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  1. Home
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  3. Behavioral Emergencies for the Emergency Physician
  • Cited by 6
Publisher:
Cambridge University Press
Online publication date:
April 2013
Print publication year:
2013
Online ISBN:
9781139088077
DOI:
https://doi.org/10.1017/CBO9781139088077
Subjects:
Psychiatry and Clinical Psychology, Emergency Medicine, Medicine, Psychiatry
Information

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 2 of 3

Contents
  • Chapter 21 - Use ofverbal de-escalation techniques in the emergency department
    pp 155-163
  • View abstract

    Summary

    In malingering and factitious disorder, the patient pretends to be ill or intentionally causes his or her own symptoms. This chapter reviews the diagnosis, assessment, and management of these, often difficult, patients, providing practical advice to the emergency physician. Malingering and factitious disorder are both forms of somatization in which the patient is aware of producing or feigning their symptoms. A sub-category of factitious disorder, Munchausen syndrome, named after the famous 18th century traveling storyteller, Baron von Munchausen, is characterized by patients who travel widely and tell elaborate tales about their illnesses and treatments thus becoming career medical imposters. Both malingering and factitious disorder are diagnoses of exclusion. While recognition is the first step in the psychiatric management of malingering and factitious disorder, this is not easy to do when an unknown patient presents to the emergency department (ED). The chapter summarizes recommendations for the management of these disorders.
  • Chapter 22 - Use ofagitation treatment in the emergency department
    pp 164-169
  • View abstract

    Summary

    Patients with delirium, dementia, and those with both delirium and dementia can be the most challenging patients in the emergency department (ED). Integration of psychiatric emergency services into the ED can help with cognitive assessment and management. Patients can also have delirium superimposed on dementia, making diagnosis and management more challenging. Although delirium can occur in patients across the lifespan, most studies have focused on older adults, as does this chapter. The most popular instruments for efficient screening of patients have been the Mini-Mental State Examination (MMSE), Confusion Assessment Method (CAM), CAM-ICU, Six-Item Screener (SIS), and the Mini-Cog. Treatment strategies for managing delirium are divided into non-pharmacologic and pharmacologic interventions and can definitely be implemented in the ED. Alzheimer's disease is the most common form of dementia, accounting for 50-80% of cases. The neuropsychiatric sequelae of dementia can make the diagnosis of a presenting patient more challenging.
  • Chapter 23 - Management of aggressive and violent behavior in the emergency department
    pp 170-176
  • View abstract

    Summary

    Excited delirium syndrome (ExDS) is a specific type of extreme agitation. As patients with ExDS are often transported to an emergency department (ED), they are also cared for by emergency medicine clinicians. Currently, the majority of reported cases of ExDS are associated with stimulant drug use, such as cocaine or methamphetamine, although cases of ExDS still occur in psychiatric patients who are untreated or have abruptly discontinued their medication. This chapter reviews the existing literature on evaluation and treatment considerations for ExDS. Expert consensus guidelines recognize three classes of medications for initial calming of agitated patients: benzodiazepines, first-generation antipsychotics (FGA), and second-generation antipsychotics (SGA). Attention to airway maintenance, breathing adequacy, and volume resuscitation, along with rapid treatment of hypoglycemia, hyperthermia, and metabolic acidosis may be life saving. ExDS is a medical emergency, and cooperative protocols are needed between law enforcement, EMS, and local emergency departments to best manage these patients.
  • Chapter 24 - Restraint and seclusion techniques in the emergency department
    pp 177-181
  • View abstract

    Summary

    It is given that medical illness is common in psychiatric patients and that psychiatric pathology is common in medical conditions. Within the emergency department, psychiatric patients make-up one of the major diagnostic categories. Evaluation of pre-existing and comorbid psychiatric conditions and their treatments, which can have a profound impact on the patient's medical evaluation, differential diagnosis, and treatment plan, should quickly follow stabilization of the emergency condition. According to the NIMH Epidemiologic Catchment Area Program, more than half of those that abuse drugs have a psychiatric comorbidity with an odds ratio of 4.5. Polypharmacy is a growing national problem, not just in the comorbid medical-psychiatric patient, and is noted especially in select patient populations like nursing homes, a growing referral source for many emergency departments. Psychiatric patients are often taking adjunctive medications such as tricyclic antidepressants, anticonvulsants, and benzodiazepines that can be adjusted to serve dual therapeutic purpose.
  • Chapter 25 - Use ofpsychiatric medications in the emergency department
    pp 182-189
  • View abstract

    Summary

    This chapter gives a brief overview of the eating disorders (EDs) such as anorexia nervosa (AN), Bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS). It discusses recognition of EDs and commonly associated medical complications and their management in the acute setting. Patients with EDs are often quite reluctant to disclose their illness to healthcare providers and may present to the emergency department with vague non-specific complaints rather than complaints directly attributable to their ED. Identification and proper management of these patients requires the healthcare provider to maintain a high index of suspicion for these illnesses and to readily recognize signs and symptoms consistent with ED pathology. Common presenting complaints include headache, mood changes, sore throat, dizziness/syncope, palpitations, fatigue/generalized weakness, sports-related or overuse injuries, and gastrointestinal (GI) complaints such as indigestion, abdominal pain, bloating, constipation, and hematemesis. The chapter also provides suggestions for definitive, long-term treatment referral.
  • Chapter 26 - The patient withneuroleptic malignant syndrome in the emergency department
    pp 190-196
  • View abstract

    Summary

    This chapter describes the epidemiology of co-occurring disorder (COD), and discusses its assessment. It suggests the use of simplified diagnostic criteria to confirm substance use disorder (SUD) in a patient with known or suspected serious mental illness (SMI), assess and treat the patient with known or suspected SMI for a concurrent drug intoxication. The chapter also discusses disposition of the COD patient who is no longer acutely intoxicated, withdrawing or suffering from an acute medical condition. In the emergency department (ED) setting, patients with potential or known COD typically present with acute behavioral disturbance. The Drug Abuse Screening Test Modified for ED (DAST-ED) is adapted for specific use in the ED and is based on two well-known drug abuse screening tests that have been well studied and validated for use in the outpatient setting. Psychosocial treatments shown to be effective include motivational interviewing, cognitive behavioral therapy, and social skills training.
  • Chapter 27 - Treatment ofpsychiatric illness in the emergency department
    pp 197-205
  • View abstract

    Summary

    In a busy emergency department (ED), agitation requires immediate attention and intervention. This chapter addresses methods of verbal de-escalation for the patient who is agitated, but still in control, or who can regain control without the need for restraints or medication, but who, without some verbal intervention, could escalate into full-blown agitation and behavioral dyscontrol. Verbal de-escalation takes no more than five or ten minutes. The best treatment for agitation is to prevent it, or prevent it from escalating. This chapter addresses techniques of verbal de-escalation that the emergency physician can quickly learn and implement as an alternative to seclusion and restraint. Ultimately, verbal de-escalation improves staff morale and patient adherence, because it uses a non-coercive, patient-centered approach. Verbal de-escalation takes no more than five to ten minutes and enhances the doctor-patient relationship, while seclusion and restraint require more staff and takes more time to implement.
  • Chapter 29 - Pediatric psychiatric disorders in the emergency department
    pp 211-218
  • View abstract

    Summary

    Emergency physicians are frequently required to care for unknown patients with acute undifferentiated agitation. Agitation is known to be associated with several other psychiatric and medical causes. Agitation, regardless of the etiology, is a behavioral emergency. Both typical (first-generation) and atypical (second-generation) antipsychotics are frequently used in the management of agitation. Several of the typical antipsychotics have been associated with QT prolongation and torsades de pointes. Other acute adverse effects of antipsychotic use in the treatment of acute agitation include anticholinergic effects, movement disorders, and neuroleptic malignant syndrome. Benzodiazepines are commonly used in the acute management of agitation. In addition to rapid sedation, ketamine's short duration of action, parenteral administration, and in particular the preservation of protective airway reflexes, are attractive properties in the management of patients with acute agitation. According to the Joint Commission Standards, restraints can only be used when clinically justified or when warranted by patient behavior.
  • Chapter 30 - Geriatric psychiatric emergencies
    pp 219-229
  • View abstract

    Summary

    With the risk of violence being so high in the emergency department (ED), it is essential for ED physicians and staff to have an understanding of the progression of violence and the appropriate de-escalation techniques to defuse potentially violent situations. Techniques for de-escalation should occur in a step-wise pattern beginning with verbal techniques, followed by the offering of a pharmacologic intervention, a show of force, and finally physical restraint. At times, it may be necessary to use physical restraints until parenteral medications have had their desired effect. The most frequently used medication strategies consist of benzodiazepines, second-generation antipsychotic medications alone or in combination with a benzodiazepine, and haloperidol (Haldol) alone or in combination with a benzodiazepine. The ED can best be prepared for a hostage crisis by developing well-defined procedures for securing the area, for alerting the appropriate law enforcement agencies, and by designating clear lines of authority.
  • Chapter 31 - Disaster and terrorism emergency psychiatry
    pp 230-234
  • View abstract

    Summary

    Restraints are used in the healthcare setting primarily in two general situations: violent and/or self-destructive situations when the patient has demonstrated or poses an imminent danger to themselves or another, and disruption of therapy or non-violent, non-self-destructive situations. Chemical restraints are an effective and safe tool in caring for patients when used wisely. This chapter intends to provide an overview of the pharmacology, indications, side effects, and dosages of the three most commonly used medications for chemical sedation: lorazepam, haloperidol, and ketamine. Physical restraint application requires training and the demonstrated competency of involved staff. Alternatives to both chemical and physical restraints should always be explored before their initiation. Seclusion is another form of behavior control used in emergency departments and hospitals, and is simply defined as the confinement of a patient in a closed space for a specific amount of time.
  • Chapter 32 - Trauma and loss in the emergency setting
    pp 235-243
  • View abstract

    Summary

    This chapter reviews the most common psychiatric medications used in the emergency setting. It discusses the larger group of psychiatric medications one encounters daily on patients' medication lists. The most commonly prescribed psychiatric medications are the antidepressants, subdivided into four classes: tricyclic antidepressants (TCAs), heterocyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs). Antipsychotics, despite numerous side effects, have revolutionized the treatment of schizophrenia, allowing patients who once had to be hospitalized to live fairly normal lives. Several medications are considered mood stabilizers, also referred to as antimania medications. They include lithium, carbamazapine, valproic acid, and some atypical antipsychotics. Chemical restraint of an agitated patient is perhaps the most common reason psychiatric medications are used in the emergency department. The most common medications used for chemical restraint are haloperidol, droperidol, ziprasidone, olanzipine, lorazepam, and midazolam. The atypical antipsychotics are increasingly being used for acute agitation.
  • Chapter 33 - Management ofhomeless and disadvantaged persons in the emergency department
    pp 244-250
  • View abstract

    Summary

    The evidence for the hypothesis that dopamine blockade is central to neuroleptic malignant syndrome (NMS) is mostly circumstantial, but is related to the fact that NMS is precipitated by antipsychotics that block dopamine receptors. Dopamine receptors in the hypothalamus are integral to the regulation of body temperature and their blockade results in hyperthermia and autonomic instability. The patient with NMS classically develops worsening altered mental status over the course of several days after, or during, treatment with an antipsychotic medication. The most important aspect of treatment for NMS is the discontinuation of the offending medication (or restarting a previously held dopamine agonist) followed by supportive care. Benzodiazepines should be used as a component of supportive care in patients with increased sympathetic tone. Dopamine agonists such as bromocriptine and amantadine have been advocated as possible therapies based on a theory that NMS is primarily caused by dopamine blockade.
  • Chapter 34 - Management of neurobehavioral sequelae oftraumatic brain injury in the emergency department
    pp 251-259
  • View abstract

    Summary

    This chapter reviews the acute treatment process from evaluation and determination of the disease, which may or may not have a psychiatric origin, to stabilization. Psychosis is disruption in perception, organization of speech and/or organization of behavior. There are several disorders related to psychosis: brief psychotic disorder, schizophreniform, schizophrenia, severe mood disorders (depression or mania) with psychosis, schizoaffective disorder, delusional disorder, and shared psychotic disorder. Stabilization of the psychiatric patient in the emergency department (ED) depends largely on the presenting symptoms but can be thought of as having three main components: de-escalation, treatment, and evaluation of safety. De-escalation is needed for the agitated patient, to ensure safety. There are various treatment strategies for psychosis; the decision is based on several factors, such as patient preference, cost, and access to care. Disposition is largely determined on severity of illness.
  • Chapter 35 - Management of psychiatric illness inpregnancy in the emergency department
    pp 260-269
  • View abstract

    Summary

    Psychiatric patients in the emergency department (ED) present unique and difficult challenges for the emergency medicine physician. This chapter reviews current therapies, as well as newer and investigational treatment options useful to diminish acute psychiatric symptoms. All ED staff involved in the use of restraints must be well versed in criteria for use of restraints and their proper and appropriate application. The most used typical antipsychotics in the ED for rapid lysis of acute psychosis have been haloperidol (Haldol) and droperidol (Inapsine). The atypical antipsychotics such as risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), and ziprasidone (Geodon) have a pharmacologic profile that is favorable. An agent that would provide the acute lysis of suicide thoughts and provide for a cooling off period for patients while they achieve therapeutic benefit from antidepressant therapy and receive outpatient therapy would be quite useful in the ED setting.
  • Chapter 36 - Cultural concerns and issues in emergency psychiatry
    pp 270-281
  • View abstract

    Summary

    Children and adolescents who come to the emergency department (ED) with a psychiatric crisis are a concern for all ED professionals. The disposition plan for the suicidal child or teen should include mental healthcare referral. The substance use may represent an incidental finding in the ED, or the substance use can cause directly a youth's presentation in the ED due to symptoms of intoxication. Schizophrenia and bipolar disorder, two common and severe psychiatric disorders arising in young adulthood, can occur with an earlier onset if there is strong familial genetic loading for the condition. Post-traumatic stress may emerge in children and teens who are exposed to overwhelming experiences: accidental trauma; physical or sexual abuse; repeated or prolonged medical or surgical hospitalizations with difficult procedures to endure. Some ethnic and racial minority patients are at increased risk for traumatic experiences, including child abuse.
  • Chapter 38 - Coordination of emergency department psychiatric care with psychiatry
    pp 291-296
  • View abstract

    Summary

    This chapter focuses on the essential elements of an immediate post-disaster assessment and treatment plan for emergency physicians (EPs). The increasing frequency and impact of natural disasters combined with the ever-present threat of terrorism make the management of disaster victims an essential skill for the EP. Dissociation in disaster victims can be difficult to distinguish from delirium due to medical causes. After ruling out any serious medical issues which require stabilization, the focus should shift to assessing the degree of traumatic exposure and individual risk factors for adverse psychiatric outcomes. The concept of acute psychiatric care for victims of trauma is derived from the experience of military psychiatrists in handling traumatized soldiers. Various clinical trials have examined the role of propranolol in traumatic memory consolidation and as a potential agent for post-traumatic stress disorder (PTSD) prevention in traumatized emergency department (ED) patients.
  • Chapter 39 - Integration with community resources
    pp 297-302
  • View abstract

    Summary

    This chapter focuses on the acutely traumatized person presenting to the emergency department (ED) and addresses grief and bereavement along with the vicissitudes, various sub-types of response: acute, impacted, delayed, traumatic, and chronic. It also addresses how the emergency physician (EP) can best recognize and manage acute trauma and grief, and identifies other presentations that may be indirect expressions of bereavement or trauma. EDs are in themselves traumatic places where people receive unexpected bad news, a serious diagnosis, the need for emergency, life-threatening surgery, the loss of a loved one's life. Traumatic grief is a risk factor for mental and physical morbidity, including an increased incidence of suicide within the first 2 years of bereavement. The chapter examines how care providers can recognize the signs of their own secondary or vicarious traumatization and identifies strategies to prevent or remedy them.
  • Chapter 40 - The role of telepsychiatry
    pp 303-307
  • View abstract

    Summary

    This chapter describes the epidemiology of homelessness and mental illness in the United States, and explores some of the unique factors faced by this population. Psychiatric illness, particularly schizophrenia, bipolar disorder, and major depression, have a high prevalence in the homeless population. High rates of alcohol and substance abuse in the homeless population compound the psychiatric and medical problems. Homeless persons use the emergency department (ED) at a higher rate than non-homeless. The assessment of homeless patients with psychiatric complaints follows a process similar to domiciled persons. There are several areas in which the patient's homeless status should be given special consideration. The chapter discusses these considerations and further illustrates them using case studies. It concludes by discussing the process of assessing and providing care for these patients while reflecting on systemic challenges for improving emergency care for patients with homelessness and mental illness.
  • Chapter 41 - Emergency medical services psychiatric issues
    pp 308-312
  • View abstract

    Summary

    Neurobehavioral sequelae after concussion may have both somatic and neuropsychiatric components. The impact of injury on neurotransmitter function is poorly defined but clearly could provide a biological explanation for some of the behavioral changes seen after traumatic brain injury (TBI). Chronic traumatic encephalopathy has been associated with both repeat concussion and with genetic predisposition. Before focusing on the neurobehavioral complaints of the patient who has sustained a concussion, a comprehensive history and physical exam is required. The history focuses on the events preceding and succeeding the concussion. The use of neurocognitive testing in athletes before and after injury has contributed to our understanding of postconcussive cognitive performance. Cognitive and physical rest are key components to recovery. Recognizing the possibility of a mild (mTBI) patient developing neurobehavioral sequelae, education is a key component of the discharge process.
  • Chapter 42 - Triage of psychiatric patients in the emergency department
    pp 313-319
  • View abstract

    Summary

    This chapter presents the major mental health topics of concern in pregnant patients and offers guidelines in the management of these patients in the emergency setting. Suicidal and violent symptoms should be assessed in any patient presenting with emotional, psychological, or social stress. Unipolar disorders, such as major depression, and bipolar disorders comprise the mood disorders. They tend to have an age of onset that coincides with the peak years of childbearing. The management of depression in pregnancy depends upon the severity and course of illness, presence of depression before pregnancy, treatment before or during pregnancy, available resources, and the patient's level of support. Like the mood disorders, anxiety disorders remain problematic during pregnancy; pregnancy is not protective against these symptoms. Patients with a positive domestic violence screen should be referred for treatment. Treatment varies from formal domestic violence consultations to safe havens.
  • Chapter 43 - The Emergency Medical Treatment and Active Labor Act (EMTALA) and psychiatric patients in the emergency department
    pp 320-323
  • View abstract

    Summary

    In the field of emergency psychiatry, a person's ethnic background, race, religion, values, beliefs, customs, and language can affect the symptoms with which a psychiatric illness may present. A culturally competent evaluation of the psychiatric patient includes assessment of the cultural identity of the individual, the role of culture in the expression and evaluation of psychiatric symptoms, and the effect of cultural differences on the relationship between patient and clinician. The cultures of the clinician and system of care influence diagnosis, treatment, and delivery of care. Language barriers influence the authenticity of the informed consent process. According to federal classification, the four most recognized racial and ethnic minority groups in the United States are Hispanic Americans/Latinos, African Americans/Blacks, Asian Americans and Pacific Islanders, and American Indians and Alaska Natives. Culture-bound syndromes in Hispanic populations include ataque de nervios (attack of nerves), nervios (nerves), and susto (fright or soul loss).
  • Chapter 44 - Assessing capacity, involuntary assessment, and leaving against medical advice
    pp 324-334
  • View abstract

    Summary

    This chapter discusses some challenges to rural emergency psychiatric care. An appreciation of these challenges will help emergency medical and psychiatric providers collaboratively address them and prospectively develop effective, local paradigms of optimal emergency psychiatric care unique to their particular rural environment. The perception of mental illness by those in rural communities is an important clinical issue. Determining the level of suicidal or homicidal risks is an important component of any risk assessment in rural PES. One of the most important clinical issues in assessing behavioral health patients is the risk assessment. A paradigm of care should be developed and implemented in a public health approach to address rural emergency psychiatric care. Medical clearance continues to be a challenging issue in rural settings. To implement telepsychiatry, the participating physicians and institutions will need to implement consultation protocols, patient confidentiality protections, and develop mechanisms to streamline provider credentialing.
  • Chapter 45 - Best practices for the evaluation and treatment of patients with mental and substance use illness in the emergency department
    pp 335-346
  • View abstract

    Summary

    This chapter addresses three themes relevant to the coordination of care between the emergency medicine and psychiatry clinicians: who is involved in the coordination of care; creating a coordination team; and the benefits of nonclinical interdisciplinary collaboration. Coordinating care with mental health professionals suggests the challenge of understanding who's who, and who's likely to be doing what. Creating an effective team requires additional steps, including assessing the availability of willing resource-partners, recognizing the abilities and liabilities of those resource-partners, and designing a model for coordinating care. These themes were chosen to highlight differences in culture, training or approach and may provide providers with the clarity to decrease interdepartmental frustrations and improve patient outcomes. In addition to coordinating patient care, collaborations between psychiatry and emergency services can be helpful for growing departments in several ways including through education for capacity building, research initiatives, and improving well-being and morale.
  • Chapter 47 - Physical plant for emergency psychiatric care
    pp 355-361
  • View abstract

    Summary

    This chapter familiarizes emergency department (ED) physicians with the community mental health model and introduces non-inpatient community resources along the psychiatric crisis continuum. It primarily focuses on publicly funded community resources because the greater percentage of patients who present in psychiatric crisis to EDs lack private coverage benefits. Deinstitutionalization has often been cited as the single most important factor contributing to the current mental health system crisis. The chapter provides examples of the types of programs and interventions that may avert the need for inpatient care. Mobile crisis teams are a type of service along the psychiatric crisis continuum which consists of trained mental health and/or law enforcement personnel organized to respond to psychiatric crisis in a variety of locations. Crisis residential services can vary from organized, insurance reimbursed settings to consumer run levels of care. Several agencies define the expectations of effective case management.
  • Chapter 48 - Legal issues in the care of psychiatric patients
    pp 362-372
  • View abstract

    Summary

    Emergency telepsychiatry can improve patient care and satisfaction, reduce boarding of emergency department (ED) psychiatric patients, improve the accuracy of psychiatric diagnoses made in the ED, and decrease the baseline admission rate to psychiatric hospitals. It is important that a telepsychiatrist perform a remote site assessment before initiating services. An onsite assessment should be used to help the telepsychiatrist become aware of local collaborators and service agencies. The guidelines indicate that there should be attention to certain clinical issues. Identification and selection of qualified consulting telepsychiatrists and associated support systems are the keys to a successful collaboration in the ED. Early in the process for implementing telepsychiatry consultation to emergency departments, information technology (IT) staff should be involved. The final phase of implementation involves staff training. ED staff should know what the criteria are for getting a telepsychiatry consultation.

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