challenges to overcome caring for the patient with a psychiatric complaint • Bias against patients with mental illness • Prioritization of “sicker” patients • Patient unwilling or unable to cooperate • Time constraints

  9. McIntyre JA, Romano J: Is there a stethoscope in the house (and is it used?). Arch Gen Psych 1977; 34:114787% of surveyed psychiatrists did not routinely perform a physical examination on their inpatientsPatterson C. Psychiatrists and physical examinations: A survey. Am J Psych 1978; 135:96783% of psychiatrists did not routinely perform physical examinations on their inpatients. Reasons: - uncomfortable performing an exam- already performed by someone else, - desire to avoid transference / countertransference- dislike of performing medical examinations

  10. Riba M: Medical clearance: Fact or fiction in the hospital emergency room. Psychosomatics 1990: 31; 400-404 • Retrospective chart review of 137 ED patients with psychiatric diagnoses • 32% no vital signs • 64% no documentation of general appearance • 67% no documentation of present illness • 92% no neurologic examination • 92% no laboratory testing

  11. Tintinalli J et al. Emergency medical evaluation of psych patients. Ann Emerg Med 1994 23;4: 859-862 • Retrospective review, 298 charts of patients with psychiatric chief complaint • 12 (4%) required acute medical tx within 24 hours of admission: 10 (3%) were transferred to a medical service • Neuro exam, including mental status, was most frequent deficiency • Younger patients had a four fold greater risk of having a missed medical diagnosis

  12. General Approach to Medical Clearance • Triage based on chief complaint and vital signs • History • Physical • Laboratory testing

  13. Findings Suggestive of an Underlying Medical Disorder for Psychiatric Symptoms • Onset after age 40 / No past history of psychiatric illness • Sudden onset • Presence of a “toxidrome” • Visual hallucinations • Known systemic disease • New medication • Abnormal vital signs • Disorientation / Clouded consciousness

  14. The History • Baseline mental and physical status prior to psychiatric history • Good listeners and patient advocates have the best chance of getting an appropriate history • Involve family, friends, others • Time and rapidity of onset • Medications and / or changes in dosing • Alcohol and / or illicit drug use • “Why now”: conceptual framework to understand what overwhelmed usual coping mechanisms

  15. The Physical • Vital signs: accurate temp, pulse oximetry • Appearance • Head exam: signs of trauma • Neck exam: thyroid, meningeal signs • Cardiovascular • Abdomen • Neuro exam: • Mental status (cognition) • CN with a focus on II, III, IV, and VI • DTRs • Motor: muscle wasting, tone, automatisms • sensory • cerebellar

  16. Orientation Attention Registration / Recall (memory) Language (repetition / naming) Visual Spatial O x 3 Could not give months Could repeat but could not recall 3 objects Intact Intact Mini-Mental Status Examination (Cognition)

  17. Appearance Motor Speech Affect and mood Thought content Thought process Perception Insight / Judgement Impulse control / safety Disheveled Normal Normal Flat Paranoid, No suicidal ideation Concrete No hallucinations No insight into her illness Did not feel out of control The Psychiatric Mental Status Exam

  18. Laboratory Testing • Hall et al. Unrecognized physical illness prompting psychiatric admission: A prospective study. Am J Psych 1981; 138:629 • 100 state hospital psych patients with no known medical disease or substance abuse • SMA-34, urine tox, EEG • 60/100 had an abnormality on the SMA-34 • Did not address how many of the abnormalities were clinically significant

  19. Laboratory Testing • Henneman et al. Prospective evaluation of ED medical clearance. Ann Emerg Med 1994; 24: 672 • 100 ED patients with new psychiatric complaints • H&P, ETOH, urine tox, CBC, SMA 7; CT optional, LP if febrile • Excluded known patients with psych disorders, psych patients with medical complaints, known drug use or suicide attempt • 63/100 had medical cause identified: 30/63 tox, 25/63 neurologic, 5/63 infectious (3 CNS)

  20. Laboratory Testing • Olshaker et al. Medical clearance and screening of psychiatric patients in the ED. 1997:2:124 • 345 patients for medical clearance • 65 (19%) found to have a medical condition • History 94% sensitivity; laboratory testing 20% sensitive • Conclude that H&P is the most important part medical clearance and laboratory testing is “low yield”

  21. Summary on Medical Clearance • A complete history and physical is key to “medical clearance” • Laboratory testing is driven by the H&P • Consider laboratory testing: • Underlying medical condition • Abnormal vital signs • Elderly • New onset psychiatric complaint

  22. Medical Screen vs Medical Evaluation • “Medical screen” establishes that the patient is currently stable vs “Medical evaluation” establishes patients baseline state of health • Drug of abuse screen screen may help in the psychiatric evaluation and disposition planning • Liver function and renal function may help in the long term treatment planning • Many inpatient facilities do not have ready access to these tests • Atypical antipsychotics may increase serum glucose and lipid levels; baseline required before initiating therapy • ECG necessary to evaluate the QT interval

  23. The Case Continued ROS (by husband): 10 lb weight loss over past 6 months, occasional palpitations, periods of agitation / fear, withdrawn behavior, lack of initiative, poor hygiene General Appearance: 30 yo female, disheveled, agitated Hypervigilant with paranoid ideation that her husband was trying to poison her Rest of exam was normal including normal thyroid, no heart murmur, normal GYN exam, normal skin and hair

  24. Delirium: Definition • Acute, reversible, diffuse neuronal dysfunction usually due to a toxic-metabolic derangement • Characterized by: • Inattention • Disorientation • Agitation and/or somnolence • Hallucinations • Paranoid ideations

  25. Confusion Assessment Method (CAM Score)DeliriumMust have feature 1 and 2; and 3 or 4 • Feature 1: Acute onset and fluctuating course • History by family • Change from the baseline • Feature 2: Inattention • Feature 3: Disorganized thinking • Feature 4: Altered level of consciousness • Alert, normal • Vigilant-hyperalert • Lethargic • Difficult to arouse

  26. Delirium: Differential Diagnosis • Structural CNS lesion • Toxic: Overdose vs drug effect • Withdrawal syndrome • Metabolic • Infection: Central vs systemic • Seizure • Acute psychiatric disorder

  27. Delirium: Physical Examination • Abnormal vital signs, inattention, flucuating course • Toxidromes: • Cholinergic, anticholinergic, adrenergic, opioid, hallucinogen, sedative • Focal neurologic findings • Evidence of systemic disease: • Dehydration, hypoxia, liver / renal failure, CHF, COPD

  28. Modified Mini-mental Status Exam.(Used to diagnose cognitive impairment) 5 - Time Orientation - date, day, season 5 - Place Orientation - City, State, Building 5 - Attention - serial 7s, months forward / reverse 3 - Registration of 3 objects (immediate recall) 3 –Memory - 3 objects in 3 minutes (delayed memory) 9 – Language / Visual Spatial: repeat “no ifs ands buts, 3 stage command, write sentence, copy design 23 or less = cognitive abnormality

  29. Hustey. ED Prevalence and Documentation of Impaired Mental Status in Elderly. Ann Emerg Med 2002; 39 • 26% (78/297) of patients had altered ms • 10% (30/297) had delirium • 17/30 (57%) had documentation of abnormal mental status by ED provider • 70% of pts discharged home with cognitive impairment had no evidence available that the mental status abnormality was chronic

  30. Delirium: Laboratory Work-up • CBC / Metabolic panel • LFTs • Toxicology Screen • Brain imaging / LP • Blood cultures if sepsis suspected • EEG in select patients

  31. Case Continued The patient was diagnosed having acute delirium with psychosis. CBC, SMA 9, LFTs, tox screen were normal A CT was ordered but the patient was too agitated too cooperate

  32. Interventions for the Agitated Patient • Interview considerations • Environmental factors • Chemical control • Physical restraints

  33. Interview Considerations • Calm and Direct • Empathic • Verbalize limits / expectations • Consistency among staff

  34. Interview Techniques • Eye Contact • Personal Space • Door Position • Body Language

  35. Environmental Factors • Secure / private • Quiet • Weapons detection

  36. Medications • Benzodiazepines • Typical Antipsychotics • Haloperidol • Droperidol • Antispychotic plus Benzodiazepine • Atypical antipsychotic

  37. Benzodiazapines • Lorazepam, diazepam, midazolam • Anxiolitics not antipsychotics • Less predictable effect • Paradoxical disinhibition • Less titratability • Risk of cardiorespiratory depression

  38. Haloperidol • Butyrophenone antipsychotic • 5- 10 mg IM, PO, IV • Onset 20 minutes • t1/2: 19 hours • Side Effects • Dystonic Reaction • Akathesia • Neuroleptic Malignant Syndrome • Cardiovascular Effects: Torsades (.4%) • Seizure Threshold

  39. Droperidol • Butyrophenone antipsychotic • 2.5- 5 mg IM or IV • Onset minutes • t 1/2 2-4 hours • Side effects • Dystonic reaction • Akathesia • Neuroleptic Malignant Syndrome • Cardiovascular effects: Torsades • Seizure threshold

  40. The Droperidol Dilemma • Lancet 2000: Droperidol reported to cause QT prolongation and possibly sudden death: Janssen withdrew drug from the European market • Patients self administered large doses • Often used with other antipsychotics • FDA 2001: Black box warning “Dear Health Care Professional . . . “ • Recommended that it not be given to males with a QTc >440 and females with a QTc >450

  41. The Droperidol Dilemma • Acad Emerg Med 2002. “Behind the black box warning” • The FDA data analyzed: 93 cases of death identified • 52 cases at doses > 10 mg (most 50-100 mg IM) • 22 cases, no dose given • 11 cases of torsades; 9 cases of prolonged QTc • 13 cases of death at doses below 10 mg • 3 involved multiple doses • 3 were anesthetic related • 1 case the dose was .635 mg • 1 case the dose was .25 mg • 5 potential cases out of the original 93

  42. Atypical Antipsychotics • e.g. Respiridone • Orally administered with or without a benzodiazepine • May prolong the QTc • Role still undefined

  43. AAP. Practice guideline for the treatment of patients with delirium. Am J Psychiatry 1999; 156 (suppl):1-20 • Monotherapy with a typical antipsychotic: haloperidol or droperidol • Droperidol has a faster onset and less frequent need for a second dose • Need to monitor ECG and serum Mg levels • Benzodiazepines as a monotherapy is reserved for delirium from drug withdrawal • Generally avoided as monotherapy in the elderly • Lorazepam possibly preferred in patients with liver disease • Combined therapy of a antipsychotic plus a benzodiazepine may have faster onset of action with fewer side effects

  44. Physical Restraints • For imminent threat of harm • Preparations • Overwhelming show of force • Initiate only when prepared • Preparation / de-escalation

  45. Physical Restraint • Once initiated, swift and definitive • Suspend negotiations • Team leader • Secure large joints • Constant reassurance

  46. Monitoring • Documentation • Neurovascular • Cardiovascular • Airway • Plan for reassessment and removal

  47. Case Continued The patient was sedated with droperidol, 5 mg / lorazepam 2 mg IV CT was negative She was admitted to the Medicine Service Blood and urine cultures: negative Thyroid Function Tests: negative EEG: normal Final Diagnosis: _________________________________

  48. Schizophrenia • Psychotic disorder manifested by one or more active phase symptoms, marked social and or occupational dysfunction, and a course lasting at least 6 months. • It is a diagnosis of exclusion. • Positive symptoms include delusions, hallucinations, disorganization, and catatonia. • Negative symptoms include: affective flattening, inappropriate affect, alogia, avolition, asocialtiy, anhedonia, lack of insight, lack of initiative, poor hygiene

  49. Schizophrenia • Average age of onset for women is 27 • Three phases: • Prodrome: attenuated positive / negative symptoms • Active: emergence of active phase symptoms. May follow an acute stressor • Residual phase: Attenuated positive / negative symptoms. Relapse may occur

  50. Schizophrenia • Patient was transferred to the inpatient psychiatry service • Respiridone, 1 mg bid started and increased to 2 mg bid • Discharged after 3 weeks, stable with control of symptoms • Stopped taking medication after 3 months secondary to weight gain and sexual dysfunction • Represented to the ED six months after discharge with same symptoms

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