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Neuropsychiatric Emergencies Andy Jagoda, MD, FACEP Professor of Emergency Medicine Mount Sinai School of Medicine New PowerPoint Presentation
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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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slide1
Neuropsychiatric Emergencies Andy Jagoda, MD, FACEPProfessor of Emergency MedicineMount Sinai School of MedicineNew York, New York
the case
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

the case3
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

the questions
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?
slide5

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

slide6

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

background
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

challenges to overcome caring for the patient with a psychiatric complaint
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
slide9

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

slide10
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
tintinalli j et al emergency medical evaluation of psych patients ann emerg med 1994 23 4 859 862
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
general approach to medical clearance
General Approach to Medical Clearance
  • Triage based on chief complaint and vital signs
  • History
  • Physical
  • Laboratory testing
findings suggestive of an underlying medical disorder for psychiatric symptoms
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
the history
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
the physical
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
mini mental status examination cognition
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)
the psychiatric mental status exam
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
laboratory testing
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
laboratory testing19
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)
laboratory testing20
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”
summary on medical clearance
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
medical screen vs medical evaluation
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
the case continued
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

delirium definition
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
confusion assessment method cam score delirium must have feature 1 and 2 and 3 or 4
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
delirium differential diagnosis
Delirium: Differential Diagnosis
  • Structural CNS lesion
  • Toxic: Overdose vs drug effect
  • Withdrawal syndrome
  • Metabolic
  • Infection: Central vs systemic
  • Seizure
  • Acute psychiatric disorder
delirium physical examination
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
modified mini mental status exam used to diagnose cognitive impairment
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

hustey ed prevalence and documentation of impaired mental status in elderly ann emerg med 2002 39
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
delirium laboratory work up
Delirium: Laboratory Work-up
  • CBC / Metabolic panel
  • LFTs
  • Toxicology Screen
  • Brain imaging / LP
  • Blood cultures if sepsis suspected
  • EEG in select patients
case continued
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

interventions for the agitated patient
Interventions for the Agitated Patient
  • Interview considerations
  • Environmental factors
  • Chemical control
  • Physical restraints
interview considerations
Interview Considerations
  • Calm and Direct
  • Empathic
  • Verbalize limits / expectations
  • Consistency among staff
interview techniques
Interview Techniques
  • Eye Contact
  • Personal Space
  • Door Position
  • Body Language
environmental factors
Environmental Factors
  • Secure / private
  • Quiet
  • Weapons detection
medications
Medications
  • Benzodiazepines
  • Typical Antipsychotics
    • Haloperidol
    • Droperidol
  • Antispychotic plus Benzodiazepine
  • Atypical antipsychotic
benzodiazapines
Benzodiazapines
  • Lorazepam, diazepam, midazolam
  • Anxiolitics not antipsychotics
  • Less predictable effect
    • Paradoxical disinhibition
  • Less titratability
  • Risk of cardiorespiratory depression
haloperidol
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
droperidol
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
the droperidol dilemma
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
the droperidol dilemma41
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
atypical antipsychotics
Atypical Antipsychotics
  • e.g. Respiridone
  • Orally administered with or without a benzodiazepine
  • May prolong the QTc
  • Role still undefined
slide43
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
physical restraints
Physical Restraints
  • For imminent threat of harm
  • Preparations
    • Overwhelming show of force
    • Initiate only when prepared
    • Preparation / de-escalation
physical restraint
Physical Restraint
  • Once initiated, swift and definitive
  • Suspend negotiations
  • Team leader
  • Secure large joints
  • Constant reassurance
monitoring
Monitoring
  • Documentation
    • Neurovascular
    • Cardiovascular
    • Airway
  • Plan for reassessment and removal
case continued47
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: _________________________________

schizophrenia
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
schizophrenia49
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
schizophrenia50
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
conclusions
Conclusions
  • Patients with an acute change in behavior require a careful medical evaluation
  • Historical and physical findings provide the baseline necessary to determine diagnostic testing
  • Delirium is a medical emergency
  • In general, antipsychotics are still the pharmacologic intervention of choice in the acutely agitated patient