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Behavioral Emergencies for the Emergency Physician
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Book description

Emergency physicians, in all practice settings, care for patients with both undifferentiated psycho-behavioral presentations and established psychiatric illness. This reference-based text goes beyond diagnostics, providing practical input from physicians experienced with adult emergency psychiatric patients. Physicians will increase their understanding and gain confidence working with these patients, even when specialized psychiatric back-up is lacking. Behavioral Emergencies for the Emergency Physician is comprehensive, covering the pre-hospital setting and advising on evidence-based practice; from collaborating with psychiatric colleagues to establishing a psychiatric service in your ED. Sedation, restraint and seclusion are outlined. Potential dilemmas when treating pregnant, geriatric or homeless patients with mental illness are discussed in detail, along with the more challenging behavioral diagnoses such as malingering, factitious and personality disorders. This go-to, comprehensive volume is invaluable for trainee and experienced emergency physicians, as well as psychiatrists, psychologists, psychiatric and emergency department nurses and other mental health workers.

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Contents

Page 1 of 3

Contents
  • Chapter 6 - Drug intoxication in the emergency department
    pp 36-45
  • View abstract

    Summary

    This chapter describes the magnitude of the problem of mental illness, both globally and in terms of specific mental health-related visits encountered in emergency department (ED) settings. The WHO's cross-national comparisons show a globally high prevalence of major Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) mental disorders (anxiety disorders, mood disorders, impulse control disorders, substance use disorders) with 25th-75th percentiles ranging from 18.1% to 36.1%. The chapter describes the magnitude of the problem of ED presentations for specific mental disorders. The most prevalent conditions are highlighted. After anxiety disorders, mood disorders are the second most common psychiatric disorder in the general population, occurring in 10% of the U.S. adult population each year. Schizophrenia spectrum diagnoses account for approximately two thirds of all psychotic disorders. Almost 1 in 10 of the adult U.S. population is estimated to have an Axis II personality disorder in any year.
  • Chapter 8 - The patient withdepression in the emergency department
    pp 53-59
  • View abstract

    Summary

    This chapter introduces and describes the process of medical evaluation, also termed medical screening, of the psychiatric patient in the emergency department (ED). It discusses the diagnosis of medical mimics, along with the utility of both the patient history and physical exam and laboratory evaluations. The evaluation that an emergency physician conducts is an extremely important and, albeit, limited chance for the patient to be treated for a medical condition that may be causing their symptoms. The chapter also discusses the use of standard screening algorithms, which have been shown in several studies to decrease testing costs for ED patients undergoing medical screening. Local processes, such as coordination of care, trust between providers, wait times for subsequent psychiatric admission, facility overcrowding, and subgroup demographics may play a strong role in acceptance and accuracy of the emergency medicine evaluation process.
  • Chapter 10 - The patient with somatoform disorders in the emergency department
    pp 69-75
  • View abstract

    Summary

    This chapter discusses a composite case illustrating a man's alarming resistance to his underlying medical acuity, and to his physician. The medical condition can be diagnosed by routine history and physical examination, but it is termed occult because the patient's psychological defenses are protean, and exceptional finesse and focus are required to overcome them. Another case with a primary psychiatric diagnosis is considered in which an assessment of risk by a physician assistant (PA) is indeterminate, but an attending physician's brief, focused interview elicits the acute precipitant and accurately identifies the underlying crisis state of mind. The emergency department environment is often sub-optimal for mental health cases, making interview skill all the more necessary. The objective of the chapter, to add to the emergency practitioner's psychiatric skill set, should not draw attention away from the equally important longer term goal of reducing psychiatric visits to emergency departments.
  • Chapter 11 - The patient with anxiety disorders in the emergency department
    pp 76-82
  • View abstract

    Summary

    Drug and alcohol testing may help the emergency physician (EP) determine whether behavior is likely caused by acute intoxication versus a medical condition versus an acute exacerbation of psychiatric illness as well as guide the timing of reassessments and a reliable mental status examination. The current American College of Emergency Physicians' (ACEP) clinical policy on the evaluation of psychiatric patients presenting to the emergency department cites numerous literature sources concluding that laboratory testing is often unnecessary and is often inaccurate. In addition, positive urine drug test results often do not affect outcome or patient disposition. Each patient's level of cognition should be assessed on an individual basis. When a patient is hemodynamically stable and can provide a history and cooperate with a physical exam and all are consistent with their presentation, routine drug and alcohol testing can be avoided.
  • Chapter 12 - The patient with post-traumatic stress disorder in the emergency department
    pp 83-87
  • View abstract

    Summary

    Substance use is highly prevalent among patients presenting to emergency departments (EDs). Substance use complicates differential diagnosis of the ED patient, as substance use can mimic a variety of psychiatric syndromes. Chronic drug and/or alcohol use significantly increases the likelihood that a person will use an ED for medical treatment. The drugs of abuse and intoxication include alcohol, opiates, sedative hypnotics, stimulants, hallucinogens and dissociative agents, inhalants, and cannabinoids. Drug intoxication is commonly involved in ED visits, and patients may present with a variety of medical and psychiatric complaints. Drug intoxication complicates clinical presentation and can lead to prolonged ED length-of-stay, deployment of resources, including the use of restraints in severe intoxication syndromes, and creates a challenge for disposition and treatment.
  • Chapter 13 - The patient with psychosis in the emergency department
    pp 88-102
  • View abstract

    Summary

    The emergency physician assessing and treating a patient with a psychiatric emergency will frequently encounter patients with withdrawal syndromes. Clinically, ethanol withdrawal manifests as increased autonomic symptoms, alcohol withdrawal hallucinosis, alcohol withdrawal seizures, and delirium tremens (DTs). Patients with minor symptoms of alcohol withdrawal without a history of DTs and who intend to continue drinking are often discharged without receiving any specific medications. Sedative hypnotic agents such as barbiturates and benzodiazepines, like ethanol, exert their effects by means of augmentation of GABA inhibitory neurotransmission. Therefore, symptoms of withdrawal from these agents are very similar to alcohol withdrawal. Withdrawal from Gamma-hydroxybutyrate and its precursors are similar to alcohol withdrawal and other sedative hypnotics. Opioid withdrawal is not life-threatening. However, it is very unpleasant and painful to endure. Due to cross-reactivity of the different opioids, any opioid can be administered to alleviate withdrawal symptoms.
  • Chapter 14 - Personality disorders in the acute setting
    pp 103-112
  • View abstract

    Summary

    Mood disorders are grouped into four broad categories: depressive disorders, bipolar disorders, mood disorder due to a general medical condition, and substance-induced mood disorders. This chapter provides some guidelines on the assessment and management of mood disorders in the emergency department (ED) setting. Cardiovascular diseases, such as coronary artery disease, myocardial infarction, and stroke, are also often associated with depression. The diagnosis of a mood disorder is based on history, collateral information, and observation of the patient's behavior. Mood disorders should be suspected in patients with multiple, vague, nonspecific complaints and in patients who are frequent users of medical care. The creation of a safe and stable environment for the patient should be a first priority in management. The patient with an acute manic episode may be disruptive, refuse medical evaluation, and make repeated attempts to leave the ED.
  • Chapter 16 - The patient with delirium and dementia in the emergency department
    pp 117-124
  • View abstract

    Summary

    This chapter outlines the epidemiology and risk factors for suicide as this provides the busy emergency department (ED) physician with a good framework around which to structure the patient interview. Knowledge about the risk factors related to suicide is important as it helps to guide the assessment of the suicidal patient in the ED. The risk of suicide is related to the type and severity of the psychiatric illness. In psychotic illnesses, such as schizophrenia, the risk for suicide can be especially high if the patient is experiencing command hallucinations telling the patient to kill him or herself. When assessing suicidal patients, it can be very helpful to have a framework to help recall the risk factors for suicide. The SADPERSONS scale is one tool that is commonly used as a helpful reminder in these situations. The immediate medical stabilization of patients following a suicide attempt is the first priority.
  • Chapter 17 - The patient with excited delirium in the emergency department
    pp 125-131
  • View abstract

    Summary

    Somatoform disorders (SDs) consist of a group of psychiatric conditions that cause unintentional physical symptoms suggestive of a general medical condition. SDs specifically addressed in this chapter include somatization disorder, undifferentiated somatoform disorder, conversion disorder, pain disorder, hypochondriasis, body dysmorphic disorder, and somatoform disorder not otherwise specified. There are general similarities among the different somatoform disorders that may help guide a healthcare provider's evaluation. There are inherent difficulties to evaluating SD patients in the emergency department (ED) which may contribute to both patient and physician discontent. Stronger treatment alliances with healthcare providers form if patients do not feel blamed for producing their unintentional symptoms. A treatment alliance can start in the ED, but ideally continues with inpatient or outpatient mental healthcare professionals or other specialists. Cognitive behavioral therapy (CBT) and antidepressant medication have each demonstrated success in treating patients with SDs.
  • Chapter 18 - Medical illness in psychiatric patients in the emergency department
    pp 132-139
  • View abstract

    Summary

    Anxiety disorders are among the most common psychiatric presentations to the emergency department (ED). The ability to differentiate anxiety symptoms and disorders from acute life-threatening conditions is paramount in providing treatment that is thorough, safe, and accurate. This can be particularly challenging when dealing with the time constraints faced in the ED, and financial limitations encountered in the un-insured and the underinsured patients. The Panic Screen Score (PSS) is one tool available for evaluation of ED patients presenting with unexplained chest pain which may be used to help determine prevalence as well as guide referral for further mental health evaluations. There is evidence to support both the efficacy and effectiveness of cognitive behavioral therapy (CBT) as an acute treatment for adult anxiety disorder. In cases where pharmacological therapy is necessary in the ED and even more rarely, upon discharge, short-acting benzodiazepines such as Lorazepam and Alprazolam can be used.
  • Chapter 19 - Acute care ofeating disorders
    pp 140-149
  • View abstract

    Summary

    This chapter highlights the two specific psychiatric manifestations of trauma, acute stress disorder (ASD) and its counterpart post-traumatic stress disorder (PTSD). It discusses management strategies for patients with ASD/PTSD in the emergency department (ED) and shows how the emergency physician (EP) can effectively identify the various presentations of PTSD, even when the symptoms are sub-threshold for a formal diagnosis. Symptoms of avoidance and re-experiencing are unique to PTSD and should help distinguish it from related anxiety disorders. The potential for clinically relevant physiologic manifestations of psychiatric stress is demonstrated by Takotsubo cardiomyopathy (TCM). In instances when the patient meets the diagnostic criteria for ASD/ PTSD, referral to outpatient psychiatric treatment is recommended. Such therapy may include psychopharmacology and cognitive behavioral, cognitive processing, or exposure therapy. In most practice settings, pharmacologic treatment should be initiated and managed outside of the ED by a primary care physician or mental health professional.
  • Chapter 20 - Management of the emergency department patient with co-occurringsubstance abuse disorder
    pp 150-154
  • View abstract

    Summary

    This chapter covers the initial evaluation and management of a psychotic emergency department patient with particular emphasis on the process of separating psychiatric causes from medical causes of psychosis. Hallucinations, delusions, thought disorganization, agitation, and catatonia are the most common features of psychosis. Emergency physicians have a primary responsibility to determine which category, organic or functional, defines a patient's psychotic episode. Substance-induced toxicity is a more common cause of acute delirium in children, and should be considered early in the evaluation. Dementia (particularly vascular dementia and Alzheimer's disease) predisposes patients to psychosis that may require inpatient psychiatric management. The etiology of postpartum psychosis is unknown but familial susceptibility suggests a genetic link, and rapid hormone changes seem to play a triggering role. The chapter discusses the management of agitation, and provides information on the medical screening examination, which allows for ultimate categorization of psychosis and appropriate disposition.

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