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Psychiatric Emergencies. Angela S. Olomon, DO. Goals. Strengthen education on psychiatric emergencies presenting in the medical office Identify characteristics of agitated patients Identify suicide risk and protective factors. Objectives.
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Psychiatric Emergencies Angela S. Olomon, DO
Goals • Strengthen education on psychiatric emergencies presenting in the medical office • Identify characteristics of agitated patients • Identify suicide risk and protective factors
Objectives • Apply safe assessment to prevent further increase in agitation of patient • Establish plan for intervention and harm prevention and referral for additional treatment • Determine patient’s potential for danger or harm to self or others
Summary • Psychiatric emergencies can arise in any treatment office. Therefore, every physician is responsible for evaluation. Pre-crisis preparation is key to safety as well as empathetic responses.
Psychiatry in Family Practice • 40% to 60% of general medical patients have comorbid psychiatric conditions • Primary Care writes more psychiatric medications than psychiatrists • Most psychiatric patients present to primary care physicians first (you are the first responder)
CS1 • Bang! • Door vibrates and windows rattle • Staff call the police • In walks a 45 year old white male • Sluggish, unkempt, slow and unsteady gait • Speech is slurred and he is a poor historian • He has no appt. and a Hx of noncompliance
Questions? • What do you want to know?
Key Assessment Data • Meds • Alcohol • Illicit Drugs • Other Informants / Family • Recent History
Evaluation • BA • Drug Screen • BP – P • Pulse Ox • X-Ray / CT
CS2 • 47 year old white female calls • Frantically demands to speak to you • Claims Critical Emergency (like always) • States “I can’t go on!” • “I’m going to kill myself, then I won’t have to deal with it!”
Key Assessment Data • Safety: Where is she? Who is with her? • Does she have a plan? Means? • Precipitant: Why Now? • What is the last chapter of this saga? • Medications / Compliance? • Alcohol? • Illicit Drugs?
Evaluation • Hospital ER vs. Friend vs. 911 • Resources (Therapists, Family)
CS 3 • 40 year old white female in the waiting room, pacing • Demands urgent appointment • Unkempt • Speech rapid and pressured and loud • Flow of thought circumstantial • “Infectious” anxiety – talking to everyone and drawing them into her distress
Key Assessment Data • History of past Dx or hospitalizations • (Bipolar II and Chronic Pain – Spinal Stenosis) • Medications / Treatments • (Opioid Analgesic Discontinued)
Evaluation • Blood levels of medications • Verify Compliance • Initiate De-escalation Procedures • Titrate Medication • Marshal Resources (Family, Therapists)
CS 4 • 12 year old white male brought by foster mother • Restless in waiting room, demanding to know how long a wait • Mother is anxious • Patient is Irritable and Sarcastic • Receptionist and Nurse are anxious • Roomed patient and mother yelling and agitated (you wonder if you paid your office insurance premium)
Key Assessment Data • Initiate safety procedures • Initiate De-escalation Procedures • Call in support (possibly police) • Hx from Mother: • Precipitant / Stressors? • Possible Substance Abuse / Toxicity • Past Episodes?
Interventions • IM vs. PO Medication
Pre Crisis Planning • Physical Environment (everybody can get to the door) • Waiting Room (no impromptu weapons) • Reception Desk • Exam Rooms
Staff Training • Safety Plan • De-escalation Procedures • Code Drill • Practice, Practice, Practice
Aggression Risk Factors • Intoxication • Hopelessness • Irritability • Disorganized Thought • Disheveled Appearance • Psychomotor Agitation • Verbal Agitation • Behavioral Agitation
Suicide Assessment • Risk Factors • Protective Factors
Interventions • Call for Help! • Verbal De-Escalation • Quiet Room – Decreased Stimuli • Pharmacological • Patient’s Meds • Antipsychotic Meds • Benzodiazepines
Emergency Medications • PO • Risperdone 2mg • Ativan 2mg • Zyprexa Zydus 5-10mg • IM • Haldol 5mg • Ativan 2mg
Diagnosis • TRUMP METHOD • Ace Medical Disorder • Joker Substance Induced • King Mood Disorder w/ Psychosis • Queen Schizophrenia • Jack Personality Disorder
ACE • Delirium • Attention • Concentration • MMSE
Mend A Mind • Metabolic • Electrical • Nutrition • Drugs / Toxins • Arterial • Mechanical • Infectious • Neoplastic • Degenerative
Joker • Increased Risk of Suicide • Alcohol Withdrawal / Intoxication • Cannabis • Stimulants • Cocaine • Opioids
Blood Alcohol Concentration • 20-50mg/dL Decreased Fine Motor • 50-100 Decreased Gross Motor • 100-150 Difficulty Standing • 150-250 Difficulty Sitting • 300 Unresponsive to voice or pain • 400 Respiratory Depression
Opioid Withdrawal • Irritability / Agitation • Nausea / Vomiting / Diarrhea • Muscle Ache • Excessive Tears / Runny Nose / Yawn • Pupil Dilatation / Goose Flesh • Sweating / Fever / Insomnia