Psychiatric Emergencies in Clinical Practice Part 2: Common Problems

Psychiatric Emergencies in Clinical

Practice Part 2: Common Problems

Office of Medical Services CME Buenos Aires February 2012

Stephen A. Young, MD RMO/P Bogota Region

1

Suicide: The Obligatory Statistics

Slide

• 11th_{leading cause of death in the US}

• 3rd_{cause of death ages 15-19}

• Firearms used 55% of time (Anderson and Smith 2003)

• In 2002, 132,353 hospitalized following suicide attempts and 116, 639 were treated in ERs and released (about 1/4 million total) (CDC, 2004)

3

But

…..the only patient that really

matters is the one sitting in front of

Some statistics that can help identify

patients at risk

• The two groups at highest risk are those below 20 and those above 50

• Women attempt 3-4 X as frequently as men, but men use more lethal means and are 2-3 X more often successful

• Suicide is much more common in patients with an established psychiatric disorder – and this increases when combined with substance abuse

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“SAD PERSONS”: Quick Review of

Suicide Risk Factors

• S: Sex • A: Age

• D: Depression

• P: Previous Attempts • E: Ethanol Abuse

• R: Rational Thinking Loss • S: Social Supports Lacking • O: Organized Plan

• N: No Spouse:Divorced>Widowed>Single • S: Sickness (esp chronic conditions/pain)

Ways to Quantify Specific Risks

• Lethality: How specific is the plan? Could it succeed? Could the person be found? • Hopelessness: This has emerged as a

critical element in highly suicidal patients – are there protective factors present? (family, religion, higher level defense mechanisms)

• What has kept them alive so far?

• Suicide is very personal – patients must be approached in an empathic and

non-judgmental fashion

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Prior to Med Evac

• Safety is the number one concern

• RSO may need to be involved to remove weapons from residence or to assist with secure environment

• Front Office needs to know what’s going on

• MED/MHS in WDC needs to be informed • In absence of local inpatient treatment

facility patients may need to be monitored in their residence or other secure setting and will almost always require a medical

Panic Attacks

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At Least 4 Symptoms, Peak in 10 Minutes

Heart and Lung CNS GI Psyche

Panic Attacks

1. Palpitations, pounding heart, or accelerated heart rate 2. Chest Pain or discomfort

3. Shortness of breath 4. Feeling of choking

5. Feeling of dizzy, unsteady, lightheaded or faint 6. Paresthesias (numbness or tingling sensations) 7. Chills or hot flushes

8. Trembling or shaking 9. Sweating

10. Nausea or abdominal stress

11. Derealization (feelings of unreality) or depersonalization (being detached)

12. Fear of losing control or going crazy 13. Fear of dying

Panic Disorder (cont)

Typical Attack lasts just a few minutes – the

recovery time can be several minutes to hours in length

Morbidity results fromlearned reaction to event– avoidance of situations associated with attacks

Over time, the avoidance becomes more and more disabling as the individual’s comfort zone shrinks

This cognitive element ultimately becomes the most difficult aspect of the illness to treat

Differential Diagnosis

• Hyperthyroidism • Hypoglycemia

• Excessive Caffeine Use • Cardiac Event • Pulmonary Embolus • Pheochromocytoma • Carcinoid 13

Treatment Principles:

Pharmacotherapy

Benzodiazepines effective – and not always a bad idea

Longer half life agents have a number of advantages over shorter half life agents

Antidepressants found effective in multiple studies spanning decades (both Tricyclics and SSRIs) but NOT Wellbutrin

Best approach may be a strategy that combines benzodiazepine for short term symptom relief with antidepressant for longer term management

Sample Treatment Regimen

Week 1: Clonazepam 0.5 mg bid plus Zoloft 25 mg qd

Week 2 and 3: Clonazepam 0.5 mg bid plus Zoloft 50 mg qd

Week 4: Clonazepam 0.5 mg q AM plus Zoloft 50 mg qd

Week 5: Zoloft 50 mg qd

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Alcohol Related Emergencies

• Acute Intoxication

• Acute Alcohol Poisoning

• Aggression with other employees and family members • Alcohol Withdrawal

• Medical conditions directly related to alcohol use (GI bleeds, pancreatitis, ascites, Wernicke Korsakoff delirium/dementia)

Management of Intoxication and Withdrawal:

Alcohol Poisoning

• Intoxicated patients need to be monitored – do not put them in a room to “sleep it off”

• Alcohol in the stomach can raise ETOH levels even if the patient doesn’t seem “that bad”

• CNS depressant effect suppresses gag reflex and respiration – leading to aspiration, stupor and death • Key signs: confusion, excess vomiting, seizures, and

slowed respiratory rate

• Key intervention is early recognition and supportive care – often in ICU

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Signs/Symptoms of Withdrawal

• Autonomic Instability (elevated BP and HR) • Nausea • Anxiety • Diaphoresis • Tremors • Agitation • Disorientation

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When to Treat?

• First 48 hours are key because that is when seizure risk is greatest

• Don’t wait for full blown symptoms

• Previous history of significant withdrawal indicates early proactive treatment

• Diastolic BP or HR > 100 • CIWA-Ar score > 8

How to Treat?

• Benzodiazepines still the core treatment

• Clonidine will prevent autonomic symptoms but no seizure prophylaxis

• Short vs. Half life benzos

• Advantage to long half life (Librium, Valium) is self tapering

• Advantage to short half life (Lorazepam) is no active metabolites, can control risk of respiratory depression better

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Typical Regimens

• Chlordiazepoxide (Librium) 25-50 mg q 4-6 hours x 2-3 days targeted to withdrawal symptoms

• Lorazepam 1.0 mg q 4-6 hours • Diazepam 5 -10 mg q 4-6 hours or

20 mg q two hours until patient sleeping • Thiamine 100 mg po qd

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More Severe Syndromes:

Delirium Tremens

• Patients with a history of previous withdrawals or DTs at the highest risk

• Confusion, Hallucinations (visual and tactile), and severe autonomic instability

• Patients often have medical co-morbidity due to alcoholic lifestyle (malnutrition, infectious disease, exposure)

• Can be life threatening and requires emergency treatment/ICU for stabilization

Post Partum Depression and Psychosis

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• DOS Births 2010:

320

• DOS Births 2011:

340

(first 11

months)

Post Partum Depression/Psychosis

• Large number of reproductive age women in DOS • Additional psychosocial stressors of life overseas, med

evac, language barriers with local Obs etc

• 50-85% of women experience “baby blues” – normal • 10-20% post partum depression

• 0.1-0.2% post partum psychosis

• Post partum psychosis is a psychiatric emergency!

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Postpartum Depression: Prevention

• Recognizepatients who may be at risk:

• Previous history of mood disorders • Family history of mood disorders • First pregnancy

• Psychosocial Stressors • Treat:

• Supportive therapy

• Address psychosocial issues

Postpartum Psychosis: Management

• Post partum patients who present with poor self care, paranoid delusions, and/or fantasies of harming themselves or baby need to be taken very seriously • If these symptoms manifest make sure Mom is

monitored at all times – utilize family members, friends, and HU personnel

• Medevac indicated as soon as possible

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The Acutely Psychotic/Agitated

Patient

Acute Agitation

• The first rule is always safety first; never chase a patient down a hallway or engage in a physical confrontation

• Sometimes effective medical assessment may take a back seat to getting the patient under physical control

• Often you may be called to a scene where an individual is already in some type of

custody/control

• Aggression/Loss of Control does NOT

automatically mean the individual is mentally ill!

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Aggression in Embassy/HU Situations

• Fortunately notcommon

• Most likely scenarios: • Interpersonal conflicts • Intoxication or Withdrawal

• Family conflict (adolescents v. parents or spouse v. spouse)

• Autism/MR patients who become frightened or disoriented

• Acute psychosis

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Again…..Safety First: Management

• Approach the patient in a calm, non confrontational manner

• Identify yourself and make it clear your intention is to assist

• Be firm, direct, and concrete • Listen

• If possible, obtain VS and do an overall assessment of the patients current status (restless, disheveled, injured etc)

Management: Pharmacotherapy

• All HU formularies should have a few doses of injectable benzodiazepines and antipsychotics

• Antipsychotic often not required – especially if psychosis is not likely

• Lorazepam 2 mg IM is an excellent choice

• IF the patient appears psychotic – Can combine Haldol 5 mg with Lorazepam 2 mg and Benedryl 25 mg

• ALWAYS give the patient the choice to take meds po if possible

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Suggestions for Using Restraints

• At least 5 people: one for each extremity and one to control the head

• Keep talking to the patient; explain what is happening • Give the client a few seconds to comply – but don’t

negotiate

• Patient should be monitored at all times, especially monitor extremity perfusion, level of consciousness, and respiratory status

Family Advocacy

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Family Advocacy Cases

• Child Abuse • Child Neglect • Domestic Violence • 3 FAM 1810

• FAC-Wash DC: Drs. Paul Beighley & Stanley Piotroski: 202-663-1903

Family Advocacy Cases

• Always complex, always emotional. Front office at post may have limited to no experience and look to you for guidance.

• Control Information Flow – Need to Know only – DCM, RSO, and FAC in WDC

• Medical Officer Evaluates– RSO Investigates

• Both Medical Officer and RSO report separately to WDC

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Family Advocacy Cases (cont)

• WDC reviews the situation and provides guidance • Do not delay in providing information – if there is a

credible allegation the FAT should meet ASAP and WDC contacted immediately

• RSO will make determination re: safety at post (e.g., do the parties need to be separated right away?)

• Med evac may be complex – as parties may not travel together